医源性输尿管损伤的手术治疗38例报告

目的:总结38例医源性输尿管损伤的手术方法和治疗经验。方法:回顾性分析2010年1月～2017年12月我院收治的38例医源性输尿管损伤患者的临床资料。38例患者中,妇产科手术损伤15例,泌尿外科16例,普外科7例。术中发现25例,术后发现13例。确诊后均积极进行手术治疗。12例行输尿管镜下留置双J管术,8例行输尿管端端吻合术,6例行输尿管膀胱再植术,4例行输尿管膀胱角吻合术,3例行膀胱壁瓣输尿管吻合术,2例行输尿管松解术,2例先行经皮肾穿刺造瘘术,3个月后改行回肠代输尿管术,1例行患肾切除术。结果:术后平均随访18(6～36)个月,定期行B超、CT、静脉尿路造影等检查,12例输尿管镜下留置双J管术后输尿管狭窄合并中度肾积水5例,行输尿管膀胱再植术后好转;8例输尿管端端吻合术后输尿管狭窄合并中度肾积水2例,行输尿管镜球囊扩张后好转。其余患者患侧输尿管通畅无狭窄,患侧肾无积水。结论:医源性输尿管损伤的处理应根据输尿管损伤情况、患者的具体情况和医生所掌握的技术采用不同的手术治疗方案。复杂性医源性输尿管损伤行输尿管镜留置双J管和输尿管端端吻合术,术后远期输尿管狭窄发生率较高,需要密切随访,必要时进一步处理。     

医源性输尿管损伤的原因与处理

目的：探讨医源性输尿管损伤的原因、处理和预防。方法：本组16例,保守治疗行输尿管逆行插管（以J管）2例,输尿管修补术1例,输尿管端端吻合术3例,输尿管膀胱吻合术7例,肾造口术3例,其中2例后期再次行管状膀胱瓣输尿管吻合术。结果：所有患者肾功能均恢复正常。结论：了解与输尿管有关的解剖位置,细致规范的手术操作是预防医源性输尿管损伤的关键。     

医源性输尿管损伤的诊断和治疗

作者分析了１７例２０侧医源性输尿管损伤的诊断和治疗经验。损伤主要为妇科、普通外科手术所致。根据患者表现选行Ｂ超、ＩＶＵ和膀胱镜检加逆行造影或注入染料确诊。本组患者经输尿管端端吻合术４例，输尿管插管引流术１例，解结术加输尿管双Ｊ管１例，输尿管膀胱吻合术１０例，膀胱腰大肌固定术加输尿管膀胱吻合术１例；肾切除术２例。随访３月～５年，经修复手术的患者肾功能恢复良好。作者认为术式的选择应根据输尿管损伤的部位和长度。发生损伤后２～３周内手术是可行的。及时发现输尿管损伤并恰当处理效果良好，诊断延迟会造成处理困难，失肾机会增加。     

医源性输尿管损伤

目的　探讨医源性输尿管损伤的原因、类型、处理和预防。方法　回顾性分析了 11例医源性输尿管损伤的临床资料。治疗方法为输尿管逆行内支架管插管引流 2例 ;输尿管修补术 1例 ;输尿管端端吻合术 6例 ;膀胱瓣管法输尿管再吻合术 2例。结果　 1例肾积水 ,余肾功能均正常。结论　医源性输尿管损伤的早期与后期诊断有所不同 ,治疗要达到恢复排尿通路和肾功能两个目的。熟悉局部解剖 ,细致规范手术是预防医源性输尿管损伤的关键。     

输尿管镜致输尿管严重损伤的处理

目的探讨输尿管镜致输尿管严重损伤的处理方法。方法回顾性分析我院2 876例输尿管镜诊疗过程中15例输尿管严重损伤的临床资料。15例中,输尿管断裂4例,均行输尿管吻合术;输尿管全层撕脱4例,其中1例行肾下移输尿管膀胱瓣吻合,2例行回肠代输尿管术,1例行肾切除术;输尿管黏膜袖套样剥离7例,其中4例内置双J管引流,1例行输尿管膀胱瓣吻合,2例行回肠代输尿管术。结果所有患者均经随访3个月～3年,1例出现输尿管末端狭窄闭锁,行输尿管膀胱再植术后治愈,1例因反复肾感染行肾切除外,余13例均无异常。结论输尿管镜手术致输尿管严重损伤时,及时发现损伤并按损伤类型不同,分别采用输尿管吻合、输尿管膀胱吻合、回肠代输尿管等方法处理,疗效满意,预后好。     

