妇产科医源性输尿管损伤106例临床分析

妇产科手术是医源性输尿管损伤的常见原因之一 ,及时发现并妥善处理 ,则预后良好。否则会引起尿外渗 ,腹、盆腔感染 ,肾功能损害 ,严重者危及生命[1] 。本文对合肥地区 1981年 1月至 2 0 0 1年 12月因妇产科手术所致输尿管损伤 10 6例的临床资料进行回顾性分析 ,现报道如下。1　资料与方法1 1　一般资料本组 10 6例中 ,年龄 2 1～ 67岁 ,平均 45岁。输尿管损伤均为下段。手术术式及损伤类型 ,见表 1。1 2　诊断术中诊断 41例 ,为直接发现或表现手术野有较多的“渗出液”或输尿管扩张。术后发现 65例 ,表现为切口大量渗液 ,经膀胱镜逆行造影 …     

妇产科手术泌尿道损伤25例临床分析

目的:探讨妇产科手术泌尿道损伤的预防及治疗.方法:回顾性分析我院15年中收治25例妇产科手术泌尿道损伤的相关因素.结果:妇产科开腹手术11904例,泌尿系统损伤25例,发生率0.21%.其中输尿管损伤17例,膀胱损伤8例.17例输尿管损伤,经术中术后修补,均顺利恢复.8例膀胱损伤,7例Ⅰ期修复,1例经阴道修补失败后3月改行开腹二次修补成功.结论:妇产科手术中泌尿道损伤不客忽视,应及时诊断,早期处理.     

妇产科医源性输尿管损伤16例临床分析

目的:探讨妇产科手术中输尿管损伤的原因及防治措施。方法:对16例妇产科手术中输尿管损伤的病例进行回顾性分析。结果:妇产科手术中输尿管损伤多见于全子宫切除和盆腔清扫术共12例,卵巢囊肿切除术2例,腹腔镜下卵巢囊肿剥除术1例,剖宫产术1例。结论:妇产科医师必须熟悉局部解剖,尤其输尿管、膀胱与子宫、卵巢的关系,避免损伤输尿管。输尿管损伤后应尽早恢复输尿管的通畅性,保存肾功能。     

妇产科手术输尿管损伤27例临床分析

目的探讨妇产科手术所引起的输尿管损伤的诊断和处理;方法回顾分析27例妇产科手术所引起的输尿管损伤患者;结果术中发现11例,行输尿管损伤修补治愈;术后近期发现13例,3例行膀胱镜下留置双J管,2例治愈,1例改行输尿管膀胱再植术后治愈;10例通过输尿管膀胱再植术或输尿管膀胱壁瓣吻合术治愈;术后远期发现3例,1例因重度积水行肾切除术,1例行输尿管膀胱壁瓣吻合,1例行回肠代输尿管术,肾积水消失;结论妇产科手术中发现输尿管损伤可通过修补+留置双J管治愈,术后若引流呈尿液或阴道漏尿,应尽早明确输尿管损伤的部位和程度,并尽早治疗。     

妇科手术中尿路损伤32例分析

本文收集1975年以来妇科手术中发生输尿管、膀胱及尿道损伤32例,分析报道如下: 资料 1975～1985年,我院妇科手术中发生输尿管损伤4例,其中2例术中及时发现,2例术后3～4天确诊。膀胱损伤8例,其中7例术中及时发现,1例术后第5天阴道流液,术后2个月因尿瘘再次入院。余20例均为外院手术中损伤,术后因尿瘘而入院。其中输尿管损伤7例,膀胱损伤10例,尿道损伤3例。32例尿路损伤部位与妇科手术的种类见表1。     

