男性前尿道狭窄：腔内治疗疗效如何？最新循证依据一览（上）
背景与目的
腔内治疗被频繁用于男性前尿道狭窄（urethral strictures, USs）。本文旨在总结当前评估各种治疗方法临床意义的证据。流行病学、诊断、开放手术治疗及随访等内容超出本文范围，请参阅完整版指南（Lumen等，2026年）。
方法
通过先验标准识别新的证据，对筛选文献进行总结，并制定推荐意见以优先考虑临床重要决策。
主要发现与局限性
直视内切开术（DVIU）安全有效，针对较短、初治球部尿道狭窄成功率更高。尿道成形术后出现的短段复发性狭窄可以采用DVIU处理。单次扩张与DVIU效果相似，视觉引导下扩张并发症更少。间歇性自我扩张（self-dilatation）可稳定狭窄、延迟复发。
结论与临床意义
男性前尿道狭窄的腔内治疗安全，在特定情况下可提供良好的长期通畅率。对于希望接受微创治疗但不追求长期成功的患者，腔内治疗是一种替代选择。应与患者充分讨论各治疗选项，在有指征时转诊行尿道成形术。
实践进展：本研究的贡献
本文制定了男性前尿道狭窄内镜治疗选项的临床指南，讨论了预期的风险和成功率，以协助治疗方案制定。
患者概要
本文评估了男性前尿道狭窄的各种治疗方法。扩张或内切开术对短段狭窄是适合的选择，并发症少。新技术（激光切开、药物涂层球囊扩张）可能更具优势。应与临床医师充分讨论，避免无效治疗。
前尿道狭窄（urethral strictures, USs）通常采用腔内治疗。为改善腔内技术的疗效，研究人员测试了多种药物，通过不同途径给药，包括导管内软膏和切开术中注射。近年来，开发了一种药物涂层球囊，可在尿道扩张（urethral dilatation, UD）时释放紫杉醇（paclitaxel）以减少瘢痕形成。
在2026年尿道狭窄指南更新工作中，通过结构化文献评估识别新证据。对Medline、EMBASE和Cochrane数据库进行了全面文献检索，涵盖指南所有章节，时间范围为2022年4月至2025年4月。腔内治疗章节的先验纳入标准为：系统综述（systematic reviews, SRs）、≥20例患者的随机对照试验（randomized controlled trials, RCTs）及≥50例患者的前瞻性研究。
详细的检索策略可在线查阅（https://uroweb.org/guideline/urethral-strictures/）。新证据经专家组成员汇总讨论，制定推荐意见，以优先考虑临床重要护理决策。每条推荐意见的强度由替代治疗策略的利弊权衡、证据质量（包括估计的确定性）以及患者价值观和偏好的性质与变异性共同决定。
目前，“冷刀”直视内切开术（direct vision internal urethrotomy, DVIU）有两个指征。
第一个指征是作为新近诊断尿道狭窄的初始治疗。在唯一的高级别证据研究中，210例非闭塞性狭窄（位于各尿道节段）患者被随机分配至导丝扩张或DVIU组，均在局部麻醉（local anesthesia, LA）下进行。该研究通过逆行尿道造影在7次随访中收集客观数据，随访长达48个月。结果显示UD与DVIU在所有时间点的通畅率相似；12个月时，短段狭窄（<2cm）的通畅率为55%，长段狭窄（≥2cm）为20%。
第二个指征是先前治疗失败后的复发性狭窄。OPEN试验纳入至少一次DVIU、UD或尿道成形术失败的患者，将患者随机分配至尿道成形术（108例）或DVIU（112例）组，随访24个月，尽管入组困难。两组患者的LUTS评分均有相似改善。然而，尿道成形术组患者Qmax改善>10 ml/s的可能性比DVIU组高2.35倍（OR=2.35；95%CI=1.27～4.35）；尿道成形术组再治疗率为15.7%，DVIU组为39.3%。
多个研究组尝试识别“冷刀”DVIU初始治疗失败的预后因素（见表1）。近期一项系统综述将狭窄长度确定为复发的主要因素，其他风险因素包括既往干预史和术前Qmax<5ml/s。
| 作者 | 位置 | 长度 | 口径 | 既往DVIU |
|---|---|---|---|---|
一项系统综述报告“冷刀”DVIU总体并发症发生率为6.5%（见表2）。其中，勃起功能障碍（erectile dysfunction, ED）发生率为5.3%。阴茎尿道狭窄通畅率差，ED风险高，因此不建议对阴茎尿道狭窄行DVIU。
| 研究/并发症 | “冷刀”DVIU (%) | 激光DVIU (%) | P值 |
|---|---|---|---|
| Jin等 | |||
| Yenice等 | |||
| Jiangang Chen等 | |||
| Ali等 | |||
| Akdemir等 | |||
3.2 “热刀”DVIU
可用于泌尿外科的激光包括掺钕钇铝石榴石（neodymium-doped yttrium aluminum garnet, Nd:YAG）、氩、钬:YAG、磷酸氧钛钾（potassium titanyl phosphate, KTP）和铥:YAG。两项系统综述及专家组范围搜索新识别的5项RCT分别对比了“冷刀”与“热刀”DVIU（见表3）。
| 作者 | 研究类型 | 患者数/狭窄特征 | 随访时间 | 结局指标 | 结果 |
|---|---|---|---|---|---|
等离子（双极）内切开术亦被提出。Cecen等进行了一项比较等离子与“冷刀”DVIU（n=136）的RCT。9个月时通畅率分别为86%和70%，18个月时分别为63%和67%。一项关于初发狭窄<2cm的前瞻性队列研究报告，12个月时等离子内切开术通畅率为77%（23/30），“冷刀”DVIU通畅率为83%（25/30）。
关于“冷刀”与“热刀”DVIU并发症，一项RCT系统综述中，仅1/4系列报告了并发症。激光尿道切开术（laser urethrotomy, LU）中，8.9%的并发症率源于会阴造影剂外渗和尿道狭窄复发；“冷刀”DVIU中，15.5%的并发症率与出血有关。一项回顾性病例系列系统综述显示，激光DVIU并发症发生率约为“冷刀”DVIU的两倍。
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[1]中华医学会妇产科学分会妇科盆底学组. 女性压力性尿失禁诊断和治疗指南(2017)[J]. 中华妇产科杂志,2017(5).
声明：本内容仅供医学药学专业人士阅读，不构成实际治疗建议。转载请后台联系授权，侵权必究！ 编辑：吴梦霞 审核：黄鹏程