医源性胆管损伤及狭窄的防治（附54例报告）

1980～1996年，作者共收治医源性胆管损伤及狭窄病人54例。其中发生于胆囊切除术47例，发生于胃大部切除术7例。10例行胆管端端吻合术．37例行胆管空肠Roux-Y吻合术。17例行3次以上修复手术。结果51例痊愈，3例死亡。讨论了医源性胆管损伤的预防和不同时期的损伤处理.     

原发性输尿管息肉15例临床分析

目的 探讨原发性输尿管息肉的临床特点与诊治方法。方法 回顾性分析15例原发性输尿管息肉的临床表现、诊断方法和治疗原则。结果 1例行肾切除加输尿管大部切除术，3例行病变节段输尿管切除加输尿管端端吻合术，7例行病变节段输尿管切除加肾盂成形术或输尿管膀胱吻合术，4例经输尿管镜息肉电切和电灼术。术后12例获随访6～68个月，未见息肉复发及恶变。结论 原发性输尿管息肉确诊依靠输尿管镜检查及活检，行病变节段输尿管切除术可以治愈，经输尿管镜息肉电切和电灼术是治疗本病的理想方法。     

原发性输尿管恶性肿瘤（附34例报告）

为探讨原发性输尿管肿瘤的诊断方法和治疗效果，报道原发性输尿管恶性肿瘤３４例，其中移行细胞癌３１例，鳞癌２例，平滑肌肉瘤１例。男性２３例，女性１１例；年龄２５～８４岁，平均５４．５岁。１７例行患侧肾及输尿管全切及膀胱袖状切除术，３例行患侧肾及输尿管部分切除术，４例行输尿管节段切除术，１例行患侧肾输尿管及膀胱全切术。２６例获随访，死亡８例。认为尿路造影、膀胱镜检查是最重要的诊断手段，患侧肾输尿管全切及膀胱袖状切除术是首选术式，本组５例存活５年以上者均为采取此术式患者。     

手术中输尿管损伤的治疗体会

输尿管损伤临床少见,多为医源性损伤。我院1990年以来共发生手术中输尿管损伤6例,占同期盆腔手术病人的1.2％。现报告如下。 临床资料 本组6例,男1例,女5例 年龄23～75岁,平均49岁。其中新式剖宫产术1例,全子宫切除术2例,直肠癌Miles手术1例,原发性骶前肿瘤切除2例。术中发现4例,分别行端端吻合、内置双J管3例,均恢复满意。术后发现2例,1例行输尿管膀胱吻合术,恢复良好,另1例因继发肾脏严重感染,行左肾切除。     

显微外科技术在医源性输尿管损伤后狭窄修复中的应用

目的探讨不同类型输尿管损伤引起狭窄、梗阻的手术方法和预防措施。方法对27例输尿管损伤，采用显做技术，根据不同部位损伤，进行输尿管肾下极侧侧吻合术5例，肾盂输尿管再成形术6例，输尿管端端吻合术11例，输尿管膀胱角吻合腰大肌悬吊术5例。结果27例输尿管损伤术后，全部治愈，1周拔除膀胱造瘘管，3～4周拔除肾造瘘管，3个月拔除输尿管支架，随访6个月～3年，经B超，静脉肾盂造影复查，3例轻度肾积水，占11.11％；1例轻度输尿管反流，占3．70％；5例尿频，占18．52％。无1例漏尿。结论采用显微外科技术进行输尿管吻合术，可清晰显示断端的解剖层次，得以准确对合，提高远期效果。     

输尿管损伤的诊断和治疗(附41例报告)

