Neheman Amos, Rappaport Yishai H, Verhovsky Guy, Bush Nicol, Snodgrass Warren, Lang Erez, Zisman Amnon, Efrati Shai
Departments of Urology, Shamir (Assaf-Harofeh) Medical Center, Zerifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Departments of Urology, Shamir (Assaf-Harofeh) Medical Center, Zerifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
J Pediatr Urol. 2020 Apr;16(2):163.e1-163.e7. doi: 10.1016/j.jpurol.2020.01.002. Epub 2020 Jan 14.
Hypospadias cripple patients pose a major surgical challenge with high complication rates attributed mainly to graft contraction. Hyperbaric oxygen therapy (HBOT) is an established treatment for compromised grafts and used extensively as a salvage therapy for compromised grafts and ischemic non-healing wounds.
We evaluated the graft-take rates in hypospadias cripple cases undergoing a staged tubularized autograft repair (STAG) and compared between patients treated with or without preemptive HBOT.
All patients underwent a STAG. Patients receiving preemptive HBOT were compared with patients receiving the standard surgical procedure without HBOT. The HBOT protocol included a daily session, 5 days per week for four weeks before the surgery and 10 additional daily sessions immediately after first-stage surgery. Each HBOT session included 90 min exposure to 100% O at 2 atmospheres absolute with 5 min air breaks every 20 min. The primary endpoint was graft take. Sequential tubularization without tension at second stage was defined as success.
Seven boys received HBOT and 14 boys comprised the control group. All patients in the HBOT group had good graft take with no graft contraction. In the control group, 57% had good graft take and could proceed to the second-stage surgery and 43% had graft contraction (Table). Except for one patient who had claustrophobia while entering the chamber, no significant side-effects developed during the HBOT.
The basic pathophysiology of compromised flaps includes both ischemia and reperfusion injury, which can be attenuated by HBOT. The beneficial effects of HBOT relates to several mechanisms, including hyperoxygenation, fibroblast proliferation, collagen deposition, angiogenesis, and vasculogenesis. Graft contraction is a well-known complication in hypospadias cripple population with reported failure rate of 39-63%. The HBOT procedure was found to be very effective and the entire HBOT group had a good graft take. Accordingly, all patients in the HBOT group proceeded to a successful second-stage tubularization. In addition, HBOT was found to be safe and generally well tolerated by this pediatric population. Study limitations were a relative small, non-homogenous sample size and lack of prospective randomization. Success was defined as sufficient graft elasticity sufficing for tubularization of the neourethra, and exact graft measurements are lacking in this study.
Preemptive HBOT can be used safely in the hypospadias cripple pediatric population and can potentially reduce the expected high surgical failure secondary to graft contraction.
尿道下裂致残患者带来了重大的手术挑战，并发症发生率高，主要原因是移植物收缩。高压氧治疗（HBOT）是一种针对受损移植物的既定治疗方法，广泛用作受损移植物和缺血性不愈合伤口的挽救疗法。
我们评估了接受分期管状化自体移植物修复（STAG）的尿道下裂致残病例的移植物成活率，并比较了接受或未接受预防性HBOT治疗的患者。
所有患者均接受STAG治疗。将接受预防性HBOT的患者与接受无HBOT的标准手术程序的患者进行比较。HBOT方案包括每天一次治疗，每周5天，在手术前持续四周，在一期手术后立即再进行10次每日治疗。每次HBOT治疗包括在2个绝对大气压下暴露于100%氧气90分钟，每20分钟有5分钟的空气间歇。主要终点是移植物成活。第二阶段无张力的连续管状化定义为成功。
7名男孩接受了HBOT治疗，14名男孩组成对照组。HBOT组的所有患者移植物成活良好，无移植物收缩。在对照组中，57%的患者移植物成活良好，可以进行第二阶段手术，43%的患者出现移植物收缩（见表）。除一名患者在进入舱室时患有幽闭恐惧症外，HBOT治疗期间未出现明显副作用。
受损皮瓣的基本病理生理学包括缺血和再灌注损伤，HBOT可减轻这些损伤。HBOT的有益作用涉及多种机制，包括高氧合、成纤维细胞增殖、胶原蛋白沉积、血管生成和血管发生。移植物收缩是尿道下裂致残人群中众所周知的并发症，报道的失败率为39%-63%。发现HBOT程序非常有效，整个HBOT组移植物成活良好。因此，HBOT组的所有患者均成功进行了第二阶段管状化。此外，发现HBOT是安全的，并且该儿科人群通常耐受性良好。研究局限性在于样本量相对较小且不均匀，以及缺乏前瞻性随机分组。成功定义为移植物具有足够的弹性以满足新尿道的管状化，本研究缺乏确切的移植物测量数据。
预防性HBOT可安全用于尿道下裂致残的儿科人群，并有可能降低因移植物收缩导致的预期高手术失败率。
