微创技术治疗妇科手术后输尿管损伤(附33例报告)

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目的:探讨妇科手术导致输尿管损伤行输尿管镜和腹腔镜治疗的安全性及有效性。方法:回顾性分析2008年1月~2016年6月妇科手术发生输尿管损伤并微创治疗的33例患者临床资料。平均年龄45(20~69)岁。术中发现输尿管损伤5例,即刻使用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端端吻合;术后延迟发现输尿管损伤28例,其中1例为孤立肾患者,术后8h发现引流液量异常多并行输尿管镜检查,见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7~35d出现阴道残端漏尿。先行输尿管镜直视下置入双J管,置管成功16例,予以留置2~3个月。失败11例患者行腹腔镜探查。若损伤位置低,输尿管与膀胱直接插入吻合。若损伤位置高,则游离裁剪膀胱壁瓣并缝合成管状与输尿管吻合。结果:16例术后延迟发现输尿管损伤并成功置入双J管,有1例患者长期漏尿,3个月后再行腹腔镜手术成功,其余膀胱镜下拔除双J管无漏尿的发生。11例置管失败的患者均一期行腹腔镜修复手术成功。手术耗时110~160min,平均132min。术后住院5~8d,平均6d,予以保留导尿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个月行B超检查提示轻度肾积水。结论:妇科手术致输尿管损伤可置入双J管,置管成功经保守治疗效果理想。置管后保守治疗失败可行腹腔镜治疗,虽然具有一定挑战,但安全有效,相比传统手术具有创伤小、瘢痕少、术后恢复快等优势,可最大限度地减少患者心理负担,避免医患纠纷的发生。 Objective: To investigate the safety and effectiveness of ureteroscopic and laparoscopic treatment of ureteral injury caused by gynecological surgery. Methods: The clinical data of 33 patients with ureteral injury and minimally invasive treatment of gynecologic surgery from January 2008 to June 2016 were retrospectively analyzed. The average age of 45 (20 ~ 69) years old. Intraoperative findings of ureteral injury in 5 cases, immediate use of laparoscopic or cystoscopy into double J tube, laparoscopic ureter repair or ureteral end anastomosis; delayed ureteral injury found in 28 cases, of which 1 case of isolated kidney patients, 8h after surgery found abnormal drainage fluid volume parallel ureteroscopy, see the lower ureter local defect, to be placed in double J tube laparoscopic ureter repair. The remaining 7 to 35 days postoperative vaginal stump leakage. Ureteroscopy under direct urethral double J tube placement, catheterization in 16 cases, to be placed 2 to 3 months. Failure of 11 patients underwent laparoscopy. If the lesion is low, the ureter and bladder are directly inserted and anastomosed. If the injury position is high, then the bladder wall flap free cut and suture into the tube and ureter anastomosis. Results: In the 16 cases, ureteral injury was delayed and double J tube was successfully inserted. One case had long-term leakage of urine and three months later laparoscopic operation was successful. The other cases underwent cystoscopic double-J tube leakage-free . All 11 patients who failed the catheterization were treated with laparoscopic repair successfully. Surgery time-consuming 110 ~ 160min, an average of 132min. Postoperative hospital 5 ~ 8d, an average of 6d, to be retained catheterization for 3 to 4 weeks, 4 to 8 weeks after cystoscopy removed double J tube. All cases 3 to 6 months after the line B-ultrasound showed mild hydronephrosis. CONCLUSION: Gynecological surgery may result in double J tube ureteral injury. The successful management of the catheter by conservative treatment is satisfactory. Laparoscopic treatment of failure of conservative treatment after catheterization may be safe and effective although it possesses certain challenges. Compared with traditional surgery, it has the advantages of less trauma, less scarring and faster postoperative recovery, which can reduce the psychological burden of patients and avoid the problems of doctors and patients Occurrence of disputes.
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