妇科手术泌尿系统损伤42例临床分析

目的 探讨妇科手术泌尿系统损伤的临床特点和处理。方法 对1990年1月1日至2001年12月31日期间在北京协和医院妇科手术中发生的42例泌尿系统损伤的类型,时间,术后尿瘘的发生和诊治经过,进行回顾性分析。结果 在12849例妇科手术中,发生泌尿系统损伤42例,发生率为0.33%。其中,输尿管损伤11例,包括输尿管下段损伤5例,近膀胱入口段损伤4例和骨盆入口段损伤2例。发生率为0.09%;膀胱损伤31例,均发生于膀胱底部或后壁,发生率为0.24%,发现损伤的时间,术中32例（76%）,术后10例（24%）,尿瘘形成14例（33%）,其中10例经过尿,血和引流液电解质,肌酐和尿素氮含量的比较而明确尿瘘存在;9例行美蓝实验和（或）膀胱镜检查,其中4例经此项检查诊断为膀胱瘘;8例经静脉肾盂造影诊断为输尿管瘘;经过术中及时修补,置入输尿管双J管和（或）保留尿管开放治疗,41例治愈。结论 大部分妇科手术泌尿系统损伤,经及时诊断和处理,预后较好。     

腹腔镜下子宫切除术中输尿管损伤的临床表现及处理

目的：探讨腹腔镜子宫切除术中输尿管损伤的发生、诊断、治疗及预防。方法：回顾性分析河南省人民医院2011年7月至2014年7月3年间腹腔镜子宫切除术中6例输尿管损伤的病例资料。结果3589例腹腔镜子宫切除术中,共发生6例输尿管损伤,发生率约为0．17％,其中1例术中及时发现,并采取腹腔镜下输尿管端-端吻合术＋输尿管置管术（D-T管,下同）;1例术后6小时因腹腔引流液多而发现,及时开腹行手术修复;4例晚期发现者,均行膀胱镜下输尿管置管,3个月后拔管,3例治愈,1例再次出现尿瘘行二次开腹手术修补。结论：早期发现并修复输尿管损伤,患者预后转归好,并能减少远期后遗症,诸如输尿管狭窄、瘘管形成或肾功能衰竭的发生。     

妇产科手术泌尿道损伤25例的临床分析

目的对妇产科手术泌尿道损伤发生的原因进行分析,并探讨积极的处理方法。方法选取25例患者作为研究对象,对其发生损伤的原因进行分析,并探讨有效的处理方法。结果输尿管损伤18例,膀胱损伤7例;有效治疗后,18例输尿管损伤患者均顺利、有效恢复,无1例由于肾功能受损或者治疗失败将肾脏切除;7例膀胱损伤患者中,6例均为Ⅰ期修复,愈合情况良好,另外1例应用阴道修补术治疗失败,三个月后转为开腹二次修补术治疗成功。结论输尿管损伤为妇产科手术的常见损伤,为有效降低泌尿道损伤,要术前要做好充分准备工作,并严格根据操作规程进行操作。     

腹腔镜广泛全子宫切除术后输尿管瘘7例临床分析

目的:探讨腹腔镜广泛全子宫切除术后输尿管瘘的预防及处理体会。方法:回顾分析2014年1月～2016年12月在皖南医学院第一附属医院行腹腔镜广泛全子宫切除术后发生输尿管瘘的7例患者临床资料。患者经确诊后行膀胱镜、输尿管镜检查,术中放置D-J管,放置D-J管后持续漏尿或放置失败均行二次手术修补。结果:2例保守治疗成功,2例置入D-J管后持续漏尿,行膀胱输尿管吻合,3例置入D-J管失败直接行膀胱输尿管吻合。5例修复手术中3例经腹腔镜完成,均手术成功,愈合良好。结论:热损伤及输尿管过度游离是腹腔镜下广泛全子宫切除术后输尿管瘘较为常见的原因,术后一经发现,可经早期腹腔镜下修复,效果满意。     

子宫颈癌患者术中并发症分析

目的了解宫颈癌患者术中并发症的情况及其相关因素.方法对我院25年来收治的155例宫颈癌患者的临床资料进行回顾性分析.结果患者平均年龄44.19±10.72岁,临床分期由0～Ⅳb期.共行手术140例,其中子宫根治术+盆腔淋巴结清扫术84例,术中平均出血量为902.9±508.7 ml(1968年～1989年),1 192.7±683.86 ml(1990年～2001年).术中出血量与术后尿管保留时间具有相关性.共发生4例(2.86%)输尿管损伤,其中根治术3例(3.57%);1例肠管损伤.结论提高手术技巧,熟悉解剖结构是减少术中出血和避免输尿管损伤的关键.一旦发生输尿管损伤,及时发现及时修补可以避免术后尿瘘的发生.     

