妇科腹腔镜手术泌尿系损伤的临床分析

目的：探讨妇科腹腔镜手术发生泌尿系损伤的相关因素、诊断、治疗方法及预防措施。方法：回顾分析2002年1月至2012年12月北京大学人民医院妇科腹腔镜手术发生泌尿系损伤患者的临床资料。总结分析患者的疾病类型、手术方式、损伤特点、诊疗情况及预后等。结果：妇科腹腔镜手术共4773例，泌尿系损伤发生18例（0.38％），其中8例发生于腹腔镜恶性肿瘤手术，8例发生于腹腔镜辅助阴式全子宫切除术（LAVH），2例发生于腹腔镜附件手术。18例泌尿系损伤患者中5例有腹部手术史，有腹部手术史者的泌尿系损伤发生率高于无手术史者（P〈0.05）。18例泌尿系损伤患者中膀胱损伤4例，其中3例位于膀胱后壁，1例位于膀胱三角区；输尿管损伤14例，其中输尿管上段损伤2例，中段损伤10例，下段损伤2例；左侧输尿管损伤2例，右侧12例。术中发现损伤10例，其中4例膀胱损伤和6例输尿管损伤；术后发现8例，均为输尿管损伤，于术后1～10天发现，均经静脉肾盂造影确诊。11例经再次手术修补成功，7例放置输尿管支架6个月（3～12个月）保守治疗成功。结论：腹腔镜下恶性肿瘤手术、LAVH、有腹部手术史患者发生泌尿系损伤机率较高，输尿管损伤多于膀胱损伤。术者需高度警惕，术后严密观察，如发现泌尿道损伤，尽早请泌尿科医师共同决定治疗方法。

Urinary tract injury in gynecological laparoscopies

Objective：To investigate the main reason, diagnosis, treatment and prevention of the urinary tract injury in gynecological laparoscopies. Methods：The clinical data of 18 patients who suffered urinary tract injury in gynecological laparoscopic operation from Jan. 2002 to Dec. 2012 were retrospectively analyzed. The type of disease, way of operation, character of injury, diagnosis, treatment and prognosis were summarized. Result： There were 18 urinary tract injury（0.38% ） in 4773 gynecological laparoscopies with 8 in malignant diseases laparoscopies, 8 in laparoscopically assisted vaginal hysterectomy （LAVH） and 2 in adnexal disease laparoscopies. 5 patients had previous pelvic operations, and it turned out that the urinary tract injury rate was higher in patients who had previous pelvic operations than those who had not（P〈0.05）. There were 4 bladder injuries with 3 at back of bladder and 1 at trigone of bladder. Of the 14 ureteral injuries 2 occurred in the upper ureter, 10 in the central section of the ureter and 2 in the lower ureter. 2 left side ureter suffered while 12 right side ureter suffered. 10 of these urinary tract injuries were diagnosed during operation including all of the bladder injuries and 6 ureteral injuries. The other 8 ureteral injuries were diagnosed by image examination 1～7days after laparoscopies. 11 restoring surgeries were successful by operation while 7 ureteral injuries were placed trestle and removed after 6 （3 ～12）months. Conclusions：Most of urinary tract injuries in gynecological laparoscopies occurred in malignant tumor operations, LAVH and patients who had previous pelvic operations. Although uncommon, ureteral injury was more often than bladder injury. Awareness of urinary tract protection and more attention should be enhanced within laparoscopic surgery. When injury happens,urologist should be consulted at first place to make a good decision for the management. Most have optimal results when they are diagnosed early and treated correctly.