Diamond David A, Xuewu Jiang, Bauer Stuart B, Cilento Bartley G, Borer Joseph G, Nguyen Hiep, Cendron Marc, Rosoklija Ilina, Retik Alan B
Department of Urology, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
J Urol. 2009 Oct;182(4 Suppl):1755-8. doi: 10.1016/j.juro.2009.02.082. Epub 2009 Aug 18.
Optimal management for bulbous urethral stricture in children is poorly defined. We compared our long-term experience with direct vision internal urethrotomy and open repair to define the optimal surgical strategy.
We reviewed the records of 63 patients who underwent direct vision internal urethrotomy or open repair. A total of 46 patients (73%) were treated with 1 or more urethrotomies. Of the patients 17 (27%) underwent urethroplasty, 13 underwent end-to-end repair and 4 received a patch graft or tube. Eight of 17 cases required urethroplasty only, whereas in 9 combined open repair and urethrotomy were done. Mean patient age was 14.1 years (range 5 months to 21 years). Followup included voiding cystourethrogram, retrograde urethrogram and/or cystoscopy, or flow rate. Mean followup was 30 months for urethrotomy and 16 months for open urethroplasty.
When direct vision internal urethrotomy was the initial approach, 1 procedure was successful in 28 of 53 cases (53%). Multiple urethrotomies increased the success rate to 59% (43 of 73 cases). The 53 patients with urethrotomy required a total of 84 procedures (mean 1.6 each). When open repair was the initial approach, 1 procedure was successful in 8 of 10 cases (80%). A total of 12 procedures (mean 1.2 each) were required in those 10 cases. A combined urethrotomy/open approach with 2 procedures was successful in 78% of cases (7 of 9).
Open reconstruction is more successful than direct vision internal urethrotomy as the initial approach to bulbous urethral strictures. Although aggressive, end-to-end repair usually provides a definitive solution. Initial direct vision internal urethrotomy is successful in half of the cases and repeat urethrotomy adds little to success. The success of the combined urethrotomy/open approach approximates that of initial open reconstruction. If initial direct vision internal urethrotomy is elected, we advocate only 1 attempt, followed by open end-to-end urethroplasty if necessary.
儿童球部尿道狭窄的最佳治疗方法尚不明确。我们比较了直视下内尿道切开术和开放修复术的长期经验，以确定最佳手术策略。
我们回顾了63例行直视下内尿道切开术或开放修复术患者的记录。共有46例患者（73%）接受了1次或更多次尿道切开术。其中17例患者（27%）接受了尿道成形术，13例接受了端端修复，4例接受了补片移植或管状修复。17例患者中有8例仅需尿道成形术，而9例则同时进行了开放修复和尿道切开术。患者平均年龄为14.1岁（范围5个月至21岁）。随访包括排尿性膀胱尿道造影、逆行尿道造影和/或膀胱镜检查，或尿流率。尿道切开术的平均随访时间为30个月，开放尿道成形术为16个月。
当以直视下内尿道切开术作为初始治疗方法时，53例中有28例（53%）单次手术成功。多次尿道切开术使成功率提高到59%（73例中的43例）。53例接受尿道切开术的患者共需要84次手术（平均每人1.6次）。当以开放修复作为初始治疗方法时，10例中有8例（80%）单次手术成功。这10例患者共需要12次手术（平均每人1.2次）。联合尿道切开术/开放手术分两步进行，9例中有7例（78%）成功。
作为球部尿道狭窄的初始治疗方法，开放重建术比直视下内尿道切开术更成功。尽管积极的端端修复通常能提供确定性的解决方案。初始直视下内尿道切开术半数病例成功，重复尿道切开术对成功率提升不大。联合尿道切开术/开放手术的成功率接近初始开放重建术。如果选择初始直视下内尿道切开术，我们主张仅尝试1次，必要时随后进行开放端端尿道成形术。
