尿道下裂术后尿道皮肤瘘的个性化治疗

目的 探讨不同方法治疗尿道下裂术后各型尿道皮肤瘘的效果。方法 回顾性分析2010年1月至2015年12月收治的101例尿道下裂术后尿道皮肤瘘患儿的临床资料。患儿年龄2岁5个月至14岁3个月,中位年龄5岁1个月。101例中单个瘘口86例(85%),2个瘘口13例(13%),3个瘘口2例(2%)。101例患儿按以下方法分类处理：对于冠状沟及远端区域的瘘口,如瘘口离正常尿道开口很近且阴茎头翼融合处组织很薄为Ⅰ类,予尿道成形术;除Ⅰ类外的冠状沟瘘和阴茎体瘘,沿瘘口周围环形切开皮肤且游离瘘管,如瘘口与尿道相通处基底<3 mm为Ⅱ类,予缝扎、结扎关闭瘘口;如瘘口与尿道相通处基底≥3 mm为Ⅲ类,予连续无张力缝合修复瘘口。修补后的尿瘘外层予去上皮的带蒂Dartos筋膜或游离的带蒂睾丸鞘膜覆盖。术后拔除导尿管后随访≥1年,未出现尿道狭窄、尿道裂开、尿道憩室、再次尿瘘定义为手术成功。结果 本研究101例共111个瘘口,其中Ⅰ类24个,Ⅱ类57个,Ⅲ类30个。101例术后随访1～4年,平均2.8年。1例术后出现尿道狭窄,予尿道扩张后排尿通畅;无尿道憩室和尿道裂开病例。13个瘘口出现再次尿道皮肤瘘,发生率为11.7%(13/111个),其中Ⅰ类4个(16.7%),Ⅱ类2个(3.5%),Ⅲ类7个(23.3%)。结论 根据尿道下裂术后尿道皮肤瘘的部位和瘘口大小选择合适的方法进行分类治疗的效果更佳。术中对新尿道组织进行致密的覆盖非常必要。     

尿道下裂修复术后尿道皮肤瘘的治疗

目的:探讨尿道下裂修复术后尿道皮肤瘘尿瘘的治疗方法.方法:收集1995～2004年间42例尿瘘的临床资料.根据瘘口的大小和位置分别采用简单缝合术,Y-V皮瓣成形术、皮瓣推进术进行修补.结果:42例尿瘘修补后39例成功,3例失败,一次修补成功率93%(39/42).结论:遵循尿瘘的修复原则,采用皮瓣技术和多层缝合技术,可提高尿瘘修补的成功率.     

显微外科技术修复尿道下裂术后尿瘘

目的探讨显微外科技术在修复尿道下裂术后尿瘘治疗中的作用，以提高尿瘘修复成功率。方法1999年7月至2006年5月，对33例尿道下裂术后尿瘘的44个瘘口，应用显微外科技术，分别采用Thiersch偏心圆皮肤覆盖法修复28例；对伴发尿道狭窄、阴茎弯曲者5例，行阴茎瘢痕组织及狭窄尿道切除，以阴囊皮瓣重建尿道，阴茎皮瓣覆盖尿道。结果Thiersch法修复33个瘘口有5个复发；部分尿道切除加阴囊皮瓣尿道成形术修复5例，共11个瘘口，皮瓣全部成活，尿瘘无复发。结论应用显微外科技术可提高尿瘘修复的成功率，尿瘘修复的成功率还与瘘口局部情况、术式选择等有关。     

镍钛尿道支架管在尿道下裂修复术中的作用

目的探讨镍钛记忆合金尿道支架管在预防尿道下裂术后尿瘘及尿道狭窄中的作用.方法 2001年1月～2004年12月,应用镍钛记忆合金尿道支架管作为尿道支架修复63例尿道下裂,其中阴茎近端型19例,阴茎阴囊型22例,阴囊会阴型8例,为一期尿道重建;尿道下裂术后尿瘘行尿瘘修补术10例;尿道下裂术后尿道狭窄再次重建尿道4例.结果 63例伤口均Ⅰ期愈合,术后获随访2个月～2年,排尿通畅,均无尿瘘和尿道狭窄发生.其中62例于术后2～3个月后拔除尿道支架,1例于12个月后拔除.结论镍钛记忆合金尿道支架管可有效预防尿道下裂术后尿瘘及尿道狭窄的发生.     

