Savremeni pristup u hirurškom lečenju stenoze uretre

Abstract

Uvod: Stenoza uretre predstavlja suženje lumena uretre različitog stepena. Kliničke karakteristike stenoze uslovljavaju izbor odgovarajuće hirurške procedure za njeno rešavanje. Na raspolaganju su nam sledeće terapijske opcije: dilatacija (bužiranje) uretre, endoskopska resekcija (uretrotomija interna), ugradnja uretralnih stentova i otvorene hirurške procedure („end-to-end“anastomoza i augmentaciona uretroplastika). Pretpostavka je da su česti recidivi ove bolesti, koje srećemo u kliničkoj praksi, rezultat neadekvatnog terapijskog pristupa. Ciljevi: Cilj ove studije je definisanje optimalne metode u lečenju stenoze uretre poreĎenjem ishoda tri različita načina lečenja: uretrotomija interna (UI), augmentacija uretre uz korišćenje vaskularizovanog kožnog režnja i augmentacija uretre korišćenjem transplantata bukalne mukoze (BMG). Osim procene efikasnosti lečenja, cilj rada bio je i utvrĎivanje vrste i učestalosti komplikacija koje prate svaku od navedena tri modaliteta lečenja, kao i analiza kliničkih karakteristika stenoza uretre i njihovog uticaja na ishod lečenja. Matrijal i metode: Tokom ove studije praćeno je 84 pacijenata koji su lečeni zbog stenoze uretre u periodu od februara 2007. do januara 2015. Posmatrani paciijenti su bili podvrgnuti sledećim operativnim zahvatima: kod dvadeset i šest (26) pacijenata uraĎena je uretrotomija interna (grupa 1), kod 17 pacijenata uraĎena je augmentacija uretre primenom režnja penilne kože (grupa 2), a kod 41 pacijenta uraĎena je operacija augmentacije uretre primenom grafta bukalne mukoze (grupa 3). Svi pacijenti su redovno praćeni tokom ranog postoperativnog perioda, a zatim 1, 6 i 12 meseci od operativnog zahvata, i kasnije po potrebi. Pacijenti su davali usmeni izveštaj o kvalitetu mokrenja i navodili subjektivni osećaj ispražnjenosti bešike i podatak o postojanju urinarnih infekcija. Tokom perioda praćenja pacijentima je raĎena urofloumetrija i ultrazvučno im je merena količina rezidualnog urina. Ukoliko su postojale jasne subjektivne smetnje, ili nalazi urofloumetrije ili ultrazvuka nisu bili zadovoljavajući, raĎene su dodatne procedure u vidu uretrografije ili uretroskopije. Uspeh operativne procedure definisan je kao mogućnost spontanog mokrenja, brzina mokrenja merena urofloumetrijom od najmanje 15 ml/s i odsustvo potrebe za nekom od dodatnih intervencija uključujući i bužiranje uretre. Rezultati: Na osnovu anamnestičkih i kliničkih podataka utvrdili smo da je kod najvećeg broja pacijenata uzrok stenoze bila je hipospadija (21), zatim kateterizacija mokraćne bešike ili endoskopska intervencija (19), nepoznat uzrok (19), trauma (10), lichen sclerosus (8), infekcija (7)...

Introduction: Urethral stenosis presents narrowing of the urethral channel. Clinical characteristics of every urethral stricture determine the choice of surgical treatment for its repair. Following surgical options are available: dilation, direct vision internal urethrotomy, urethral stents and open surgical repair (“end-to-end” anastomosis and augmentation urethroplasty). We suppose that recidivant urethral strictures, which can be noted frequently, are result of inadequate treatment. Objective: Goal of this study is to define optimal method in the treatment of urethral strictures, by comparison of three different treatment options: internal urethrotomy, augmentation urethroplasty using fasciocutaneous skin flap and augmentation urethroplasty using buccal mucosa graft. Furthermore, we evaluated the types and rate of postoperative complications, as well as impact of clinical characteristics on outcome of the treatment. Materials and methods: In the period from February 2007 to January 2015, 84 patients were treated because of urethral stricture disease. First group of patients (26) underwent internal urethrotomy, second group (17) underwent urethroplasty using faciocutaneous flap, and third group (41) underwent urethroplasty using buccal mucosa graft. All patients were followed during early postoperative period and 1, 6 and 12 months thereafter, and longer if needed. Patients reported voiding habits, feeling of emptying of the bladder and history of urinary tract infections. All patients underwent uroflowmetry and measurement of postvoiding residual urine. Additional evaluation, as urethrography or urethroscopy were conducted if patient reported symptoms of obstruction or unsatisfactory uroflow measurements were found. Success was defined as possibility for normal and complete voiding without need for additional procedures (including dilations) and Qmax at least 15ml/sec. Results: According to history and clinical features we found that 21 patients had stricture due to failed hypospadias, 19 patients develop urethral stricture after catheterization or transurethral procedures, 19 had stricture of unknown origin, 10 had trauma, 8 had lichen sclerosus and 7 had an infection. Twenty patients had their stricture in glandial urethra, 23 in penile urethra, 25 in bulbar, and 16 had panurethral or multiple strictures. Follow up period was 14 to 109 months (mean 41 months). Success rate in first group (internal urethrotomy) was 26,9% (7/26), while in 19 patients (73,1%) additional procedures were necessary for definitive treatment of urethral stricture. Success rate in second group (fasciocutaenous flap) was 76,5% (13/17)...