李茂林 卓棟 章靜 王治國 敖平

1皖南醫(yī)學(xué)院附屬弋磯山醫(yī)院泌尿外科 241001 安徽蕪湖

微創(chuàng)技術(shù)治療婦科手術(shù)后輸尿管損傷(附33例報(bào)告)

李茂林1卓棟1章靜1王治國1敖平1

1皖南醫(yī)學(xué)院附屬弋磯山醫(yī)院泌尿外科 241001 安徽蕪湖

目的：探討婦科手術(shù)導(dǎo)致輸尿管損傷行輸尿管鏡和腹腔鏡治療的安全性及有效性。方法：回顧性分析2008年1月～2016年6月婦科手術(shù)發(fā)生輸尿管損傷并微創(chuàng)治療的33例患者臨床資料。平均年齡45(20～69)歲。術(shù)中發(fā)現(xiàn)輸尿管損傷5例，即刻使用腹腔鏡或膀胱鏡置入雙J管，腹腔鏡下輸尿管修補(bǔ)縫合或輸尿管端端吻合；術(shù)后延遲發(fā)現(xiàn)輸尿管損傷28例，其中1例為孤立腎患者，術(shù)后8 h發(fā)現(xiàn)引流液量異常多并行輸尿管鏡檢查，見輸尿管下段局部缺損，予置入雙J管并腹腔鏡下修補(bǔ)輸尿管。其余均在術(shù)后7～35 d出現(xiàn)陰道殘端漏尿。先行輸尿管鏡直視下置入雙J管，置管成功16例，予以留置2～3個(gè)月。失敗11例患者行腹腔鏡探查。若損傷位置低，輸尿管與膀胱直接插入吻合。若損傷位置高，則游離裁剪膀胱壁瓣并縫合成管狀與輸尿管吻合。結(jié)果：16例術(shù)后延遲發(fā)現(xiàn)輸尿管損傷并成功置入雙J管，有1例患者長期漏尿，3個(gè)月后再行腹腔鏡手術(shù)成功，其余膀胱鏡下拔除雙J管無漏尿的發(fā)生。11例置管失敗的患者均一期行腹腔鏡修復(fù)手術(shù)成功。手術(shù)耗時(shí)110～160 min，平均132 min。術(shù)后住院5～8 d，平均6 d，予以保留導(dǎo)尿3～4周，術(shù)后4～8周膀胱鏡下拔除雙J管。全部病例術(shù)后3～6個(gè)月行B超檢查提示輕度腎積水。結(jié)論：婦科手術(shù)致輸尿管損傷可置入雙J管，置管成功經(jīng)保守治療效果理想。置管后保守治療失敗可行腹腔鏡治療，雖然具有一定挑戰(zhàn)，但安全有效，相比傳統(tǒng)手術(shù)具有創(chuàng)傷小、瘢痕少、術(shù)后恢復(fù)快等優(yōu)勢，可最大限度地減少患者心理負(fù)擔(dān)，避免醫(yī)患糾紛的發(fā)生。

微創(chuàng)技術(shù)；婦科手術(shù)；輸尿管損傷

女性生殖系統(tǒng)與輸尿管位置毗鄰。在女性生殖系統(tǒng)相關(guān)手術(shù)治療時(shí)可能會(huì)因解剖變異、術(shù)中操作不當(dāng)或術(shù)者經(jīng)驗(yàn)不足等造成輸尿管不同程度的損傷。既往對(duì)于輸尿管損傷后保守治療失敗的患者多采用開放二次手術(shù)，該類手術(shù)創(chuàng)傷較大、術(shù)后恢復(fù)時(shí)間長。短期內(nèi)連續(xù)手術(shù)易引起患者及家屬的不滿，容易導(dǎo)致醫(yī)患糾紛。近年來輸尿管損傷治療已逐步從開放修復(fù)手術(shù)到微創(chuàng)治療，如輸尿管支架置入術(shù)、腹腔鏡下支架置入修補(bǔ)術(shù)、腹腔鏡輸尿管斷端再吻合術(shù)以及輸尿管膀胱再植術(shù)[1]。本研究回顧性分析2008年1月～2016年6月我院婦科手術(shù)發(fā)生輸尿管損傷并行微創(chuàng)技術(shù)治療的33例患者臨床資料，現(xiàn)將結(jié)果報(bào)告如下。