The effect of platelet rich fibrin on growth factor levels in urethral repair

Aim

Platelet rich fibrin (PRF) is an autologous source of growth factors and promotes wound healing. An experimental study was performed to evaluate the effect of PRF on growth factor levels in urethral repair.

Materials and Methods

Eighteen Wistar albino rats were included in the study. Rats were allocated in three groups (n:6): control (CG), sham (SG), and PRF (PRFG). In SG, a 5 mm vertical incision was performed in the penile urethra and repaired with 10/0 Vicryl® under a microscope. In PRFG, during the urethral repair as described in SG, 1 cc of blood was sampled from each rat and centrifuged for 10 minutes at 2400 rpm. PRF obtained from the centrifugation was placed on the repair site during closure. Penile urethras were sampled 24 hours after PRF application in PRFG and after urethral repair in SG. Transforming growth factor beta receptor (TGF-β-R-CD105), vascular endothelial growth factor (VEGF) and its receptor (VEGF-R), as well as endothelial growth factor receptor (EGFR), were evaluated in subepithelia of the penile skin and urethra. Groups were compared for growth factor levels and growth factor receptor expression with the Kruskal Wallis test.

Results

TGF-β-R levels were significantly decreased in SG when compared to CG (p < 0.05). In PRFG, TGF-β-R was increased in both subepithelia of penile skin and urethra with respect to SG (p < 0.05). When VEGF levels and its receptor expression were compared between SG and PRFG, VEGF levels were found to be increased in penile skin subepithelium, whereas VEGF-R expressions were decreased in urethral subepithelia in PRFG (p < 0.05). There was no difference between groups for EGFR levels (p > 0.05).

Conclusion

Use of PRF after urethral repair increases TGF-β-R and VEGF expressions in urethral tissue. PRF can be considered as an alternative measure to improve the success of urethral repair.     

Time course and histology of urethrocutaneous fistula formation in a porcine model of urethral healing

OBJECTIVE: Urethrocutaneous fistula is a well-known complication of hypospadias surgery and is reported in 5-10% of repairs. Using a previously described juvenile pig model, we present a histological analysis of the healing of the ventral aspect of the urethral repair and describe the histological mechanism of fistula formation. MATERIALS AND METHODS: Twelve juvenile pigs underwent ventral, longitudinal urethral incision and closure over a 5-French feeding tube. The ventral aspect was closed in running fashion using two closure techniques and three suture types in each animal. Three animals were sacrificed on postoperative day 3, three on day 5, three on day 12, one on day 14, and two on day 21. Closure was one-layered incorporating urethral mucosa in the animals sacrificed on days 3, 5, and 21. An extra-mucosal suture technique was used in the group sacrificed on day 12. Sections of the penis were cut, paraffin embedded, and treated with Hematoxylin and Eosin staining. RESULTS: Fistulae were seen in 12 specimens and in association with each suture type. Fewer sections of the extra-mucosal technique showed fistulization. Fistulae lined with immature epithelium were seen by day 5. Mature fistulae were observed by day 12. Skin epithelium and urethral mucosa migrated along suture tracts. By days 12 and 21, in addition to mature fistulae, several sections showed well-healed ventral repairs with clearly extramucosal suture tracts. CONCLUSIONS: Fistula formation begins early in the healing process after ventral urethral repair. Incorporation of urethral mucosa in the ventral repair is a substrate for fistula formation with rapid migration of urethral mucosa and skin epithelium into suture tracts. The importance of a multi-layered repair and extra-mucosal suture technique are thus emphasized with respect to urethral repair. Whether the mucosal or dermal migration along suture tracts can be attenuated or prevented by changing the biochemical environment awaits further investigation.     