目的总结输尿管损伤的原因、诊断与治疗。方法对41例输尿管损伤的临床资料进行回顾性分析。结果41例输尿管损伤中,医源性损伤35例,外伤性损伤6例;输尿管下段损伤32例,上段9例;左侧损伤28例,右侧13例。手术治疗39例,逆行输尿管插管治疗2例;肾切除1例;肠梗阻死亡1例。结论B超检查简单易行,结合静脉尿路造影(IVU)和逆行输尿管造影(RP)多能确诊。早期发现、及时手术或腔内治疗是治愈输尿管损伤的关键。     

Iatrogenic ureteral injury

We treated 27 patients with iatrogenic ureteral injuries during a 6-year period. Gynecological operations were the most common antecedent surgical procedures (52 per cent). The diagnosis of ureteral injury was made immediately in 4 patients and was delayed 1 to 34 days in 23. Three of the 4 injuries recognized during an operation were repaired successfully at the time of injury; the primary repair in the remaining patient leaked and ultimately resulted in a nephrectomy. In the delayed diagnosis group retrograde ureteral catheterization was successful in only 1 of 20 attempts. Of the 23 patients with injuries recognized in the postoperative period 11 were managed successfully with percutaneous nephrostomy (with or without stenting) alone, 3 required surgical repair after temporary percutaneous nephrostomy drainage, 4 were treated surgically without prior nephrostomy drainage and 1 had spontaneous resolution of hydronephrosis. The remaining 3 patients required nephrectomy: 1 because of a urinary fistula in a previously irradiated field, 1 because of a concomitant (ipsilateral) renal cell carcinoma and 1 because of renal hypertension. Percutaneous nephrostomy or ureteral stenting was successful as primary therapy in 73 per cent of the patients in whom it was used.     

Ureteral injuries complicating vascular surgery: is repair indicated?

We have managed 8 patients who sustained an iatrogenic ureteral injury during either placement or revision of a vascular graft. Primary repair was performed in all 5 patients diagnosed at injury. Persistent extravasation necessitating nephrectomy occurred in 2 of these patients. The diagnosis was delayed in 3 patients. Two patients underwent successful ureteral reconstruction and 1 required nephrectomy. Graft complications did not occur. Ureteral repair is recommended as the preferred method to manage ureteral injuries associated with vascular reconstruction.     

Iatrogenic injuries to ureter, bladder and urethra during abdominal and pelvic operations

Abdominal and pelvic operations at Departments of Obstetrics and Gynaecology, and General Surgery play an important role in ureteral, bladder and rarely urethral injuries. Fifty-nine patients with iatrogenic ureteral, bladder and urethral injuries were treated at the Department of Urology, Atatürk University Research Hospital, between 1985 and 1995. These injuries were urinary vaginal fistulas in 43 patients (vesicovaginal 33, ureterovaginal 7, urethrovaginal 2 and vesicovaginal plus urethrovaginal 1), ureteric ligation in 9, bladder laceration in 7. These injuries were treated by different methods. All patients were followed up by intravenous urography (IVU) and urine culture three months later. It must be borne in mind that iatrogenic urinary tract injuries are not rare. Bladder and ureteral catheterization must be performed to prevent these complications.     

Management of iatrogenic ureteral strictures after urological procedures

At our institution more of the iatrogenic ureteral injuries seen are caused by urologists than by gynecologists or general surgeons. The management of 94 such injuries is discussed, 55 of which were the result of open operations, 34 of endourological procedures and 5 of transurethral operations. More than half of the injuries (52 per cent) involved the ureteropelvic junction. Endourological procedures were successful in correcting the problem in 58 patients and consisted of endopyelotomy (38), dilation (10), ureteral meatotomy (8), antegrade ureterotomy (1) and percutaneous ureterotomy (1). Endourological procedures failed in 20 other cases. Altogether, 36 patients (38 per cent) required an open operation consisting of ureteroureterostomy (9), ureterocalicostomy (7), ureteral reimplantation (6), Boari flap (5), pyeloplasty (4), ileal interposition (3), undiversion (1) and nephrectomy (1). The treatment options that appear to be most suitable for particular types of injury are discussed. Final results were satisfactory in all patients.     