Outcome of laparoscopic repair of ureteral injury: follow-up of twelve cases

Study ObjectiveTo review the feasibility of laparoscopic repair in cases of ureteral injuries occurring during gynecologic laparoscopy.DesignRetrospective study (Canadian Task Force classification II-3).SettingInstitution-specific retrospective review of data from a tertiary referral medical center.PatientsPatients suffering from iatrogenic ureteral injuries diagnosed during or after surgery, and cases with deliberate ureteral resection and repair because of underlying disease.Measurements and Main ResultsWe conducted a retrospective review of all (10 345) laparoscopic gynecologic surgeries performed in our institute between February 2004 and November 2008. Twelve cases (median: 45.5 years, range: 27–63) of ureter transections were diagnosed and repaired laparoscopically by endoscopists. Of these, 10 had previous surgeries, pelvic adhesions, or a large pelvic-abdominal mass. One patient had undergone a segmental resection and laparoscopic ureteroureterostomy for deep infiltrative endometriosis. Of the remaining 11 iatrogenic ureteral transections, 10 were repaired via laparoscopic ureteroureterostomy, whereas 1 had undergone a laparoscopic ureteroneocystostomy. One injury was recognized on the second postoperative day, but intraoperative recognition was attained in 11 cases. The median duration of double J stenting was 73 days. Three patients had development of strictures (between 42 and 79 days after surgery) treated with restenting, but 1 had to undergo an ureteroneocystostomy for ureter disruption when trying to restent. One patient had development of leakage of the anastomotic site but recovered with a change of the double J stent. Only 1 case required another laparotomy for ureteroneocystostomy. Laparoscopic primary repair of ureteral injury was successful for 11 of 12 patients. All the patients were well and symptom free at the conclusion of the study period.ConclusionEarly recognition and treatment of ureteral injuries are important to prevent morbidity. Laparoscopic ureteroureterostomy could be considered in transections of the ureter where technical expertise is available. To the best of our knowledge, this is the largest series, to date, of ureteral repairs via laparoscopy.     

Prevention of ureteral injuries in gynecologic surgery

Pelvic surgery is the most common cause of iatrogenic ureteral injury. The majority of patients with ureteral injuries have no identifiable predisposing risk factors. A simple maneuver that has been taught successfully at our institution that facilitates the identification of the ureter is described. When injury is discovered during surgery, correction of the injury can be repaired with minimal risk of long-term sequelae. Postoperatively, patients with ureteral injury typically present with costovertebral angle tenderness, ileus, fever, and flank pain with a minimal rise in serum creatinine. To prevent ureteral injuries, the surgeon must have a thorough knowledge of the location of the ureter during various pelvic procedures and the specific regions where it is most susceptible to injury.     

剖宫产术中输尿管损伤的识别与处理

输尿管损伤是剖宫产重要并发症之一,高危因素有急症剖宫产手术、剖宫产手术史、剖宫产术中子宫切除术、其他盆腹腔手术史以及盆腔感染史。损伤部位多发生在下段输尿管,尤其是距输尿管膀胱连接的1.5～3cm处,左侧多于右侧。术中发现输尿管损伤较困难,术后可通过超声、CT尿路造影（CTU）或逆行肾盂造影等检查诊断。早期发现并及时修复输尿管损伤对预后至关重要,可以避免和减少术后并发症,降低医疗成本。如发现较晚且情况允许,也可在术后6周至3个月行延迟手术。避免剖宫产术中损伤输尿管,关键在于预防,严密观察产程、及时处理产程异常,避免长时间试产后转剖宫产,术中仔细操作,避免损伤输尿管。     

