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.     

Voiding after gynecologic surgery: Experience with 24-hour Foley catheterization

Postoperative voiding was studied in 227 gynecologic patients after the introduction of a new routine of 24-hour Foley catheterization in all patients. After catheter removal 85% of patients (laparotomy 88.2%, colposuspension 85.2% and vaginal plastic surgery 80.3%) were able to void spontaneously, with residual urine <100 ml. 13.7% of patients had intermittent catheterization 1–3 times (mean 1.6) but established satisfactory voiding before evening. Altogether 98.7% of patients (laparotomy 99%, colposuspension 98.1%, vaginal surgery 98.6%) voided adequately before the end of the first postoperative day. One patient in each group had prolonged retention and required 3–63 days before voiding normally. The differences in retention rates between the three surgical groups were not statistically significant. The regimen of 24-hour postoperative Foley catheterization followed by intermittent catheterization if required is convenient and may be recommended after all common gynecologic operations.     

Urethral catheterization in spinal surgery: a randomized prospective study

Summary In a prospective randomized study the effect of the use of an intraoperative indwelling urethral catheter (IUC) on urinary complications was investigated in patients undergoing spinal fusion. Two groups were formed; 16 patients received an intraoperative IUC and 16 patients had no intraoperative catheter (NC). All patients were, if necessary, intermittently catheterized in the postoperative period. Seven of the patients in the IUC group had positive cultures, defined as 100000 CFU/ml, compared with two patients in the NC group (n.s.). Another four patients in the NC group had cultures 10000 CFU/ml. Thirteen patients in the IUC group and 14 patients in the NC group had positive dip slides. The largest received urine volume in each patient at one intermittent catheterization did not differ significantly between the groups. However, in three patients in the NC group the volumes exceeded 1000 ml. Thus, irrespective of treatment dip slides showed bacteriuria in 84% of the patients. Perioperative indwelling catheters do not seem to cause many more infection complications than no bladder drainage during surgery, and the advantages of reduced risk of bladder distension injury and more accurate monitoring of fluid balance suggest their use.     

膀胱镜检术在妇科腹腔镜手术输尿管损伤预防及早期诊断中的作用

目的探讨膀胱镜检术及输尿管插管在妇科腹腔镜手术输尿管损伤的预防及早期诊断中的价值。方法回顾中山大学附属第三医院妇科2006年1月至2012年9月期间2542例腹腔镜手术，对复杂病例（18例）及输尿管损伤病例（3例）进行总结分析。结果有7例病例术前检查提示病灶压迫输尿管或考虑盆腔粘连严重，为预防输尿管损伤，手术开始时先行膀胱镜下输尿管置管，结果无一例发生输尿管损伤。1I例病例因手术困难，手术结束前进行膀胱镜检查，发现输尿管损伤2例。2542例共发生输尿管损伤3例，其中2例在上述膀胱镜检查中发现，另外1例手术顺利，手术后两周出现腰痛，行静脉。肾盂造影发现输尿管损伤。结论输尿管损伤是妇科腹腔镜手术的严重并发症之一，对于复杂病例，手术时行膀胱镜下输尿管置管或膀胱镜检查，能一定程度上预防及早期发现输尿管损伤。     

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.     

Ureteral injuries in gynecologic surgery

Ureteral injuries are rare but potentially devastating complications of all major gynecologic operations. They occur in straightforward as well as complicated cases, to both experienced and neophyte surgeons. Preoperative IVP or placement of ureteral stents does not prevent ureteral injury, but identification and visualization of the ureters will minimize their incidence. Failure to recognize injuries intraoperatively converts a correctable venial sin into a catastrophic mortal sin, which can lead to serious morbidity, including loss of kidney and even patient death.     