带蒂睾丸鞘膜瓣覆盖新尿道在尿道下裂再次手术中的应用

目的 探讨带蒂睾丸鞘膜瓣覆盖新尿道在尿道下裂再次手术中的临床疗效。 方法 回顾性分析2013年1月至2015年12月我院收治的45例尿道下裂再次手术患儿的临床资料。年龄1岁3个月～9岁4个月,中位年龄5岁3个月。根据患儿病史特点分为尿道下裂术后尿道裂开组(A组)和尿道下裂分期手术中的二期手术组(B组)。A组距前次手术的时间为6～14个月,平均8.3个月;阴茎勃起伸直或有<30°的轻度弯曲;其中12例为阴茎体部的尿道裂开(A1组),15例阴茎头及远端尿道裂开且尿道开口于阴茎体(A2组)。B组距一期手术的时间为6～8个月,平均6.5个月;现尿道开口于阴茎阴囊交界处。所有患儿在完成新尿道成形术后,游离合适大小的带蒂睾丸鞘膜瓣覆盖新建尿道。 结果 A组中2例伴有轻度下弯而行保留背侧神经血管束的阴茎海绵体背侧白膜折叠术伸直阴茎;B组勃起试验均提示阴茎无下弯。A1组12例修复尿道长度10～15 mm,平均12 mm;A2组尿道开口于阴茎远端8例,阴茎中部7例,修复尿道长度18～31 mm,平均26 mm;B组尿道均开口于阴茎阴囊交界处,修复尿道长度33～45 mm,平均37 mm。45例患儿术后均未出现阴囊血肿。1例阴囊红肿,经抗感染治疗后好转;2例睾丸位置抬高至阴囊上方,1例阴茎顺时针扭转;所有患者拔管后无排尿困难。拔管后6例即刻出现尿道皮肤瘘,其中A2组4例,B组2例;观察6个月后其中1例尿道皮肤瘘自愈,5例仍存在,予尿道皮肤瘘修补。术后随访1～4年,平均1.8年。随访期间A2组1例再次出现尿道皮肤瘘,B组1例再次出现尿道皮肤瘘且伴有尿道口狭窄,此2例尿道皮肤瘘行修补手术,尿道狭窄给予定期尿道扩张。未出现尿道憩室及阴茎下弯。 结论 带蒂睾丸鞘膜瓣可作为新尿道的防水组织应用于尿道下裂再次手术,术后尿道皮肤瘘的发生率较低。     

带蒂睾丸鞘膜瓣覆盖技术在复发性尿道皮肤瘘修复中的应用

目的 探讨带蒂睾丸鞘膜瓣覆盖技术在治疗尿道下裂术后复发性尿道皮肤瘘中的应用价值和优势。 方法 回顾性分析2011年1月至2015年1月25例尿道下裂术后尿道皮肤瘘患儿的临床资料。患儿均为男性,年龄1.6～14.0岁,平均6.2岁。所有患儿既往均行尿道成形术和至少1次失败的尿道瘘修补术。尿道瘘口位于冠状沟下型5例,阴茎体型6例,阴茎阴囊交界型14例。瘘孔直径3～10 mm,均为单个瘘口。已行2次修补术者16例,行2次以上修补术者9例。采用连续内翻缝合修补瘘口＋带蒂睾丸鞘膜瓣覆盖尿道瘘修复术。 结果 术后随访6个月～4年,平均2.1年。25例中一次手术成功24例,成功率96%(24/25)。阴茎外观满意,排尿正常,无尿道皮肤瘘和尿道狭窄,勃起时阴茎伸直满意。1例术后因局部创面感染致尿道皮肤瘘复发。取鞘膜瓣侧的睾丸大小、位置、形态正常,睾丸彩色多普勒超声检查正常。 结论 对于尿道下裂术后复发性尿道皮肤瘘患儿,在瘘口处加盖带蒂睾丸鞘膜瓣操作简单,能有效提高手术成功率,明显降低术后尿道皮肤瘘发生率,适用于任何位置的尿道皮肤瘘。     

Challenging abdominal incisional hernia repaired with platelet-rich plasma and bone marrow-derived mesenchymal stromal cells. A case report

