口腔粘膜移植在阴道再造术中的应用

【摘 要】 目的 探讨口腔粘膜移植在阴道再造术中的应用疗效。方法 2007 年3 月- 2009 年4 月,收治400 例先天性无阴道患者。年龄13 ~ 45 岁,平均27岁。患者第二性征发育正常,阴道前庭处未探及阴道或仅有浅凹陷,双侧卵巢正常,激素水平正常,染色体均为46,XX。腔内B超显示均为无子宫或始基子宫。术中取患者双侧颊部粘膜6.0cm × 2.0cm,将其切割成网状皮片,蒙在棉质模具顶端。置于直肠与尿道之间的阴道再造腔穴。结果 阴道再造术手术时间为1 ~ 2 h,术中出血50~100mL。2例尿道损伤,5例直肠损伤,均于再次修补后成功。其余393例均无术后并发症发生。400例均获随访,随访时间4个月 ~ 4年。再造阴道深10 ~ 15cm,粘膜光滑红润,弹性好,近阴道外口处阴道壁可见皱襞,病理检查示复层鳞状上皮。外阴外观与正常女性相似,无手术瘢痕。口腔内供粘膜区域无继发畸形。本组无并发症患者均于术后一个月后开始性生活或使用电动仿真模具,均未出现疼痛、出血。有并发症患者经修补术后,均可正常性生活。结 论 口腔粘膜移植阴道再造术,阴道粘膜逼真,创伤小,口腔及外阴形态无破坏,使阴道再造手术以假乱真。

  【关键词】 先天无子宫无阴道 口腔粘膜 自体移植阴道再造

  CLINICAL APPLICATION OFAUTOLOGOUS BUCCAL MUCOSA GRAFT IN VAGINALRECONSTRUCTION

  Chen Fenglin, Chen Shuo

  Gynecology Department, BeijingAnti Hospital

  【Abstract】 Objective Toinvestigate the effect of vaginal reconstruction with autologous buccal mucosa graft.Methods From March 2005 and April 2009, 400patients with absence of vagina were treated, aged 13-45 years (mean 27 years).All of them were congenital absence of vagina. They all exhibited normalsecondary sexual characteristics, normal hormonal levels and 46, XX karyotype.Their Rectum ultrasounography revealed the normal ovaries and tubes but absenceof the uterus or small rudimentary horns. The buccal mucosa graft was cliped tothe flap with mesh and was transplanted to the cavity which was dissectedbetween the bladder and the rectum. Results Theoperation was performed successfully in all cases. The operative time was about1-2 hours and operative blood loss was 50-100mL. Two cases of Urethral injuryand five cases of rectal injury were taken after the successful re-repair. Thepatient recovered and the wound healed well after immediate management. The othershealed primarily without any complications. All cases were followed up for 4months to 4 years. The depth of neovagina which was formed was 10-15cm and thewidth was about two fingers. The lining was pink-colored and smooth, and wasconfirmed as nonkeratizing squamous stratified mucosa by histopathologicalexamination. The donor sites healed uneventfully with no change in mouthopening. The perineal area was not disturbed. All of patients were satisfiedwith their sexual life and electrical simulation of penis without pain andbleeding. Conclusion Vaginal reconstruction with autologous buccalmucosa graft is a vaginal mucous membrane realistic, minimally invasive anduseful method.

  【Keywords】 Absence ofvagina Buccal mucosa Mucosa graft Vaginal reconstruction

  先天性无阴道、阴道闭锁及后天的各种损伤、肿瘤切除后的盆腔清扫和放射治疗等造成的阴道缺如或缺损,以及男性要求女性化者等均需阴道再造。目前,临床上阴道再造主要采用墙角阴道复位术、乙状结肠、腹膜或脱细胞真皮[1-8],但均有其缺点。2005 年3 月-2009 年4 月,我们应用口腔粘膜游离移植再造阴道400 例,疗效满意。报告如下。

  11 临床资料

  1.1 一般资料

  本组患者均为女性,年龄13 ~ 45 岁,平均27 岁。均为先天性无子宫无阴道。入院检查:患者乳房、外阴发育良好,阴蒂及尿道外口正常;其中167 例在阴道前庭部可见约4 ~ 5 cm 浅凹陷,无处女膜。肛诊时均未触及子宫或宫颈,激素水平正常。染色体检查均为46,XX。