妇科腹腔镜手术中输尿管损伤的临床特点及处理

目的探讨妇科腹腔镜手术中输尿管损伤的主要原因及诊断、治疗和预防的方法。方法回顾性分析我院13年间,妇科腹腔镜手术中发生输尿管损伤患者的临床资料、疾病类型、盆腔情况、手术类型、损伤特点、诊治情况及预后。结果．5541例妇科腹腔镜手术中,共发生输尿管损伤8例,发生率为0．14％,其中腹腔镜辅助阴式子宫切除术(LAVH)发生输尿管损伤6例,腹腔镜下全子宫切除术(TLH)1例,盆腔侧壁粘连松解手术1例。主要妇科疾病为：子宫腺肌症、子宫内膜异位症、子宫肌瘤;8例均有盆腔粘连,4例有盆腹腔手术史,7例子宫手术者,子宫均有增大(6～10周)。输卵管损伤症状出现于术后0～13d,包括：引流量增多、腹痛或腹胀、腰疼、恶心呕吐、发热、尿量减少、阴道流水、腹部皮下水肿、腹膜炎等。诊断时间在术后0～17d,主要确诊方法为静脉肾盂造影。损伤位于输尿管下段6例,入盆腔段2例。2例早期发现者均行开腹手术修补,晚期发现者,2例输尿管置管成功,3例置管当时失败,1例置管后又出现尿瘘行开腹修补。预后均较好。结论输尿管损伤是妇科腹腔镜手术少见而严重的并发症。术后引流量的异常增多以及出现发热、腰腹痛、急腹症、阴道流水等症状时,应警惕输尿管损伤的可能。治疗以手术为主。     

Laparoscopic repair of ureteral injuries

STUDY OBJECTIVE: To assess the outcome of laparoscopic repair of pelvic ureter injuries. DESIGN: Retrospective case series (Canadian Task Force classification II-2). SETTING: Large urban tertiary care medical center. PATIENTS: Four women who had pelvic ureter injuries and laparoscopic repair during laparoscopic gynecologic procedures. INTERVENTION: Laparoscopic ureteroureterostomy. MEASUREMENTS AND MAIN RESULTS: All injuries were identified immediately and repaired laparoscopically. No patient required repeat surgery. On assessment by physical examination, serum creatinine, and intravenous urogram, no patient had evidence of renal insufficiency. One woman had a narrowing at the site of ureteroureterostomy 6 weeks after repair; it was resolved on urogram 8 months after the injury. CONCLUSION: Laparoscopic ureteroureterostomy is feasible in some cases of ureteral injury. Experience with laparoscopic suturing is necessary to perform this procedure.     

Ureteral injuries during classic intrafascial supracervical hysterectomy: an 11-year experience in 1163 patients

STUDY OBJECTIVE: To examine the incidence, characteristics, and treatment of ureteral injuries during classic intrafascial supracervical hysterectomy for benign gynecologic diseases. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Department of obstetrics and gynecology, university teaching hospital. PATIENTS: A total of 1163 women with benign gynecologic diseases. INTERVENTIONS: Classic intrafascial supracervical hysterectomy. MEASUREMENTS AND MAIN RESULTS: A retrospective chart review was conducted to determine the rate of ureteral injury. Four cases of ureteral injuries occurred among the 1163 classic intrafascial supracervical hysterectomy procedures (0.34%). Ureteral injury occurred during peritoneal dissection in 1 case, which was treated immediately with laparoscopy. In 2 cases, ureteral injuries were recognized by watery vaginal discharge several days after the operation and were treated with laparotomy procedures. Ureteral injury was not detected postoperatively in another case, resulting in a laparoscopic nephrectomy caused by a nonfunctioning kidney 3 years after the initial operation. The predisposing factors for ureteral injury were adhesion as a result of endometriosis, and earlier surgery in which the normal pelvic anatomy was distorted. CONCLUSION: The incidence of ureteral injury during classic intrafascial supracervical hysterectomy as noted in this study is 0.34%. Postoperative cases were associated with high morbidity. Early detection of ureteral injury is crucial for appropriate management as intraoperative diagnosis and repair of the injury then has fewer consequences and less serious complications than postoperative cases.     