IntroductionThe necessity to develop new treatment options for challenging procedures in hernia surgery is becoming even more evident and tissue engineering and biological technologies offer even newer strategies to improve fascial healing. The present case reports a patient-tailored surgical technique performed to repair a grade IV abdominal incisional hernia, with a combined use of platelet-rich plasma and bone marrow-derived mesenchymal stromal cells, implanted on a biological mesh.Presentation of the caseA 71 year-old female patient complained of an abdominal incisional hernia, complicated by enterocutaneous fistula, four-months following laparostomy. Contrast enhanced computed tomography showed an incisional hernia defect of 15.5 × 20 cm, with a subcutaneous abscess and an intestinal loop adherent to the anterior abdominal wall, with a concomitant enterocutaneous fistula. Surgery involved abdominal wall standardized technique closure, with in addition platelet-rich plasma and bone marrow-derived mesenchymal stromal cells implanted on a biological mesh. Two years follow up showed no recurrences of incisional hernia.DiscussionCoating surgical meshes with patient’s own cells may improve biocompatibility, by reducing inflammation and adhesion formation. Moreover, platelet-rich plasma is a good source of growth factors for wound healing, as well as a good medium for bone marrow multinucleate cells introduction into fascial repair.ConclusionThis approach is likely to improve abdominal wall repair in high grade (IV) incisional hernia, with the real possibility of improving prosthetic compatibility and reducing future recurrences. The authors agree with the necessity of further studies and trials to assure the safety profile and superiority of this procedure.     

同种异体富血小板血浆对创面胶原合成的作用及其机制研究

目的 探讨同种异体来源的富血小板血浆(PRP)促进创面胶原合成的作用及机制。 方法 采用7周龄雄性SD清洁级大鼠50只,10只大鼠用来制备富血小板血浆,其余40只大鼠随机分为PRP组和对照组,每组各20只,PRP组大鼠创面涂抹0.1 ml同种异体的PRP,对照组涂抹同等剂量的生理盐水,观察创面再生愈合情况,采用Masson染色分析细胞及组织形态学变化,免疫印迹法检测Ⅰ型和Ⅲ型胶原的蛋白表达情况;采用实时定量PCR检测Ⅰ型和Ⅲ型胶原组织mRNA的表达。计量资料的比较采用 t检验,组间比较采用单因素方差分析。 结果 创面形成后第3、6、10、15天,PRP组创面愈合率明显高于对照组(30.33±3.35比18.35±2.04,55.51±2.74比36.83±2.34,79.64±1.40比56.92±1.44,86.88±2.12比65.80±1.76),差异有统计学意义( t＝13.66～50.48, P值均<0.05);Masson染色显示PRP组的创面胶原形成快、纤维粗壮、排列致密;与对照组相比,PRP组细胞Ⅰ型胶原蛋白(1.92±0.09比1.18±0.11)和Ⅲ型胶原蛋白(1.16±0.05比0.74±0.11)表达明显上调,差异有统计学意义( t＝22.99, P<0.01; t＝17.62, P<0.05);与对照组相比,PRP组在创面形成后第3、6、10、15天的Ⅰ型胶原蛋白(5.17±0.11比1.79±0.18,6.97±0.09比1.96±0.08,6.00±0.26比2.10±0.05,4.95±0.11比3.58±0.09)和Ⅲ型胶原蛋白(2.35±0.08比1.44±0.05,3.08±0.05比1.84±0.06,3.48±0.07比2.36±0.09,4.42±0.07比2.77±0.10)的mRNA均表达上调,差异有统计学意义( t＝43.37～188.37, P值均<0.01)。 结论 同种异体富血小板血浆可通过促进Ⅰ型和Ⅲ型胶原蛋白合成加速创面愈合。     

镍钛记忆合金尿道支架管在尿道下裂修复中的应用（附128例报告）

目的：探讨镍钛记忆合金尿道支架管在尿道下裂修复中的优点及应用前景。方法：2007年1月～2010年6月应用镍钛记忆合金尿道支架管作为尿道支架修复128例尿道下裂患者,均为一期尿道重建。结果：术后1～3个月自行脱落或拔除尿道支架,所有患者随访6～24个月,7例出现尿瘘,1例术后发生尿道狭窄,其余均获成功,手术成功率为93．75％（120／128）。结论：镍钛记忆合金尿道支架管可有效预防尿道下裂术后尿瘘及尿道狭窄的发生。     