1 資料與方法

1.1 臨床資料

本組患者33例，年齡20～69歲，平均45歲。腹腔鏡惡性腫瘤手術(shù)15例，腹腔鏡輔助陰式全子宮切除術(shù)8例，腹腔鏡子宮肌瘤切除6例，腹腔鏡附件切除術(shù)4例，患者基本資料見表1。其中5例患者因輸尿管走行區(qū)有淡紅色不明液體滲出，或腹腔鏡觀察輸尿管肌層明顯缺損而確診。術(shù)后發(fā)現(xiàn)輸尿管損傷28例中有1例為孤立腎患者，術(shù)后8 h發(fā)現(xiàn)腹腔引流量異常增多，而尿量<80 ml，檢測腹腔引流液肌酐達(dá)5 773 μmol/L，行輸尿管鏡檢查，發(fā)現(xiàn)輸尿管下段破口。其余27例均在術(shù)后7～35 d發(fā)現(xiàn)陰道殘端有不明液體異常漏出，檢測液體肌酐達(dá)1 147～8 952 μmol/L，靜脈尿路造影檢查顯示一側(cè)腎輕度積水，輸尿管下段梗阻伴尿外滲(圖1、2)。

1.2 手術(shù)方法

術(shù)中發(fā)現(xiàn)輸尿管損傷5例行腹腔鏡或膀胱鏡下置入雙J管，輸尿管全層損傷或漿肌層損傷明顯者腹腔鏡下4-0可吸收線間斷縫合。如輸尿管損傷嚴(yán)重，裁剪切除損傷段輸尿管，行輸尿管端端吻合。術(shù)后發(fā)現(xiàn)輸尿管損傷28例中的1例孤立腎患者，輸尿管鏡檢查發(fā)現(xiàn)輸尿管下段破口，輸尿管內(nèi)置入雙J管后腹腔鏡下輸尿管破損處間斷縫合；其余先行輸尿管鏡直視下置雙J管，置管成功16例，留置雙J管2～3個(gè)月，另外11例輸尿管鏡下置雙J管失敗患者行腹腔鏡探查。腹盆腔術(shù)野多粘連嚴(yán)重，用剪刀銳性加鈍性分離粘連，避免損傷腸管和髂血管。于損傷部位以上離斷輸尿管，殘端用4-0可吸收線縫扎。游離對(duì)側(cè)膀胱壁，膀胱向患側(cè)牽引，如輸尿管長度足以與膀胱吻合，輸尿管插入膀胱10 mm，輸尿管膀胱直接吻合。如損傷位置稍高，游離裁剪膀胱壁瓣并縫合成管狀與輸尿管吻合。置入雙J管引流，保留導(dǎo)尿。

2 結(jié)果

33名患者手術(shù)順利，2例輸尿管膀胱再植患者術(shù)后反復(fù)出現(xiàn)尿路感染，經(jīng)正規(guī)抗感染治療治愈。16例術(shù)后延遲發(fā)現(xiàn)輸尿管損傷并成功置入雙J管中有1例患者長期漏尿，3個(gè)月后再行腹腔鏡手術(shù)成功，其余膀胱鏡下拔除雙J管無漏尿發(fā)生。11例置管失敗患者行均一期行腹腔鏡修復(fù)術(shù)。其中行腹腔鏡輸尿管膀胱再植9例，膀胱瓣輸尿管吻合2例。手術(shù)耗時(shí)110～160 min，平均132 min。術(shù)后住院5～8 d，平均6 d。保留導(dǎo)尿3～4周，術(shù)后4～8周膀胱鏡直視下拔除雙J管。輸尿管損傷術(shù)后3～6個(gè)月復(fù)查B超提示輕度腎積水。在以后3～24個(gè)月隨訪中患者無漏尿、中重度腎積水、輸尿管狹窄等情況發(fā)生。

