Landau Exekiel H, Gofrit Ofer N, Meretyk Shimon, Katz Giora, Golijanin Dragan, Shenfeld Ofer Z, Pode Dov
Pediatric Urology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
J Urol. 2003 Oct;170(4 Pt 2):1596-9; discussion 1599. doi: 10.1097/01.ju.0000084661.05347.58.
Urethrocutaneous fistula is the most common (2% to 10%) complication of hypospadias surgery. The correction of such fistula is associated with a 10% to 40% failure rate. The key measure to ensure a successful repair is separation of the suture lines in the urethra and skin, using well vascularized elastic tissue. If the dartos fascia is unavailable and local penile skin is fibrotic as a result of previous operations, a tunica vaginalis flap may be considered. We report our experience with tunica vaginalis flap as an adjunct to fistula repair.
We used tunica vaginalis flap for the repair of recurrent urethrocutaneous fistulas in 14 children with a mean age of 7.6 years (range 3 to 15). All patients had undergone previous hypospadias repairs and previous attempts to close the fistula had failed. The mean number of fistulas per patient was 1.6 (range 1 to 4), and the locations were perineal (1), penoscrotal (3), midshaft (10), and subcoronal (8). The mean number of failed previous closures with local penile skin flaps was 2.4 (range 1 to 5). Surgery was initiated by injecting povidone solution via the urethral meatus to identify all fistulas. Calibration or cystoscopy excluded distal urethral strictures. Surgery was performed using a microscope and fistulas were closed primarily in 12 patients and with an onlay island flap in 2. The urethral suture line was covered with a flap of tunica vaginalis, which was harvested through a small scrotal incision and mobilized via a subcutaneous tunnel into the penis. The testis was then fixed to the scrotum. A urethral stent with or without suprapubic catheter drainage provided urinary diversion for 2 to 7 days.
The repair was successful in all patients. During a mean followup of 44 months (range 8 to 60) there was no evidence of recurrent fistulas or urethral strictures. Penile cosmesis was excellent, and all parents reported a straight penis when erected. No postoperative complications were encountered in the testicles.
Repair of recurrent urethrocutaneous fistulas with a tunica vaginalis flap is highly effective regardless of fistula location. This flap is easy to mobilize and provides excellent coverage of the urethral suture line. It is a simple procedure with no complications to the testicles.
尿道皮肤瘘是尿道下裂手术最常见的（2%至10%）并发症。此类瘘管的修复失败率为10%至40%。确保修复成功的关键措施是利用血运良好的弹性组织分离尿道和皮肤的缝线。如果肉膜筋膜不可用且由于先前手术导致局部阴茎皮肤纤维化，则可考虑使用睾丸鞘膜瓣。我们报告我们使用睾丸鞘膜瓣辅助修复瘘管的经验。
我们使用睾丸鞘膜瓣修复14例复发性尿道皮肤瘘患儿，平均年龄7.6岁（范围3至15岁）。所有患者均曾接受过尿道下裂修复术，且先前尝试闭合瘘管均失败。每位患者瘘管的平均数量为1.6个（范围1至4个），位置分别为会阴（1例）、阴茎阴囊（3例）、阴茎体中部（10例）和冠状沟下（8例）。先前使用局部阴茎皮瓣闭合瘘管失败的平均次数为2.4次（范围1至5次）。手术开始时，经尿道口注入聚维酮溶液以识别所有瘘管。校准或膀胱镜检查排除远端尿道狭窄。手术在显微镜下进行，12例患者主要闭合瘘管，2例采用岛状覆盖皮瓣。尿道缝线用睾丸鞘膜瓣覆盖，该瓣通过阴囊小切口获取，并经皮下隧道移入阴茎。然后将睾丸固定于阴囊。带或不带耻骨上导管引流的尿道支架提供2至7天的尿液转流。
所有患者修复均成功。在平均44个月（范围8至60个月）的随访期间，无复发性瘘管或尿道狭窄的证据。阴茎外观良好，所有家长均报告阴茎勃起时笔直。睾丸未出现术后并发症。
无论瘘管位置如何，用睾丸鞘膜瓣修复复发性尿道皮肤瘘均非常有效。该瓣易于移动，能很好地覆盖尿道缝线。这是一个简单的手术，对睾丸无并发症。
