宫腔镜代替膀胱镜行膀胱内检查及输尿管逆行插管在妇科腹腔镜手术中的应用（附28例分析）

目的探讨在妇科腹腔镜手术中,以宫腔镜代替膀胱镜行膀胱内检查及输尿管逆行插管的临床应用价值。方法对19例盆腔病变复杂的妇科腹腔镜手术,在手术前使用宫腔镜代替膀胱镜行输尿管逆行插管;另有9例腹腔镜术后使用宫腔镜代替膀胱镜观察双侧输尿管开口蠕动（喷尿）及膀胱内情况。结果术前行输尿管逆行插管的19例,术中借助导管的定位辨识,避免了输尿管损伤及相关并发症;9例术后宫腔镜代替膀胱镜检查,发现1例左侧输尿管开口蠕动消失,立即腹腔镜探查并拆除该侧输尿管周围组织缝合线,再次置镜观察,输尿管开口蠕动恢复;1例发现膀胱内菜花状新生物,定位活检病理回报为膀胱移行细胞癌,转泌尿外科诊治。28例术后肉眼血尿时间16～42h,无泌尿系感染及相关并发症发生。结论在妇科困难腹腔镜手术中,以宫腔镜代替膀胱镜进行膀胱内检查及输尿管逆行插管,能够降低和及时发现输尿管损伤,是预防妇科腹腔镜手术中输尿管损伤并发症的有效措施。     

腹腔镜技术在治疗妇科手术致输尿管损伤中的临床应用研究

目的:探讨妇科手术导致输尿管损伤行腹腔镜治疗的安全性及有效性。方法:回顾性分析2014年1月~2016年6月妇科手术发生输尿管损伤并腹腔镜修复的17例患者临床资料。平均年龄42(22~67)岁。术中发现输尿管损伤5例,即刻腹腔镜或膀胱镜置入双J管,腹腔镜下输尿管修补缝合或输尿管断端吻合。术后延迟发现输尿管损伤12例。其中1例为孤立肾患者,输尿管镜检发现输尿管下段局部缺损,予置入双J管并腹腔镜下修补输尿管。其余均在术后7~35天出现阴道残端漏尿。先在膀胱镜或输尿管镜下置双J管,置管失败11例患者行腹腔镜探查。损伤位置低,输尿管与膀胱直接插入吻合。损伤位置高,游离裁剪膀胱壁瓣并缝合成管状与输尿管吻合。结果:1例术后延迟发现输尿管损伤并成功置入双J管者长期漏尿,3个月后再行腹腔镜手术成功。其余患者均一期手术成功。术后住院5~8d,平均6d,保留导尿3~4周,术后4~8周膀胱镜下拔除双J管。全部病例术后3~6个月复查B超提示轻度积水。结论:妇科手术致输尿管损伤行腹腔镜下修复安全性好,成功率高,而且创伤小,瘢痕少,可以提高患者的满意度。     

输尿管插管在预防妇科三、四级腹腔镜手术中输尿管损伤的应用价值

目的：探讨输尿管插管在预防妇科三、四级腹腔镜手术中输尿管损伤的应用价值。方法选取2009年1月～2011年11月182例我科三、四级腹腔镜手术182例作为研究组,术前均用膀胱镜放置双侧输尿管导管,然后行腹腔镜手术,术中在输尿管导管指示下手术,术后立即拔除导管。选取同期我科三、四级腹腔镜手术200例作为对照组,术前未行输尿管插管,比较2组患者术后输尿管损伤的发生率。结果研究组双侧输尿管置管成功率98．9％（180/182）,无一例损伤输尿管。对照组术后发现输尿管损伤2例,开腹行输尿管修补术并留置双J管,术后2个月治愈;膀胱损伤2例,术中均及时发现,立即请泌尿外科会诊,在泌尿外科大夫的协助下及时行膀胱修补术,术后留置尿管2周治愈。2组并发症发生率无统计学差异（ P＝0．125）。结论在妇科三、四级腹腔镜手术中应用输尿管导管可减少术中输尿管损伤的发生。     

