尿道下裂表型不一致的同卵双胞胎的外显子组测序研究及尿道下裂术后尿瘘的整形外科修复

发布时间：2018-01-15 16:27

本文关键词：尿道下裂表型不一致的同卵双胞胎的外显子组测序研究及尿道下裂术后尿瘘的整形外科修复　出处：《北京协和医学院》2017年博士论文　论文类型：学位论文

【摘要】：第一部分:尿道下裂表型不一致的同卵双胞胎的外显子组测序研究背景与目的尿道下裂是常见的泌尿生殖系统畸形之一,但大多数患者无法找到明确的病因。目前的研究提示多种环境及遗传因素均与尿道下裂发病相关,复杂多样的致病机制为尿道下裂的病因学研究带来困难。本中心收治了两名尿道下裂患者,其各自的同卵双胞胎兄弟泌尿生殖系统发育完全正常,导致两者表型差异的可能原因之一是患者基因在受精卵分裂为两个独立胚胎后发生了突变。本研究通过应用外显子组测序技术对此假设进行验证,以期为尿道下裂的分子遗传致病机制研究提供线索。方法从两对尿道下裂表型不一致的同卵双胞胎的外周血提取DNA样品,经外显子组测序后,通过严格的生物信息学筛选得出可疑的致病变异,并通过Sanger测序进行验证。结果4个SNV和4个InDel通过筛选成为可疑变异,其中1个InDel为两名患者所共有,但经Sanger测序验证后均为阴性结果。结论本研究未能在外显子组找到可能导致两对同卵双胞胎尿道下裂表型不一致的基因变异,表观遗传差异等其他的分子遗传致病机制或可能为潜在的原因。第二部分:尿道下裂术后尿瘘的整形外科修复背景尿道皮肤瘘(简称“尿瘘”)是尿道下裂术后最为常见的并发症之一。尿瘘复杂的临床表现为手术方法的选择带来困难,尿痿直径、位置、个数及其他并发症情况均可对手术方法的选择产生影响,并可能成为影响手术结果的危险因素。如何合理地根据各种临床表现选择修复方式是尿瘘治疗的难点,目前临床上仍主要依赖手术医师的个人经验进行判断,既往相关研究在样本量或研究方法上存在一定局限,亟待补充系统性的回顾及总结。第一节尿瘘的整形外科修复策略目的通过回顾本中心接诊的尿道下裂术后尿瘘患者的相关临床资料,总结本中心在选择手术方法上的经验及策略,并提出尿瘘手术路径图。方法回顾性分析2005年1月至2015年12月因尿道下裂术后尿瘘而接受手术修复的患者,统计包括患者年龄、初始尿道下裂类型、瘘口直径、位置、个数、除尿瘘外其他并发症的类型、所采取的手术方法及治疗结果等多项参数,通过手术路径图的方式对修复策略进行总结。结果排除41名失访患者后,共有232名患者纳入研究。118例患者(50.9%)初始的尿道下裂类型为近端型,123例患者(53.0%)有至少一个直径大于或等于2mm的瘘口,74例患者(31.9%)存在多个瘘口,98例患者(42.2%)除尿瘘外存在其他并发症。177名患者(76.3%)在随访期间内无尿道相关并发症。结论处理尿道下裂术后尿瘘时,应综合瘘口直径、位置、个数、局部组织条件及合并并发症类型后个性化地采用相应的手术方式进行修复。对于单纯尿瘘的患者,无张力地关闭瘘口及应用血运良好的组织多层次地覆盖是修复成功的关键。对于合并阴茎弯曲、尿道中段狭窄及近端异位尿道外口的病例,应考虑分期重做尿道下裂的可能性。研究中提出的手术路径图可为尿瘘手术的规范化治疗提供参考。第二节尿瘘修复术的危险因素分析目的应用合适的统计学分析方法对本中心接受尿瘘修复术的患者的临床资料进行回顾分析,探讨影响尿瘘修复术成功率的潜在危险因素。方法回顾性分析2005年1月至2015年12月因尿道下裂术后出现尿瘘而接受修复术的患者,以随访期内无复瘘或其他尿道相关不良事件为手术成功的定义,统计分析患者年龄、瘘口直径、瘘口位置、瘘口个数、尿瘘修复次数、是否合并其他并发症及是否存在术后感染与尿瘘修复术成功率的关系。结果排除55例行分期手术重建尿道的患者及33例失访患者后,共185例患者纳入研究,147例患者(79.5%)手术取得成功。在单因素分析中,瘘口直径(p=0.012)、尿瘘修复次数(p=0.008)与术后感染(p=0.044)与尿瘘修复术的成功率相关。多因素非条件Logistic回归分析显示,瘘口直径(校正OR=2.42,p=0.030)与尿瘘修复次数(校正OR=3.09,p=0.008)是尿瘘修复术的两个独立危险因素,进一步的分析提示两个危险因素间不存在混杂、效应修饰作用或交互作用。结论本研究提示,瘘口直径和修复次数是尿瘘修复术的两个独立的危险因素,当瘘口直径大于或等于2mm时,手术失败的风险相对提高了 2.42倍;当患者多次接受尿瘘修复术时,该风险提高了 3.09倍;但当两个危险因素同时存在时,该风险的上升并不显著。临床上在处理相关病例时,应更为谨慎并注意采取相应的保护措施。
[Abstract]:The first part: identical twins hypospadias phenotype inconsistent genome sequencing research background and purpose of hypospadias deformity of the urogenital system is common, but most patients are unable to find a clear etiology. The present study suggests that many environmental and genetic factors were associated with hypospadias, difficult pathogenesis is complicated the etiology of hypospadias. We treated two patients with hypospadias, the identical twin of the genitourinary system development is completely normal, leading to both phenotypic differences can be one of the reasons is that patients with gene in zygote is divided into two independent embryos after mutation. In this study, through the application of explicit this sub group sequencing hypothesis verification, in order to provide clues for the study of molecular genetic pathogenesis of hypospadias. Methods from two for hypospadias Discordant monozygotic twins with peripheral blood samples of DNA isolated by exome sequencing, biological information through strict screening the suspicious pathogenic mutation, which was verified by Sanger sequencing. The results of 4 SNV and 4 InDel by screening become suspicious variation, of which 1 InDel two in total, but by Sanger after sequencing showed negative results. Conclusion this study failed to find exomes may lead to two pairs of monozygotic twins discordant for hypospadias genetic mutation, epigenetic differences and other molecular genetic pathogenesis or may be potential reasons. The second part: the urethra hypospadias fistula plastic surgery repair background urethrocutaneous fistula ("fistula") is after hypospadias surgery is one of the most common complications. Clinical manifestations of urinary fistula complicated difficult for the choice of surgical methods, urinary fistula The diameter, location, impact number and other complications can be the operation method choice, and may be the risk factors affecting the surgical results. How to reasonably according to various clinical manifestations of choice of repair of urinary fistula treatment is difficult, there are still mainly depends on the surgeon's personal experience through judgment, previous relevant research in the quantity of