  400 例先天性无子宫无阴道患者的腔内B 超检查示两侧均有正常卵巢,无子宫或仅有始基子宫。

  1.2 手术方法

  1.2.1手术在气管插管全身麻醉下进行,口腔粘膜取材 0.5% 聚维酮碘溶液消毒口腔,确定腮腺导管开口位置防止手术损伤。于颊部切取粘膜,自嘴角纵向切开2cm,深达粘膜下层,用组织剪潜行分离粘膜,大小为6.0 cm × 2.0 cm,切下粘膜,厚度> 1 mm,浸泡于生理盐水中备用,创面横向3/0可吸收线缝合。同法取另一侧颊部口腔黏膜。

  1.2.2 阴道造穴,取截石位,于尿道外口置入双腔气囊导尿管并留置导尿。于阴道前庭相当于阴道外口的陷窝或浅凹处,注射300 mL 肾上腺素生理盐水膨胀液。在阴道前庭相当于阴道外口的浅凹中央呈U 形或X 形切开,长约5 cm,钝性分离尿道和直肠间隙,直达盆底,墙角阴道或子宫下缘,宽度可容两横指。将口腔粘膜切成渔网状套在用避孕套和棉棒制成的模具上,置于穴腔内。

  1.3 术后处理

  术后不用禁食,先用吸管吸吮牛奶糖水和果汁,常规应用抗生素3 d,术后2 d拔除尿管,术后9 d 更换模具后即可出院。以后每日冲洗阴道1 次,至腔穴创面完全被粘膜覆盖。术后1 个月,如无再造阴道出血、破溃等并发症出现,即可接种正常阴道菌苗,同时可正常性生活或使用电动仿真模具。一般要连续佩戴6 个月棉质模具,鼓励性生活。

  2 结果

  阴道成形术手术时间为1 ~ 2 h,术中出血80 ~ 100 mL。2 例因包扎压力不足,于术后1 d 继发出血,经清除模具内血凝块,重新放入模具,并用紧身裤衩束缚会阴部,未再出血。阴道再造术手术时间为1 ~ 2 h,术中出血50~100mL。2例尿道损伤,5例直肠损伤,均于再次修补后成功。其余393例均无术后并发症发生。400例均获随访,随访时间4个月 ~ 4年。再造阴道深10 ~ 15 cm,粘膜光滑红润,弹性好,近阴道外口处阴道壁可见皱襞,病理检查示复层鳞状上皮。外阴外观与正常女性相似,无手术瘢痕。口腔内供粘膜区域无继发畸形。本组无并发症患者均于术后一个月后开始性生活或使用电动仿真模具,均未出现疼痛、出血。有并发症患者经修补术后,均可正常性生活。外阴外观与正常女性一样,无手术瘢痕。口腔内供粘膜区域无继发畸形,张口不受限,感觉正常。320例已婚妇女中男方性生活都较满意,均未出现性交时疼痛、出血。余未婚者均用仿真模具,等同性生活。

  4 讨论

  先天性无阴道的发病率约为1/4 000[9],严重影响患者的心理和生活质量。自1817 年Dupuytrein 采用单纯会阴造穴首次施行阴道再造以来[10],阴道再造方法发展较多,包括植皮法、皮瓣法及应用肠管再造阴道等[3-10]。但真正能够维持终生的只有肠管代阴道和脱细胞真皮两种。异体移植和腹膜代阴道只能充当暂时性覆盖物[11]。我们拟采用口腔粘膜移植再造阴道,旨在寻找一个简便实用、并发症少、副损伤小、外形满意,且术后护理方便的治疗方法。通过对粘膜移植的研究[13-16]。

  4.1 粘膜移植的优点①取材方便、取材量少。我们在患者双侧颊部各切取6.0 cm × 2.0 cm 粘膜组织,取材处创面给予缝合,愈合后无明显瘢痕,早期张口稍小,6个月左右开口如初,且术后外阴部无明显瘢痕。②手术简便。再造腔穴剥离后,仅需将切取的粘膜网织化,放在棉质模具上,挺入造穴腔顶端,外阴不用缝合。本组该过程需约30 min.③ 术后护理方便。术后9 d 更换模具,即可观察到模具下粘膜生长情况,保留模具,仅需每日洗必泰冲洗腔穴1 次,即可出院。④再造材料理想。正常阴道壁的浅层组织即为粘膜,我们应用口腔粘膜从组织学方面更贴近正常的阴道组织,术后功能恢复迅速[17]。

