保留黏膜的经前庭手术入路切除前尿道平滑肌瘤：病例报告及文献复习

文献信息

中文摘要

引言与假设： 尿道平滑肌瘤是罕见的良性平滑肌肿瘤。目前已报道约40例记录完整的病例，其中大多数起源于后尿道壁，该部位暴露相对容易。前壁病变因邻近外尿道括约肌、尿道周围筋膜和前庭黏膜而带来手术困难，必须保留所有这些结构以避免尿道阴道瘘和压力性尿失禁。我们假设，保留黏膜的经前庭入路可实现安全切除，同时保留尿道完整性和控尿功能。
方法： 一名39岁初产妇，有6个月会阴部尿道肿块伴压痛及间歇性性交后点滴出血病史。检查发现一个3 cm的前尿道肿块使外尿道口变形。盆腔MRI显示一个2.7 cm、边界清楚的前远端尿道肿块，似有尿道壁受累。麻醉下检查、膀胱尿道镜检查和芯针活检证实为平滑肌瘤。通过保留黏膜的经前庭入路切除病变，术中行导管触诊、包膜分离、分层尿道重建及中段尿道括约肌重新对合。
结果： 切除了一个3 cm的前尿道平滑肌瘤，伴局灶性尿道相通。出血量极少；无术中并发症。经尿道导管留置21天。排尿性膀胱尿道造影证实尿道完整，无瘘管；患者控尿。组织病理学证实为良性平滑肌瘤（SMA阳性、desmin阳性、MIB-1 < 1%）。
结论： 前尿道平滑肌瘤是女性会阴部肿块的重要鉴别诊断。保留黏膜的经前庭技术可提供极佳的前尿道暴露，同时保留前庭黏膜和尿道周围筋膜，从而降低尿道阴道瘘和术后尿失禁的风险。

英文摘要

INTRODUCTION AND HYPOTHESIS: Urethral leiomyomas are rare benign smooth-muscle tumors. Approximately 40 well-documented cases have been reported, most arising from the posterior urethral wall where exposure is relatively straightforward. Anterior wall lesions pose surgical difficulty because of proximity to the external urinary sphincter, periurethral fascia, and vestibular mucosa, all of which must be preserved to avoid urethrovaginal fistula and stress urinary incontinence. We hypothesized that a mucosa-sparing trans-vestibular approach would allow safe excision with preservation of urethral integrity and continence.
METHODS: A 39-year-old para-1 woman presented with a 6-month history of a tender peri-meatal urethral mass and intermittent post-coital spotting. Examination revealed a 3 cm anterior urethral mass distorting the external urethral meatus. Pelvic MRI demonstrated a 2.7 cm well-circumscribed anterior distal urethral mass with apparent urethral wall involvement. Examination under anesthesia, cystourethroscopy, and core biopsy confirmed leiomyoma. The lesion was excised via a mucosa-sparing trans-vestibular approach with intraoperative catheter palpation, capsular dissection, layered urethral reconstruction, and mid-urethral sphincter re-approximation.
RESULTS: A 3 cm anterior urethral leiomyoma with focal urethral communication was excised. Blood loss was minimal; there were no intraoperative complications. A transurethral catheter was maintained for 21 days. Micturating cystourethrogram confirmed an intact urethra without fistula; the patient was continent. Histopathology confirmed benign leiomyoma (SMA-positive, desmin-positive, MIB-1 < 1%).
CONCLUSIONS: Anterior urethral leiomyomas are an important differential in women with a peri-meatal mass. The mucosa-sparing trans-vestibular technique provides excellent anterior urethral exposure while preserving vestibular mucosa and periurethral fascia, thereby reducing the risk of urethrovaginal fistula and postoperative incontinence.