不同处理方法对胰腺创面愈合影响的实验研究

为探讨不同处理方法对胰腺创面愈合的影响，作者将４５条实验犬分为三组，即胰尾组、胰头组、胰头加全身应用生长抑素组。每条狗按分组要求在胰腺制作四个等大小创面，分别采用四种方法处理创面：紧密缝合（ＣＳ）、稀疏缝合（ＳＳ）、不缝合（ＮＳ）及不缝合但覆盖网膜（ＯＣ）。术后７～１０天再次开腹观察胰腺创面愈合情况为：每组中ＮＳ优于ＣＳ及ＳＳ（ｐ＜０．０５）ＯＣ优于ＣＳ及ＳＳ（Ｐ＜０．０１）；胰尾组ＮＳ及ＯＣ优于胰头组ＮＳ及ＯＣ（Ｐ＜０．０５）；加生长抑素组ＮＳ及ＯＣ优于胰头组ＮＳ及ＯＣ（Ｐ＜０．０５）；各组间ＣＳ及ＳＳ均无差异（Ｐ＞０．０５）；胰尾组中ＳＳ优于ＣＳ（Ｐ＜０．０５）。结论：缝合造成组织局部缺血，引起组织缺血性坏死脱落，创面非但不愈合反而扩大；缝线是一种异物，可引起缝线周围组织反应，不利于创面愈合；生长抑素对胰腺外分泌有强大抑制作用，抑制了胰液分泌，使创面相对干燥不受胰液侵蚀，有利于胰腺创面愈合。     

不同处理方法对胰腺创面愈合影响的实验研究

为探讨不同处理方法对胰腺创面愈合的影响,作者将45条实验犬分为三组,即胰尾组、胰头组、胰头加全身应用生长抑素组。每条狗按分组要求在胰腺制作四个等大小创面,分别采用四种方法处理创面：紧密缝合（CS）、稀疏缝合（SS）、不缝合（NS）及不缝合但覆盖网膜（OC）。术后7～10天再次开腹观察胰腺创面愈合情况为：每组中NS优于CS及SS（P<0.05）OC优于CS及SS（P<0.01）;胰尾组NS及OC优于胰头组NS及OC（P<0.05）;加生长抑素组NS及OC优于胰头组NS及OC（P<0.05）,各组间CS及SS均无差异（P>0.05）;胰尾组中SS优于CS（P<0.05）。结论：缝合造成组织局部缺血,引起组织缺血性坏死脱落,创面非但不愈合反而扩大;缝线是一种异物,可引起缝线周围组织反应,不利于创面愈合;生长抑素对胰腺外分泌有强大抑制作用,抑制了胰液分泌,使创面相对干燥不受胰液侵蚀,有利于胰腺创面愈合。     

A Newly Designed Anal Fistula Plug: Clinicopathological Study in an Experimental Iatrogenic Fistula Model

We report on a clinicopathologic study in an animal model of treatment with a new bioabsorbable polymer plug (BAPP). Over a 2-week period, 6 porcine models, which each had 4 anal fistulae, were created using Blake drains. The pigs were divided into 2 groups: the BAPP-treatment group (n = 12 fistulae) and the control group (n = 12 fistulae). Two weeks later, the pigs were humanely killed, and the perianal sites were excised and examined with gross and pathologic studies. Each fistula in the BAPP group was completely cured. In the pathologic study, the treatment sites had little disarray, few defects in the muscular layer, and small numbers of inflammatory cells. The control group had a significantly greater number of inflammatory cells and microabscesses than the BAPP group. The newly developed BAPP reduced the infection and induced good healing in anal fistulae. The BAPP may be a useful new device for the clinical treatment of anal fistulae.     

The use of autologous platelet–leukocyte gels to enhance the healing process in surgery,a review

Background The therapeutic use of autologously prepared, platelet–leukocyte-enriched gel (PLG) is a relatively new technology for the stimulation and acceleration of soft tissue and bone healing. The effectiveness of this procedure lies in the delivery of a wide range of platelet growth factors mimicking the physiologic wound healing and reparative tissue processes. Despite an increase in PLG applications, the structures and kinetics of this autogenously derived biologic material have not been observed. Methods A review of the most recent literature was performed to evaluate the use of PLG in various surgical disciplines. Results The review showed that the application of PLG has been extended to various surgical disciplines including orthopedics, cardiac surgery, plastic and maxillofacial surgery, and recently also endoscopic surgery. Conclusion This review demonstrates the usefulness of PLG in a wide range of clinical applications for improvement of healing after surgical procedures.