  4.2 阴道造学

  在阴道再造术中关键环节是阴道造穴。由于造穴部位前面紧邻尿道后壁,后面紧邻直肠前壁,较易损伤。我们出现两例尿路损伤和直肠损伤。经过一次修复成功。

  4.3 术后处理

  术后再造阴道挛缩和术后换药也是需注意事项。各种阴道再造术后均要求有一阴道模具支撑再造阴道。既往多采用木材、橡胶及玻璃等模具材料,对组织刺激性强,硬度高,并且无引流作用,再造阴道常发生感染坏死而导致手术失败[18]。为此,我们设计了新型棉质模具,起支撑作用,减轻患者不适感,利于长久佩带,也便于更换及冲洗再造阴道。再造阴道大部分粘膜化可以性生活或用电动仿真模具,保证了手术远期效果。我们采用口腔粘膜再造阴道的方法手术简便,效果可靠,副损伤小,外形满意,术后护理方便。缩短手术时间,降低了手术风险,为阴道再造提供了一种新的技术方法和手段。

  5 参考文献

  1 Akn S. Experience with neovaginal constructionusing the full-thicknessskin graft in vaginal agenesis. Ann Plast Surg, 2004,52(4): 391-396.

  2 Wee JT, Joseph VT. A new technique of vaginalreconstruction usingneurovascular pudendal-thigh flaps: a preliminary report.Plast ReconstrSurg, 1989, 83(4): 701-709.

  3 李森恺, 刘元波, 李养群, 等. 阴股沟皮瓣阴道再造术12例分析. 中华妇产科杂志,2000, 35(4): 216-218.

  4 朱飞, 宁金龙, 李小静, 等. 改进的薄型阴股沟皮瓣再造阴道. 中国美容医学, 2006, 15(5): 525-526.

  5 Parsons JK, Gearhart SL, Gearhart JP. Vaginalreconstruction util izingsigmoid colon: compl ications and long-term results. JPediatr Surg,2002, 37(4): 629-633.

  6 Imparato E, Alfei A, Aspesi G, et al. Long-term results of sigmoid vaginoplastyin aconsecutive series of 62 patients. Int rogynecol J PelvicFloor Dysfunct, 2007,18(12): 1465-1469.

  7 Fedele L, Bianchi S, Frontino G, et al. The laparoscopic Vecchietti’smodified technique inRokitansky syndrome: anatomic, functional, and

  sexual long-term results. Am J Obstet Gynecol,2008, 198(4): 377. e1-6.8 Michala L, Cutner A, Creighton SM. Surgicalapproaches to treatingvaginal agenesis. BJOG, 2007, 114(12): 1455-1459.

  9 Evans TN, Poland ML, Boving RL. Vaginalmalformations. Am J ObstetGynecol, 1981, 141(8): 910-920.

  10 Goldwyn RM. History of attempts to form avagina. Plast ReconstrSurg, 1977, 59(3): 319-329.

  11 Jackson ND, Rosenblatt PL. Use of intercedeAbsorbable AdhesionBarrier for vaginoplasty. Obstet Gynecol, 1994, 84(6):1048-1050.

  12 Panici PB, Bellati F, Boni T, et al. Vaginoplasty using autologous invitro cultured vaginal tissue in a patient withMayer-von-Rokitansky-Kuster-Hauser syndrome. Human Reprod, 2007, 22(7):2025-2028.

  13 Lin WC, Chang CY, Shen YY, et al. Use of autologous buccal mucosa forvaginoplasty: astudy of eight cases. Human Reprod, 2003, 18(3): 604-607.

  14 Zhang ML, Wang CY, Chang ZD, et al. Microskin grafting. II. Clinicalreport. Burns InclTherm Inj, 1986, 12(8): 544-548.

  15 Gümüş N, Kaya Y, Karakaya S, et al.Skin defect coverage with microskin graft. Ulus Travma Derg, 2002, 8(2): 78-81.

  16 Cheung LK. The epithel ial ization process inthe heal ing temporal ismyofascial flap in oral reconstruction. Int J OralMaxillofac Surg, 1997,26(4): 303-309.

  17 Simman R, Jackson IT, Andrus L. Prefabricatedbuccal mucosa-l inedflap in an animal model that could be used for vaginalreconstructionPlast Reconstr Surg, 2002, 109(3): 1044-1049.

  18 Görgü M, Erdoğan B, Aköz T, et al.Silicone gel sheeting for stabil izationof skin grafts. Dermatol Surg, 1998,24(10): 1073-1076.

  1作者单位:北京安太医院妇科(北京,100067)

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