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Management of ischemic tissues and skin flaps in Re-Operative and complex hypospadias repair using vasodilators and hyperbaric oxygen.
Journal of Pediatric Urology ( IF 1.578 ) Pub Date : 2020-07-31 , DOI: 10.1016/j.jpurol.2020.07.034
Chrystal Chang,Christine White,Alan Katz,Moneer K Hanna

Introduction

Repeated and multiple surgeries for hypospadias result in varying degrees of scarring and hypovascularity of penile tissues which may result in poor healing and increasing complication rates with each additional repair. Vasodilator agents such as Nitroglycerine (NTG) can be helpful in the immediate postoperative period to improve flap viability. Hyperbaric oxygen therapy (HBOT) has well-established benefits to promote angiogenesis and wound healing. We hypothesized that NTG and HBOT, methods to promote blood flow and wound healing, would provide better outcomes in redo hypospadias surgeries and reduce complication rates; and, that HBOT and NTG would provide better outcomes compared to NTG alone.

Objectives

Herein, the authors review the results of their strategy of the past 5.5 years in managing these compromised hypovascular tissues using 2% NTG and HBOT for redo surgery of hypospadias.

Study design

Between 2014 and 2019, 82 patients (2–24 years old) exhibiting varying degrees of scarring of skin and subcutaneous tissues underwent re-operative repair of hypospadias complications following failed surgeries (3–9 operations, average 5.5 failed previous repairs). There were two groups of patients: Group I (49 patients) received trimodal therapy consisting of NTG, HBOT, and local steroids. The patients were examined every 3 weeks and every 3 months thereafter. The postoperative site was photographed by the parents or by the older patient prior to each visit. Group II (33 patients) received NTG and local steroids, but not HBOT for various reasons.

Results

In Group I: 44/49 (88.8%) of the repairs were successful. The complications in this group included a distal repair breakdown (n = 2) and urethral fistula (n = 3). In Group II, a successful outcome was noted in 23/33 (69.6%). The follow up of the 78 patients who completed their repairs varied between 5 months and 4 years. Results are highlighted in the table.

Discussion

In accordance to previously published data, the study results further support promising outcomes of application of NTG and HBOT to improve flap viability. Limitations include non-randomization of our treatment groups resulting in a retrospective evaluation of our protocol; and, the intrinsic heterogeneity of our patient population, previous surgical repairs, and scar tissues.

Conclusions

The proposed treatment of combining NTG and HBOT appears to result in reversal of tissue hypoxia and improved wound healing. This preliminary report shows improved outcomes with less morbidity in a group of patients with multiple hypospadias surgical failures and it warrants further application in a larger number of patients.

Summary Table. Single stage surgeries and complications.

Protocol (NTG + HBOT + local steroids)No protocol (NTG + local steroids)
45 patients33 patients
Repair of recurrent glans dehiscence [13]
Re-dehiscence 2/13
Repair of recurrent glans dehiscence [11]
Re-dehiscence 4/11
GTIP Urethroplasty [7]
Urethral fistula 2/7
GTIP Urethroplasty [8]
Glans Dehiscence & fistula 3/8
Urethral mobilization [6]
No complications
Urethral mobilization [9]
Distal breakdown 2/9
Repair of recurrent urethral fistula [10]
Recurrent fistula 1/10
Repair of recurrent urethral fistula [5] Recurrent fistula 2/5
Recurrent chordee & stricture [5] and skin scarring [4]
No complications



中文翻译:

使用血管扩张剂和高压氧在再手术和复杂尿道下裂修复中管理缺血组织和皮肤皮瓣。

介绍

尿道下裂的重复和多次手术导致阴茎组织不同程度的瘢痕形成和血管不足,这可能导致不良的愈合并增加每次修复的并发症发生率。血管扩张剂,例如硝酸甘油(NTG)在术后立即改善皮瓣活力方面可能会有所帮助。高压氧疗法(HBOT)具有公认的优势,可以促进血管生成和伤口愈合。我们假设NTG和HBOT是促进血液流动和伤口愈合的方法,将在重做尿道下裂手术中提供更好的结果并降低并发症发生率。与单独使用NTG相比,HBOT和NTG将提供更好的结果。

目标

在此,作者回顾了他们过去5.5年使用2%NTG和HBOT进行尿道下裂重做手术以管理这些受损血管组织的策略的结果。

学习规划

在2014年至2019年之间,对82名表现出不同程度皮肤和皮下组织瘢痕形成的患者(2-24岁)进行了手术失败后尿道下裂并发症的再次手术修复(3-9例手术,平均5.5例先前的修复失败)。有两组患者:第一组(49例患者)接受了三联疗法,包括NTG,HBOT和局部类固醇治疗。每3周检查一次患者,此后每3个月检查一次。每次访视前,由父母或年长的患者对术后部位进行拍照。第二组(33例患者)由于各种原因接受了NTG和局部类固醇治疗,但未接受HBOT治疗。

结果

在第一组中,修复成功的比例为44/49(88.8%)。该组的并发症包括远端修复失败(n = 2)和尿道瘘(n = 3)。在第二组中,成功的结果为23/33(69.6%)。78名完成修复的患者的随访时间在5个月至4年之间。结果在表中突出显示。

讨论区

根据先前发表的数据,该研究结果进一步支持了NTG和HBOT应用于改善皮瓣生存力的有希望的结果。局限性包括我们治疗组的非随机性,导致对我们方案的回顾性评估;以及我们患者群体的固有异质性,先前的手术修复和疤痕组织。

结论

NTG和HBOT联合治疗的提议似乎可以逆转组织缺氧并改善伤口愈合。这份初步报告显示,在患有多个尿道下裂手术失败的患者中,改善的结果和较少的发病率,因此有必要在更多的患者中进一步应用。

汇总表。单阶段手术和并发症。

协议(NTG + HBOT +局部类固醇)无协议(NTG +局部类固醇)
45位患者33位患者
复发性龟头裂开的修复[13]
再裂开2/13
复发性龟头裂开的修复[11]
再裂开4/11
GTIP
尿道成形术[7]尿道瘘2/7
GTIP尿道成形术[8]
龟头裂开和瘘管3/8
尿道动员[6]
无并发症
尿道动员[9]
远端故障2/9
复发性尿道瘘的修复[10]
复发性瘘1/10
复发性尿道瘘的修复[5]复发性瘘2/5
反复性脊柱狭窄和狭窄[5]和皮肤疤痕[4]
没有并发症

更新日期:2020-07-31
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