腹腔镜子宫切除术后输尿管阴道瘘的原因及处理

目的探讨腹腔镜子宫切除术后输尿管阴道瘘的原因及外科处理方法的选择。方法 2002年3月~2009年6月对22例妇科腹腔镜子宫切除手术导致输尿管阴道瘘施行即时经膀胱镜放置双J管（2例）;膀胱镜置管失败者采用经输尿管镜置入斑马导丝然后再置入双J管（4例）;上述2种方法均失败者采用经腹膜外或腹腔途径输尿管膀胱再吻合术,输尿管内置双J管（16例）。结果通过手术探查和输尿管镜检发现电刀电凝伤7例,血运障碍6例,直接损伤3例,输尿管缝扎2例,解剖变异2例;2例经膀胱镜双J管置入治愈未能了解原因。22例随访6~48个月,平均25.7月,6例经内镜支架管置入中3例术后出现输尿管下段狭窄行输尿管膀胱再吻合术;16例行输尿管膀胱再吻合术,其中15例治愈,1例术后2个月再次出现输尿管阴道瘘,经皮肾穿刺肾造瘘后3个月再行膀胱肌瓣输尿管吻合术治愈。结论输尿管阴道瘘是腹腔镜妇科手术的严重并发症,一经确诊应积极处理,但应根据患者具体病情制定个体化的治疗方案,治疗措施以恢复正常排尿通路及保护患侧肾脏功能为原则。     

医源性腔镜下输尿管损伤的原因分析与处理

<正>随着微创外科的发展,输尿管镜、腹腔镜、电切镜得到越来广泛地应用,由此带来的输尿管医源性损伤[1～4]并不少见。早期发现输尿管损伤并及时处理能够改善患者预后,减少输尿管狭窄[5]等远期并发症,避免或减少医疗纠纷,维护医疗安全。2010年1月～2016年12月我院开展输尿管镜检查及碎石术351例,妇科腹腔镜子宫切除手术273例,膀胱肿瘤电切手术127例,其中27例腔镜下输尿管医源性损伤,经过早期手术干预,患者预后良好,未出现远期并发症,现报道如下。     

预置输尿管导管在妇科复杂腹腔镜手术中的应用

目的:探讨预置输尿管导管在妇科复杂腹腔镜手术中的应用价值。方法:选取200例妇科复杂腹腔镜手术,术前均用膀胱镜置入双侧输尿管导管,然后行腹腔镜手术,术中在导管指示下手术,术后立即拔除导管,其中宫颈癌根治术20例,全子宫切除术68例,鞘内子宫切除术43例,卵巢囊肿剥除术25例,子宫肌瘤切除术26例,子宫内膜异位症病灶清除术18例。结果:双侧输尿管置管成功率99.5%,200例中无一例损伤输尿管,明显降低了输尿管损伤的发生率。结论:在妇科复杂腹腔镜手术中应用输尿管导管可明显降低术中损伤输尿管的可能性。     

腹腔镜盆腔手术致泌尿系脏器损伤的防治

目的总结腹腔镜盆腔手术致泌尿系脏器损伤的原因、处理方法及预防措施。方法回顾性分析26例因腹腔镜盆腔手术致泌尿系脏器损伤的临床资料,包括普外科直肠手术3例、妇科手术23例;输尿管损伤21例、膀胱损伤5例。结果术中及时发现泌尿系损伤者7例,分别经内置双J管、输尿管端端吻合、输尿管或膀胱修补处理,均一期愈合,无并发症发生。术后发现泌尿系损伤者19例,其中膀胱阴道瘘3例,行耻骨上经膀胱修补成功;输尿管损伤16例,2例行逆行插管置双J管、14例行开放输尿管膀胱再植术治愈。结论腹腔镜盆腔手术创伤小、疗效高,提高手术操作技巧、积累经验有利于减少并发症的发生。     

