『尿道下裂與陰莖彎曲手術的學習曲線』經驗分享

林介山^{1, 2}、江恆杰¹、陳建廷¹、王百孚¹、張進寶¹、嚴孟意¹、黃勝賢¹、石宏仁¹、

周明智²

彰化基督教醫院 外科部 泌尿科¹；中山醫學大學醫學研究所²

THE LEARING CURVE IN HYPOSPADIAS AND CHORDEE SURGERY 

Jesun Lin^{1, 2} Herng-Jye Jiang¹, Jian Ting Chen¹, Bai-Fu Wang¹, Chin-Pao Chang¹, Mon-I Yen¹, Sheng-Hsien Huang¹, Hon-Jen Shi¹, and Ming-Chih Chou²

¹Division of Urology, Department of Surgery, Changhua Christian Hospital, Changhua

²Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan

 

Purpose: The surgery of hypospadias and chordee is one of the most common and difficult procedures in pediatric urology. We would provide an insight into the “learning curve” of fellowship-trained pediatric urologists associated with reconstruction of hypospadias and chordee. I would present and share the experiences of learning the surgery in more than 30 years.

Materials and Methods: We evaluated the factors that may influence the results of surgery for hypospadias and chordee. We reviewed our experiences in the management of fresh and redo patients in order to understand and resolution of the presenting Problems.

It was a retrospective observational study. Patients with complete record available were included in the study. We reviewed the records of 118 redo-operations and 868 fresh hypospadias patients between January 1986 and December 2016. We underwent MAGPI and Mathieu's repairs for most patients who had penile or distal hypospadias, TIP (Tubularized Incised Plate) urethroplasty was performed for the middle and proximal types. Patients with severe chordee had Duckett Island flap urethroplasty(OIP) procedure. Patients having moderate or mild chordee were subjected to the orthoplasty and/or Nesbit Procedure. The presenting problems of failed hypospadias repair might be various in the same patient. The main problems to be (1) 86 urethrocutaneous fistulae, (2) 36 urethral strictures, (3) 15 meatal stenosis (4) 36 remaining chordee, (5) 14 diverticula and (6) 6 hairy urethra. The penile shaft and perineum fistulas were repaired with the “pants-over-vest¨ urethroplasty modified to the procedure of Turner-Warwick. We wrapped Dorsal dartos or subcutaneous flap to cover the neourethra for preventing urethrocutaneous fistula. We performed double-tube stent for stent and drainage. We used Mini-Vac vacuum drain in subcutaneous layer for prevention of hematoma and infection.

Results: The over all successful rate for urethrocutaneous fistula including perineal, scrotal, penile shaft and coronal regions is 76%. The successful rate for urethral strictures is 82%, for meatal stenosis is 70%, for chordee is about 70%, for diverticula is about 85%, for the hairy urethra is about 70%. We followed up the outcome of consequent surgery from 6 months to more than ten years. The number of redo-operations ranged from 1 to 8 attempts.

Conclusions: We have to correct them in a single stage preferably at least 3 months after previous repair. In redoing this reconstruction, we should be conversant with all the existing methods for hypospadias and chordee repair and be able to apply them appropriately.