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。

Clinical analyses of 42 cases of urinary tract injury in gynecologic surgery

Objective To determine the clinical characteristics and management of urinary tract injuries incidental to gynecologic surgery. Methods During the study period from Jan. 1,1990 to Dec. 31, 2001, forty-two patients with urinary tract injuries in gynecologic surgery were analyzed retrospectively focusing on type and time of injury, diagnostic methods and managements of urinary fistula. Results Forty-two urological injuries were incurred during the performance of 12 849 gynecologic surgical procedures, an incidence of 0.33% including of 11 ureteral injuries and 31 bladder injuries, an incidence of 0.09% and 0.24% respectively. Of the 11 ureteral injuries 5 occurred in the lower ureter, 4 occurred at the level of vecical entrance and 2 were in the region of the infundibulopelvic ligaments. Of the bladder injuries, all 31 occurred at the bottom or back of the bladder. Urinary tract injury was made intraoperatively in 32 patients (76%) and made postoperatively in 10 patients (24%). Urinary fistulae occurred in 14 patients (33%). Ten patients with urinary fistulae were diagnosed by comparing the concentration of electrolyte, urea nitrogen and creatine in drainage fluid with those in urine and blood. Infusion of methylene blue and/or cystoscopy were checked in 9 patients and 4 bladder fistulae were found positive results. All 8 ureteral fistulae were diagnosed by intravenous pyelography. An appropriate repair during operation, putting the double J-catheter and/or catheterization was useful. Forty-one patients were healed. Conclusion Most of urinary tract injuries in gynecologic surgery had optimal results when they were diagnosed early and managed correctly.