输尿管镜下双 J管置入术治疗输尿管损伤的疗效分析（附36例报告）

目的：探讨输尿管镜手术治疗输尿管损伤的临床疗效。方法回顾性分析2006年1月～2013年12月采用输尿管镜下置入双J管内引流治疗36例输尿管损伤患者的临床资料。结果33例顺利经输尿管镜置入双J管引流，术后1～3周停止漏尿，其中13例术后1～3个月拔除双J管，20例盆腔肿瘤放疗者术后5～11个月拔除或更换进口巴德（ BADE）内支架管，术后随访3个月～6年，泌尿系CT成像（ CTU）检查证实患侧输尿管通畅，6例肾积水及输尿管扩张较前明显减轻，其余正常。1例腹腔镜下全子宫切除术中发现右侧输尿管损伤，术后40天拔出双J管后输尿管阴道瘘，因局部瘢痕及漏口较大，再次置管失败，改行输尿管膀胱再植术。2例因前列腺癌或宫颈癌放疗后严重输尿管狭窄，行永久性双肾造瘘术。结论输尿管镜下置入双J管内引流术治疗输尿管损伤的疗效可靠，微创，患者易于接受。     

妇科手术中泌尿系损伤9例临床分析

目的探讨妇科手术中泌尿系损伤的易发因素、临床特点及预防方法。方法对2001年1月1日至2010年12月31日10年间在中山大学附属三院妇科手术中发生泌尿系损伤的9例病例的损伤高危因素、损伤情况、损伤后诊治及预后进行回顾性分析。结果 10年间妇科手术8672例,发生泌尿系损伤9例,发生率为0.10%,其中输尿管损伤6例,发生率0.07%,膀胱损伤3例,发生率0.03%。主要疾病为子宫腺肌症、子宫内膜异位症4例（44.4%）,子宫肌瘤2例（22.2%）,宫颈肌瘤1例（11.1%）,晚期卵巢癌1例（11.1%）,宫颈癌1例（11.1%）。9例中有盆腔粘连7例（77.8%）,子宫增大（6～13周）7例（77.8%）,盆腹腔手术史4例（44.4%）,2例（22.2%）为新开展宫、腹腔镜手术时发生。发现损伤的时间,术中6例（66.7%）,术后3例（33.3%）,术后发现者均为输尿管损伤,症状出现于术后3～14天,包括腹胀、腰疼、低热、尿量减少、阴道流水等。结论盆腹腔的严重粘连、子宫增大、盆腹腔手术史是妇科手术中泌尿系损伤的易发因素,输尿管损伤在术中易漏诊,应重视泌尿系损伤的易发因素,术前术中积极防治以减少损伤。     

双根“DJ”管治疗妇科腹腔镜手术输尿管热损伤的应用体会

目的：探讨治疗腹腔镜妇科手术后延迟发现的输尿管热损伤安全、有效、微创的方法。方法：回顾分析4例腹腔镜术后发现输尿管损伤患者的临床资料。其中子宫肌腺症2例、宫颈癌1例、卵巢子宫内膜异位囊肿1例。分别行腹腔镜下全子宫切除、宫颈癌根治、卵巢囊肿切除术。于术后第8天、第8天、第16天、第10天确诊输尿管热损伤，输尿管镜下见损伤处位于输尿管开口上1—10cm，局部苍白破渍，输尿管断裂面达1／3～2／3。结果：4例患者中2例放置单根“DJ”管失败后重置双根均获成功；2例直接放置双根“DJ”管成功。4例患者均于置管后3个月拔管，最长随访2年余，无异常。结论：对于延迟发现的腹腔镜妇科手术导致的输尿管热损伤，双根“DJ”管的内支架与引流更充分、不堵塞，可有效预防远期瘢痕狭窄、避免再次手术，是有效的保守治疗方式。     

Prophylactic ureteral catheterization in gynecologic surgery: a 12-year randomized trial in a community hospital

Introduction  The aim of this study is to determine the efficacy of preoperative ureteral catheterization as a prophylactic measure to prevent ureteral injury and related complications. Methods  All major gynecologic operations performed between January 1996 and December 2007 were included and prospectively randomized into with and without catheterization groups. The medical records allowed the identification of all urinary tract complications and ureteral injuries. Results  Bilateral prophylactic ureteral catheterization was performed in 1,583 patients. A ureteral injury occurred in 19 (1.20%) out of 1,583 patients. Seventeen ureteral injuries (1.09%) occurred out of 1,558 patients without prophylactic ureteral catheterization. There was no statistically significant difference in the incidence of ureteral injury between the different interventional groups (p = 0.774). Conclusion  The use of prophylactic ureteral catheters did not eliminate ureteral injuries in our patients. The presence of ureteral catheters should not supplant meticulous surgical techniques and direct visualization of the ureters during gynecologic surgery.     