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。     

Computer-enhanced robotic surgery in gynecologic oncology

Background This study aimed to report the computer-enhanced robotic surgery experience of the authors’ gynecologic oncology division. Methods From January 2001 to August 2006, 41 patients underwent laparoscopic surgery by our gynecologic oncology service using a computer-enhanced surgical robot. This report describes a retrospective review of these patients. Results The patients ranged in age from 27 to 77 years (mean, 44.2 years), in weight from 44 to 131 kg (mean, 72.1 kg), in operative time from 1 h and 50 min to 9 h (mean, 5 h and 2 min), and in estimated blood loss from 50 to 1,500 ml (mean, 253 ml). Of the 20 patients with gynecologic malignancies, 14 had cervical cancer. A total of 21 patients had benign indications for surgery. Complications included shoulder palsy, robot failure, colotomy, bradycardia, and intraabdominal bleeding requiring minilaparotomy and ligation of a bleeding pedicle. Conclusion This case series is one of the first to report the use of a computer-enhanced surgical robot in gynecologic oncology. This approach proved to be feasible and well tolerated in this series of patients and deserves further study for clarification of its indications, benefits, and safety.     

自制发光输尿管导管系统在腹腔镜手术中预防输尿管损伤的临床应用

目的探讨自制发光输尿管导管系统在腹腔镜手术中预防医源性输尿管损伤的有效性。方法腹腔镜手术操作前,在膀胱镜直视下向输尿管插入发光输尿管导管系统约22～30cm(因人而异),术中由助手协助操作间歇或连续按压电钮让已插入输尿管导管发光便于术者辨认或者避开输尿管。结果66例输尿管上段结石,22例肾盂结石都能准确快速找到病变部位,避免损伤周围血管;106例子宫切除术无1例损伤输尿管;22例直肠肿瘤手术(包括2例粘连严重腹腔镜下无法顺利完成手术改开放手术)均未损伤输尿管。结论腹腔镜下微创手术应用自制发光输尿管导管系统能有效预防医源性输尿管损伤。     

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。     

机器人单孔腹腔镜妇科手术11例临床观察

目的探讨达芬奇机器人单孔腹腔镜手术系统施行妇科手术的安全性及可行性。 方法回顾性分析解放军总医院妇产科2017年12月至2018年1月为11例患者施行达芬奇机器人单孔腹腔镜手术系统辅助妇科手术的临床资料。 结果达芬奇机器人单孔腹腔镜手术系统共施行11例妇科手术,均获得成功。包括卵巢囊肿剥除术4例,全子宫＋双附件切除术3例,子宫肌瘤剔除＋卵巢囊肿剥除术1例,盆腔粘连松解＋卵巢囊肿剥除术1例,单侧附件切除术1例,输卵管系膜囊肿剥除术1例。手术操作时间(49.0±19.3)min,术中出血量(33.6 ± 24.2)ml,术后排气时间(17.3±3.1)h,术后住院时间(2.3±0.9)d。11例患者在术中、术后均无并发症发生,均痊愈出院。术后随访患者脐部切口隐蔽,瘢痕不易发觉。 结论达芬奇机器人单孔腹腔镜手术系统应用于妇科领域是安全、可行的,但要求术者要熟悉盆腔解剖结构,而且应具备娴熟的腹腔镜技术。     

达芬奇机器人手术系统在妇科肿瘤的临床应用

机器人手术作为一个创新微创手术方法已经越来越多的应用于妇科领域。与传统的腹腔镜手术系统相比,其主要的优势为达芬奇机器人手术系统提供了高分辨率的三维立体视觉使术者手术视野环境极大改进。可以360°旋转的器械臂,能够精确完成各种精细手术操作。术者节省体力的同时过滤人手的抖动,使操作臂更稳、更精确。我们通过回顾相关文献评估和描述达芬奇机器人系统在妇科肿瘤的实际应用和临床效果。     