samples or research methods there are certain limitations, to supplement the review and summarization system. The first section of plastic surgery to repair strategy by reviewing the admissions center of urinary fistula after hypospadias repair of urinary fistula were related to clinical data, summarize the experience and strategy in the choice of surgical methods on the center, and put forward the operation path of urinary fistula figure. Methods a retrospective analysis from January 2005 to December 2015 because of urinary fistula after hypospadias underwent surgical repair of patients, including patients with early age statistics. Only the type of hypospadias, fistula diameter, location, number, type and other complications except for urinary fistula, a number of parameters to the surgical methods and results of treatment, to repair strategy summed up through the operation path graph. The results excluding the 41 patients lost to follow-up, a total of 232 patients were included in the study.118 patients (50.9%) the initial type of hypospadias were proximal type, 123 patients (53%) had at least one diameter greater than or equal to 2mm fistula, 74 patients (31.9%) there are multiple fistula, 98 patients (42.2%) in the presence of other fistula complications in.177 patients (76.3%) no urethral related complications during the follow-up period. Conclusion the treatment of postoperative urinary fistula, fistula diameter should be comprehensive, position, number, condition and complication of local tissue after using personalized type of surgical repair for simple urinary fistula patients, no one To close the fistula and the application of good blood supply organization multi-level coverage is the key to the successful repair. For patients with penile curvature, mid urethral stricture and proximal ectopic urethral orifice cases, should consider the possibility to redo the staging of hypospadias. Provide reference for the standardized treatment of surgical path for urinary fistula surgical repair of the second section. The risk factors of urinary fistula were retrospectively analyzed clinical data were analyzed using appropriate statistical analysis methods to the center for repair of urinary fistula, the potential risk factors of urinary fistula repair success rate. Methods: a retrospective analysis of patients from January 2005 to December 2015 due to urinary fistula occurred after hypospadias surgery received repair, in the follow-up period no other urethral fistula or related adverse event was the definition of success, statistical analysis of the age of patients, the diameter of the fistula, The location of fistula, fistula number, urinary fistula repair times, if combined with other complications and whether postoperative infection rate and urinary fistula repair. Results 55 cases excluded surgical staging of urethral reconstruction and 33 patients lost to follow-up patients, a total of 185 patients were included in the study, 147 patients (79.5%) surgery success. In univariate analysis, the fistula diameter (p=0.012), urinary fistula repair times (p=0.008) and postoperative infection (p=0.044) associated with urinary fistula repair success rate. Non conditional Logistic regression analysis showed that the diameter of fistula (adjusted OR=2.42, p=0.030) and OR=3.09 (the number of fistula repair correction. P=0.008) is the two independent risk factors of urinary fistula repair, further analysis showed that two risk factors do not exist between hybrid, modified the effect or interaction. Conclusion this study indicates that the diameter of fistula and urinary fistula repair repair times is two Independent risk factors, when the diameter is greater than or equal to 2mm, the relative risk of surgical failure is increased by 2.42 times; when the patient repeatedly accepted repair of urinary fistula, the risk increased by 3.09 times; but when the two risk factors existing at the same time, the increased risk is not significant. In the clinical treatment cases, should be more cautious and take corresponding measures to protect them.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R699.6

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