Accuracy of cystoscopy in the diagnosis of ureteral injury in benign gynecologic surgery

Our objective was to review our experience and attempt to identify risk factors for ureteral injury during gynecologic surgery for benign conditions. A retrospective chart review was performed of all cases of ureteral injury during gynecologic surgery for benign conditions, at Temple University Hospital, from January 1992 to September 2002. We analyzed hospital records to determine whether the injury was diagnosed intraoperatively, with postprocedure cystoscopy, or if cystoscopy was ineffective in diagnosing the injury. There were nine ureteral injuries during the study period. Of these, two were diagnosed during the procedure, two were discovered by immediate postprocedure cystoscopy, and the other five were discovered during the postoperative period. Of these five, three patients had immediate postprocedure cystoscopy and the injuries were not detected. Risk factors associated with ureteral injury included: a large uterus (5), high-grade cystocele (3), ectopic insertion of the ureter into the bladder (1), and previous surgeries (4). Our conclusion was that negative cystoscopy cannot be solely relied on to rule out ureteral injury, as cases with partial obstruction and ureteral patency can be missed.Abbreviations CVA Costovertebral angle - IVP Intravenous pyelography - UVJ Ureterovesical junction Editorial Comment: Ureteral injury during routine benign gynecologic surgery is rare. However, a significant amount of morbidity is associated with delayed diagnosis and with the subsequent therapeutic interventions that occur. It seems intuitive that altered anatomy, whether from previous surgery or from a large myomatous uterus, increases the risk of ureteral injury. Careful and thorough intraoperative ureteral identification combined with routine cystoscopy reduces the incidence of delayed diagnosis of complete ureteral obstruction. For partial ureteral obstruction, though, the role of cystoscopy is less clear. Because ureteral efflux can still occur in partial obstruction, there may be a lot more unrecognized ureteral injuries or kinking. In spite of these limitations, cystoscopy has little morbidity associated with it, and reduces the delay in diagnosis of other injuries to the lower urinary tract. A high clinical index of suspicion in the immediate postoperative period may be the only way to reduce the subsequent morbidity associated with the delayed diagnosis of partial ureteral obstruction.     

Laparoscopy and re-laparoscopy in the diagnosis and treatment of postoperative complications

Experience of repeated laparoscopic surgeries in early and late postoperative period in 112 patients is analyzed. In early postoperative period repeated laparoscopy was performed in 75 patients for prevention, diagnosis and treatment of postoperative complications. In 54 patients repeated laparoscopy was carried out for programmed control for pathologic process. Laparoscopic surgery for diagnosis and treatment of postoperative complications was performed in 27 patients. In this group complications were seen in 2 patients. Technical features of repeated laparoscopy are demonstrated. Laparoscopic surgeries after laparotomic and laparoscopic operations are a good component of complex treatment and prophylaxis of severe complications in abdominal surgery. Prior performed abdominal operation is not contraindication for laparoscopy.     

Prophylactic ureteral catheterization in gynecologic surgery

Objectives. To examine the frequency of ureteral catheter usage, its efficacy in preventing injury, and related complications, because the preoperative routine placement of ureteral catheters as a prophylactic measure to prevent ureteral injury is controversial.Methods. All major gynecologic operations performed between January 1992 and December 1994 were identified. All gynecologic procedures that were preceded by ureteral catheter placement were also identified. A data base maintained by the Department of Quality Management allowed identification of all urinary tract complications and ureteral injuries. Four categories of surgery were analyzed: exploratory laparotomy with catheters, exploratory laparotomy without catheters, operative laparoscopy with catheters, and operative laparoscopy without catheters. The medical records of all patients with urinary tract complications were reviewed.Results. Bilateral prophylactic ureteral catheterization was performed in 469 (15.3%) of 3071 patients. A ureteral injury occurred in 4 (0.13%) of 3071 patients. All four ureteral injuries (0.17%) occurred among 2338 patients who underwent exploratory laparotomy. None of the 733 patients who underwent operative laparoscopy suffered ureteral injury. The incidence of ureteral injury in patients who had ureteral catheters placed before exploratory laparotomy was 2 (0.62%) of 322. Two (0.10%) of 2016 patients who did not have prophylactic ureteral catheters suffered a ureteral injury. There was no statistically significant difference in the incidence of ureteral injury between patients who did and patients who did not undergo ureteral catheterization (P = 0.094).Conclusions. The use of prophylactic ureteral catheters did not affect the rate of ureteral injury in our patients. The very low incidence of ureteral injury among our patients is attributed mainly to meticulous surgical technique.     