Robotic surgery in gynecologic oncology: evolution of a new surgical paradigm

Robotic surgical platforms were first developed with telesurgery in mind. Conceptualized by NASA and the military to provide surgical expertise to remote locations, some telesurgical success has been documented, but progress has been held back by communication bandwidth limitations. Telepresence surgery, where the surgeon is in proximity to the patient but is provided with an ergonomic console equipped with three-dimensional vision and autonomous control of wristed laparoscopic surgical instruments and energy sources, has shown efficacy first in cardiac and then urologic cancer surgery. Interest is currently focused on the application of this technology in the field of gynecology, with techniques being described to perform simple hysterectomy, myomectomy, tubal anastomosis, and pelvic reconstruction procedures. This article will review the application of robotic- and computer-assisted surgery in the specialty of gynecologic oncology.     

Postoperative ureteral obstruction after confirmed ureteral patency: a case report

Ureteral injury after pelvic floor surgery and anti-incontinence surgery is a well-known risk [1, 2, 3]. It is common practice to evaluate ureteral patency immediately after surgery prior to leaving the operating theater to assure that the ureters are open and functional [1, 2]. In this report we discuss the case of a patient who was admitted 9 days after surgery with acute onset of ureteral obstruction after having patent ureters documented at the time of surgery. A literature search failed to show any documented cases.Abbreviations UTI Urinary tract infection     

择期结直肠手术预防性应用抗生素的随机对照研究

目的探讨择期结直肠手术预防性应用抗生素的合理方案。方法将165例接受结直肠手术的患者随机分成3组：治疗1组（55例）在术前晚服用硫酸镁行肠道准备,麻醉诱导期静脉给予抗生素（头孢拉定2．0g）,术后追加应用2次抗生素（头孢拉定2．0g、0．5％甲硝唑100ml静脉滴注,24h内相隔12h应用）;治疗2组（50例）在治疗1组基础上,术后持续使用抗生素3～5d;对照组（60例）在治疗2组基础上,术前口服抗生素2～3d（甲硝唑0．4g,每日3次,卡那霉素0．2g,每日3次）。观察比较三组患者术后并发症（手术部位感染、吻合口漏、肠道菌群失调等）、术后白细胞变化、体温、住院时间和费用等指标。结果三组在术后手术部位感染、吻合口漏、术后白细胞计数及其下降幅度、术后体温、住院时间等方面差异均无统计学意义（P〉0．05）;治疗1组菌群失调发生率显著低于对照组（P〈0．05）;治疗1组平均抗生素使用费用显著低于另外两组（P〈0．05）。结论麻醉诱导期静脉给予抗生素,术后24h后停用抗生素是择期结直肠手术预防性应用抗生素的合理方案,可有效预防术后手术部位感染,抗生素相关不良反应少,并具有良好的经济效益。     

不同超前镇痛时点应用帕瑞昔布钠对妇科手术后的镇痛效果

目的 观察与比较不同超前镇痛时点应用帕瑞昔布钠对妇科手术后镇痛的作用效果.方法 将60例ASA Ⅰ或Ⅱ级择期妇科手术患者随机分为A、B两组,A组分别于麻醉诱导前10 min以及术后12h静脉注射帕瑞昔布钠40mg,而B组于手术结束时以及术后12h静脉给予帕瑞昔布钠40mg.两组患者术后均采用芬太尼进行患者自控静脉镇痛(PCA).观察术后12和24h患者PCA的总按压次数和PCA有效按压次数、术后2、4、6、12和24 h的疼痛强度(VAS评分)、满意程度(BCS评分)、镇痛的补救措施以及相关不良反应.结果 与B组比较,A组术后12和24 hPCA总按压次数和PCA有效按压次数降低(P＜0.05),术后2、4、6和12 h的VAS评分降低而BCS评分提高(P＜0.05),而两组24 h疼痛强度和满意度以及有关不良反应发生率差异尤统计学意义.结论 妇科手术超前应用帕瑞昔布钠,能减少术后芬太尼的用量,提高镇痛质量.