圖1 左輸尿管下段造影劑外溢伴左腎輕度積水

圖2 右輸尿管下段造影劑外溢

圖3 28例延遲發(fā)現(xiàn)輸尿管損傷患者治療流轉(zhuǎn)示意圖

3 討論

輸尿管損傷是一種少見手術(shù)并發(fā)癥，然而據(jù)估計(jì)，52%～82%的醫(yī)源性輸尿管損傷發(fā)生在婦科手術(shù)中[2]。近年隨著婦科腹腔鏡技術(shù)應(yīng)用越來越廣泛，手術(shù)適應(yīng)證和手術(shù)范圍不斷擴(kuò)大，術(shù)中誤損輸尿管也有增多的趨勢。據(jù)統(tǒng)計(jì)，因婦科腹腔鏡手術(shù)導(dǎo)致輸尿管損傷發(fā)病率為0.03%～0.13%，而在復(fù)雜手術(shù)中輸尿管損傷率高達(dá)0.2%～1.6%[3]。本組中輸尿管損傷發(fā)病率為0.18%(33/18 334)，與文獻(xiàn)[3]類似。醫(yī)源性輸尿管損傷如能術(shù)中發(fā)現(xiàn)應(yīng)立即修補(bǔ)，保障輸尿管通暢，避免嚴(yán)重情況發(fā)生。然而不幸的是，50%～70%的輸尿管損傷在術(shù)中并沒有及時(shí)發(fā)現(xiàn)[4]。本組中28例(84.84%)輸尿管損傷術(shù)后確診，高于文獻(xiàn)報(bào)道?？赡芘c腹腔鏡手術(shù)中能量器械的運(yùn)用導(dǎo)致熱損傷難以發(fā)現(xiàn)有關(guān)。目前對(duì)于延遲診斷的輸尿管損傷處理尚有分歧。提倡分期手術(shù)者認(rèn)為分期手術(shù)可減輕輸尿管局部血腫、炎性反應(yīng)和水腫，有利于手術(shù)修復(fù)成功，減少圍手術(shù)期并發(fā)癥。也有學(xué)者認(rèn)為2周內(nèi)確診輸尿管損傷可予以即時(shí)手術(shù)修復(fù)，可使住院時(shí)間縮短，漏尿、傷口感染等手術(shù)并發(fā)癥減少，也可減輕患者在等待修復(fù)期間許多心理壓力和精神創(chuàng)傷[5]。

近年來微創(chuàng)治療輸尿管損傷已越來越多的報(bào)道，治療已逐步從開放修復(fù)手術(shù)到微創(chuàng)治療，如輸尿管支架置入術(shù)、腹腔鏡下支架植入修補(bǔ)術(shù)、腹腔鏡輸尿管斷端再吻合術(shù)以及遠(yuǎn)端輸尿管膀胱再植術(shù)[1]，其治療的可行性、安全性及有效性也得到更多的證實(shí)。Rajamaheswari等[6]報(bào)道輸尿管損傷案例中輸尿管支架置入術(shù)成功率可高達(dá)76 %(13/17)，經(jīng)保守治療拔出雙J管平均隨訪24.6個(gè)月中無漏尿等并發(fā)癥的發(fā)生。Kumar等[7]報(bào)道84例輸尿管損傷，輸尿管支架通過率僅僅9%(8/84)，術(shù)后也取得較滿意的治療效果。本組延遲診斷的輸尿管損傷中僅有16例(57.14%)雙J管成功置入，遺憾的是有1例患者長期漏尿，后行腹腔鏡治療。我們建議最好在輸尿管鏡直視下置雙J管，一方面可避免盲目置管導(dǎo)致輸尿管損傷加重，同時(shí)可以評(píng)估輸尿管損傷的程度。如果損傷缺損嚴(yán)重，可一期行腹腔鏡修復(fù)。置雙J管治療，無再次手術(shù)切口創(chuàng)傷，患者痛苦小，費(fèi)用低，心理上也更易接受。

置雙J管失敗行輸尿管端端吻合或遠(yuǎn)端輸尿管膀胱再植術(shù)時(shí)，腹腔鏡具有微創(chuàng)以及放大作用的優(yōu)勢，使得在操作過程中更加精細(xì)。另外，腹腔鏡更易在腹膜后較深且有限的空間進(jìn)行手術(shù)修復(fù)。有學(xué)者報(bào)道腹腔鏡輸尿管端端吻合術(shù)的成功率為88.24%～100%[8, 9]。本組術(shù)中發(fā)現(xiàn)的5例輸尿管損傷患者行腹腔鏡輸尿管修補(bǔ)或端端吻合術(shù)均取得手術(shù)成功。我們在所有的患者隨訪中并未出現(xiàn)輸尿管狹窄。但隨訪時(shí)間尚較短。Rassweiler等[10]指出，相對(duì)于開放手術(shù)，腹腔鏡輸尿管膀胱再植術(shù)具有術(shù)后痛苦小，住院時(shí)間短，康復(fù)快等優(yōu)勢。Pal等[11]提出雖然傳統(tǒng)輸尿管重建術(shù)是輸尿管下段梗阻的治療標(biāo)準(zhǔn)，但腹腔鏡下輸尿管膀胱再植在技術(shù)上的優(yōu)勢，逐漸成為治療輸尿管下段梗阻一個(gè)可行性選擇。本組輸尿管陰道瘺11例患者行腹腔鏡探查，術(shù)中局部炎癥反應(yīng)粘連比較嚴(yán)重，游離輸尿管損傷部位及其遠(yuǎn)端比較困難，我們選擇腹腔鏡下輸尿管與膀胱吻合術(shù)。如輸尿管損傷位置較高，游離膀胱瓣并縫合形成管狀再與輸尿管吻合。手術(shù)的難點(diǎn)在于是二次手術(shù)，腹腔及手術(shù)術(shù)野粘連嚴(yán)重。既要保證輸尿管膀胱充分游離，又必須避免副損傷發(fā)生，特別是避免腸管損傷、腸瘺發(fā)生等嚴(yán)重的后果。我們的經(jīng)驗(yàn)是游離過程中盡量采用剪刀冷分離，保證了術(shù)野和分離層面的清晰，同時(shí)也避免了超聲刀、電刀等導(dǎo)致的熱損傷。腹腔鏡通道應(yīng)用原婦科腹腔鏡手術(shù)通道位置，不增加患者損傷，降低了患者的不滿。術(shù)后平均住院6 d(5～8 d)。隨訪3～24個(gè)月，無漏尿、輸尿管狹窄等發(fā)生。