Robotic-assisted laparoscopy in gynecological surgery.

BACKGROUND: Laparoscopic surgery has revolutionized the concept of minimally invasive surgery for the last 3 decades. Robotic-assisted surgery is one of the latest innovations in the field of minimally invasive surgery. Already, many procedures have been performed in urology, cardiac surgery, and general surgery. In this article, we attempt to report our preliminary experience with robotic-assisted laparoscopy in a variety of gynecological surgeries. We sought to evaluate the role of robotic-assisted laparoscopy in gynecological surgeries. METHODS: The study was a case series of 15 patients who underwent various gynecologic surgeries for combined laparoscopic and robotic-assisted laparoscopic surgery. The da Vinci robot was used in each case at a tertiary referral center for laparoscopic gynecologic surgery. An umbilicus, suprapubic, and 2 lateral ports were inserted. These surgeries were performed both using laparoscopic and robotic-assisted laparoscopic techniques. The assembly and disassembly time to switch from laparoscopy to robotic-assisted surgery was measured. Subjective advantages and disadvantages of using robotic-assisted laparoscopy in gynecological surgeries were evaluated. RESULTS: Fifteen patients underwent a variety of gynecologic surgeries, such as myomectomies, treatment of endometriosis, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, and Moskowitz procedure. The assembly time to switch from laparoscopy to robotic-assisted surgery was 18.9 minutes (range, 14 to 27), and the disassembly time was 2.1 minutes (range, 1 to 3). Robotic-assisted laparoscopy acts as a bridge between laparoscopy and laparotomy but has the disadvantage of being costly and bulky. CONCLUSION: Robotic-assisted laparoscopic surgeries have advantages in providing a 3-dimensional visualization of the operative field, decreasing fatigue and tension tremor of the surgeon, and added wrist motion for improved dexterity and greater surgical precision. The disadvantages include enormous cost and added operating time for assembly and disassembly and the bulkiness of the equipment.     

经腹与经腹膜外腹腔镜下前列腺癌根治术的效果比较

目的 比较经腹与经腹膜外途径腹腔镜下手术治疗前列腺癌的临床效果.方法前列腺癌患者33例行腹腔镜下前列腺癌根治术,其中经腹21例,经腹膜外12例.对2组患者手术时间、术中出血量、术中并发症、肠功能恢复时间、术后住院时间、术后并发症等资料进行比较分析.结果 33例手术均成功.经腹与经腹膜外2组手术时间分别为(299±46)和(309±64)min,出血量分别为(618±448)和(677±469)ml,2组比较差异无统计学意义(P＞0.05).经腹组术中发生大出血3例、膀胱损伤2例、单侧输尿管损伤1例,经腹膜外组术中发生大出血1例、闭孔神经损伤1例、腹膜损伤1例、膀胱三角损伤1例.2组术后留置导尿时间分别为(14.6±3.8)和(12.3±2.9)d,肠功能恢复时间分别为(2.7±0.7)和(2.1±0.5)d,术后住院时间分别为(17.0±3.6)d和(11.2±3.5)d,2组比较差异均有统计学意义(P＜0.05).结论 腹腔镜下前列腺癌根治术经腹膜外比经腹途径具有视野清晰、对腹腔器官影响小、术后恢复快、术后住院短等优点.     

Ureteral risk in celioscopic surgery]

In recent years, there has been a significant improvement in laparoscopic surgery which had led to more and more frequent use of this technic in various cases. As a consequence, the ureteral injury which have been a less common iatrogenic pathologic up to know is likely to be more and more frequent in the years to come. The authors present 2 cases of 28 and 36 years old patients. In both cases the laparoscopy was indicated for gynecologic pathology. The healing ureteral occurred in those cases during a revealing postoperative peritonitis. Treatment consisted in healing up the lesion by ureteral stent. Treatment and evolution of this injury are discussed.