医源性输尿管损伤手术时机探讨(附20例报告)

目的 提高对医源性输尿管损伤的认识和选择手术治疗时机的选择。方法 对1998年-2005年收治的20例医源性输尿管损伤病例进行回顾分析。结果 3例行双“J”管内支架保守治疗，余17例分别在2月内行手术治疗，所有病例均获满意疗效。结论 对医源性输尿管损伤只要术前、术中明确诊断，可打破传统手术时机观念及时早期手术处理。     

Renal and ureteric trauma: diagnosis and management in Poland

OBJECTIVE: To analyse retrospectively kidney and ureteric injuries (the former often associated with multiple-organ trauma) and thus optimize diagnostic and treatment methods. PATIENTS AND METHODS: The records and details of kidney and ureteric injures treated between 1995 and 1999 in 61 urological departments in Poland were analysed. RESULTS: In all, 887 kidney injuries were analysed; blunt trauma comprised 97%, with most injuries classified as renal contusion and minor parenchymal damage (687 cases). Intravenous urography was used in 80% of the patients and computed tomography in only 20%. In all, 234 patients (26%) underwent surgery; nephrectomy was the most common surgical treatment, in 170 patients (73% of those undergoing surgery). Complications occurred in 9% of patients after conservative treatment and in 5% after surgery. Of the 452 ureteric injuries, 340 (75%) were iatrogenic, 81 (18%) blunt injuries and 31 (7%) open injuries. Of the iatrogenic injuries 73% occurred during gynaecological procedures, 14% in general surgery and 14% in urological procedures. The most frequent diagnostic method was intravenous urography (244 cases), with retrograde pyelography (98) and ureteric catheterization in 125. The diagnosis was established immediately during surgery in 104 patients. The most frequent surgical treatment was uretero-neocystostomy (213, 47%), the others being a Boari flap (113, 25%), end-to-end anastomosis (92, 20%), reconstruction with an ileal loop (30, 7%) and autotransplantation (four, 1%). CONCLUSION: In Poland, patients with blunt kidney injuries often undergo surgery, with nephrectomy the most frequent procedure. Computed tomography with the intravenous administration of contrast medium should be considered the diagnostic method of choice for kidney injures. Catheterization of the ureters before surgery and an indigocarmine intravenous infusion (to stain the urine) when a ureteric injury is suspected may reduce the rate of iatrogenic injury and improve the rate of intraoperative diagnosis. We suggest catheterizing the ureters in any doubtful case to avoid injury, because prevention is better than treatment.     

医源性输尿管下段损伤或狭窄的处理：（附14例报告）

为探讨对医源性输尿管损伤或狭窄的处理，降低并发症，回顾分析１９８６￣１９９６年治疗的医源性车尿管下段损伤１１例和狭窄３例（４侧），其中泌尿外科、妇科、普外科手术所造成的输尿管下段损伤或狭窄分别为９例（６４．３％）、４例（２８．６％）、１例（７．１％），以泌尿外科手术引起的发生率最高，可能与输尿管镜等腔道内手术的广泛开展及各类开放性手术的失误升并发症有关。除普外科造成的１例在损伤当即被发现并修复外，     

Obstetric and gynecological lesions of the ureter: Experience with 88 injuries

Over the past 17 years, 65 patients have been treated in our department for a total of 88 obstetric and gynecological ureteral lesions. Bilateral injury was involved in 23 cases. Conservative treatment was used in 13 injuries, diverting procedures in 8, nephrectomy in 5, and various surgical reconstructive techniques in 45. Seventeen patients refused therapy.An evaluation of the data shows that significantly better results were obtained when treatment was immediate (92%) than in cases in which treatment was purposely delayed (48%). Furthermore, in the latter group both nephrectomy and definitive diverting procedures were carried out in larger numbers. For optimal results, ureteral lesions must be repaired as soon as they are diagnosed, as long as the general condition of the patient permits.