Ureteral injury after laparoscopic surgery

Ureteral injuries are uncommon but serious complications of laparoscopic pelvic surgery. When unrecognized, patients experience fever, abdominal pain, signs of peritonitis, and leukocytosis usually 48 to 72 hours after the surgical procedure. A 48-year-old woman underwent laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and anterior and posterior colporrhapy due to a large, symptomatic uterine myoma. Postoperatively, she suffered from progressive left lower quadrant pain, with drainage of yellowish fluid from the subumbilical puncture wound 5 days after the operation. Significant urinary ascites was present. Intravenous pyelogram revealed injury to the lower third of the left ureter about 3 cm away from the ureterovesical junction. Leftsided percutaneous nephrostomy was performed after transurethral placement of a ureteral stent failed. Reanastomosis of the ureter was performed successfully 3 months later, and the patient fully recovered without compromise of the genitourinary tract.     

Urinary tract injury in laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To evaluate the incidence and characteristics of urinary tract injury after laparoscopic-assisted vaginal hysterectomy (LAVH). DESIGN: A retrospective study that evaluated all cases of urinary tract injury at the time of LAVH in an 11-year period. Parameters including surgical indication, site of injury, time of diagnosis, method of treatment, and long-term follow-up were analyzed. (Canadian Task Force classification II-2). SETTING: Tertiary care university hospital. PATIENTS: A total of 38 urinary tract injuries were found in 7725 LAVH. INTERVENTION: LAVH and repair of urinary tract injuries with transvaginal or transabdominal approach. MEASUREMENTS AND MAIN RESULTS: The incidence of urinary tract injury after LAVH was 4.9/1000 procedures: 3.9/1000 for urinary bladder injury and 1.0/1000 for ureteral injury. Prior cesarean section was the most common risk factor for bladder injuries. Ninety-six percent (29/30) of urinary bladder injuries were detected and treated during surgery. Half (4/8, 50%) of the ureteral injuries were identified during surgery. Of the 38 complications, 28 (75.7%) occurred in surgery. CONCLUSION: Most urinary tract injuries in LAVH were identified during surgery and are associated with the surgeon's experience. Bladder injury can be repaired either transvaginally or abdominally; ureteral injury can be repaired abdominally.     

Iatrogenic ureteral injury: aggressive or conservative treatment

Many different approaches are advocated for management of iatrogenic (operative) ureteric injury. We herein report our experience with 28 ureteral injuries in 26 patients. In six patients, seven injuries were recognized at the time of the initial operation; four end-to-end anastomoses and three ureteroneocystostomies were successfully performed. In 20 patients the diagnosis of injury was delayed. In 14 of them a ureteroneocystostomy with or without Boari bladder flap was performed. The other six patients were first treated by percutaneous nephrostomy, which was successful in only two cases. The other four needed subsequent operative management. The main point that has emerged from our review is that early definitive operative repair is both feasible and preferable.     

Uretero-fallopian fistula after gynecological surgery for endometriosis: a case report

Urinary tract injuries are unfortunate complications of pelvic surgery. These frequently involve the bladder. The incidence of iatrogenic ureteral lesions ranges from 0.05% to 30%. Even though some lesions are observed intraoperatively, most remain undiscovered and reveal themselves later. Fistulas of ureteral origin usually involve the vagina or more rarely the uterus. Uretero-fallopian fistulas are even more rare. We report a case of uretero-fallopian fistula that developed after surgery for endometriosis.