輸尿管損傷是婦科手術(shù)中嚴(yán)重并發(fā)癥之一，術(shù)者一定要提高對(duì)輸尿管損傷的警惕，減少損傷的發(fā)生，卓棟等[12]等報(bào)道，術(shù)前預(yù)置輸尿管導(dǎo)管支架有助于術(shù)中辨識(shí)輸尿管，并可預(yù)防輸尿管損傷。對(duì)于已經(jīng)發(fā)生輸尿管損傷建議早期處理。部分輸尿管損傷患者通過輸尿管鏡直視下置入雙J管行保守治療，可以達(dá)到滿意的效果。對(duì)于保守治療失敗者行腹腔鏡治療，雖然具有一定挑戰(zhàn)，但相比傳統(tǒng)手術(shù)具有創(chuàng)傷小、術(shù)后恢復(fù)快、住院時(shí)間短等優(yōu)勢，可最大限度的減少患者心理負(fù)擔(dān)，避免醫(yī)患糾紛的發(fā)生?？傊?chuàng)治療輸尿管損傷是安全、有效又可行的選擇。

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Minimally invasive technique in the treatment of ureteral injury after the gynecologic surgery (A report of 33 cases)

LiMaolin1ZhuoDong1ZhangJing1WangZhiguo1AoPing1

(1Department of Urology, Yijishan Hospital Affiliated to Wannan Medical College, Wuhu 241001, China) Corresponding author: Zhuo Dong, whzhuo2008@sina.com

Objective: To investigate the safety and efficacy of ureteroscope and laparoscopic surgery for the treatment of ureteral injury caused by a gynecological operation. Methods: In the study, 33 cases of ureteral injury in gynecologic operation, with mean age being 45 (20 to 69) years. 5 cases of ureteral injuries were found during the operation and immediate laparoscopic-aided D-J stent insertion was done through ureteral lesion. Repair and suture or end to end anastomosis of ureter was followed. Delayed ureteral injury was found in 28 cases, including 1 case of solitary kidney patients. In this case, abnormal drainage fluid was found 8 hours after operation, the partial lesion of the lower ureter were examined by ureteroscopy, and D-J stent insertion and laparoscopic repair were done. Vaginal stump leakage was found 7 to 35 days after operation in the rest 27 cases. Then cystoscopic-aided or ureteroscopic-aided D-J stent insertion succeeded in 16 cases, and the D-J stent retained for 3 to 2 months. Laparoscopic exploration was done in the other 11 cases of patients with D-J stent insertion failure. Low lesion location, Direct insertion of ureter and bladder was done in the cases of low lesion location. If lesion location was high, free cutting of bladder wall flap and synthesis of tubular in order we do ureteroneocystostomy by free cutting of bladder wall flap and the synthesis of tubular. Results: One of the 16 patients who did successfully D-J stent insertion had long term urinary fistula. This patient recovered after undergoing laparoscopic surgery successfully after 3 months. The 11 cases of patients with D-J stent insertion failure were also healed after one-stage laparoscopic repair. In these cases, operating time was 110-160 min (mean,132 min); ostoperative hospitalization was 5 to 8 days (mean, 6 days); retention catheterization time was 3 to 4 weeks. We removed D-J stent under the cystoscope 4 to 8 weeks after operation. B-us were carried out 3 to 6 months after operation, and mild hydronephrosis was seen in all cases. Conclusions: Ureteral injury caused by gynecological surgery can be cured by inserting the D-J stent. If the conservative treatment failed, patients can be treated by laparoscopy. Although some challenges existed, there are the advantages of safe and effective, less trauma, less scar and faster postoperative recover. And laparoscopy operation can reduce the psychological burden of patients, to avoid the occurrence of medical disputes.

minimally invasive technique; gynaecology surgery; ureteral injury

卓棟，whzhuo2008@sina.com

2017-01-16

R693

A

10.19558/j.cnki.10-1020/r.2017.02.006

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