医源性输尿管膀胱损伤的预防与处理

医源性输尿管膀胱损伤的预防与处理

段萍　饶大庞　吕杰强　朱春丹

【摘要】　目的　探讨妇产科手术引起的医源性输尿管膀胱损伤的原因、预防与处理。方法　回顾性分析1996-2006年笔者所在医院妇产科传统手术引起的31例医源性输尿管膀胱损伤的病因及相应处理的临床资料。结果　良性疾病全子宫切除术输尿管损伤2例,膀胱损伤3例;子宫癌前病变扩大子宫切除术输尿管损伤3例,膀胱损伤2例;恶性肿瘤根治性子宫切除术输尿管损伤5例,膀胱损伤7例;剖宫产术损伤输尿管1例,膀胱损伤8例。术中发现输尿管损伤7例给予断端缝合,膀胱损伤15例给予修补;术后发现输尿管损伤4例,包括输尿管下段梗阻伴患侧肾积水2例,输尿管阴道瘘2例,尽早行输尿管下段膀胱再植术;术后发现膀胱阴道瘘5例,术后3个月行经膀胱瘘管切除修补术。术后随访5个月～10年,全部痊愈。结论　妇产科手术医源性损伤重在预防,及早发现并采取积极有效的措施,可减少并发症的发生。

【关键词】　医源性疾病;输尿管损伤;膀胱损伤

【中国图书资料分类号】　R61919

P revention and treatm ent of i atrogenic u reter and bladd er inju ry

Duan Ping,Rao Dapang,Lv Jieqiang,et al1Department of G ynecology,Second Affiliated Hospital,Wenzhou Medical C ollege,Wenzhou,Zhejiang325000,China

【Abstract】　Objective　T o investigate the etiological factors and measures for prevention and treatment of iatrogenic ureteral and bladder injury during obstetric and gynecologic operations.M ethods　Iatrogenic ureteral and bladder injury happened in31patients,who underwent traditional gynecologic operation from June1996to May2006at the Department of G ynecology and Obstetrics of the Second Af2 filiated Hospital of Wenzhou Medical C ollege.The etiological factors and treatment for iatrogenic ureteral and bladder injury were analyzed retrospectively.R esu lts　The median age of the patients was44years(ranged from27to61years).2cases of iatrogenic ureteral injury and 3cases of iatrogenic bladder injury occurred in hysterectomy.3cases of iatrogenic ureteral injury and2cases of iatrogenic bladder injure oc2 curred in subtotal hysterectomy for precancerous lesion.5cases of iatrogenic ureteral injury and7cases of iatrogenic bladder injury occurred in radical hysterectomy.One case of iatrogenic ureteral injury and8cases of iatrogenic bladder injury occurred in cesarean section.Intraop2 erative ureteral injury in7patients was repaired by end2to2end anastom osis,and intraoperative bladder injury in15patients were repaired during operation.In4patients the ureteral injury was found after operation,including2cases of ureterovaginal fistula,and the injury was repaired after resection of fistulas.Bladder injury was found in5cases after operation,and the injuries were repaired by closure of fistulas of bladder3months later.All cases recovered with no relapse during the follow2up period of5months to10years.C onclusions　Iatrogenic injury occurs during gynecological surgery should be prevented first.Early discovery and effective treatments can achieve good therapeutic effects.

【K ey w ords】　iatrogenic diseases;ureteral injury;bladder injury

妇产科手术容易引起输尿管下段、膀胱损伤,医源性输尿管损伤在子宫切除术、根治性子宫切除术、剖宫产术中的发生概率为015%～110%,医源性膀胱损伤导致膀胱阴道瘘也比较常见。温州医学院附属第二医院妇产科于1996年6月-2006年6月收治15981例手术患者,其中全子宫切除9654例,扩大子宫切除1168例,根治性子宫切除427例,剖宫产4732例,阴式子宫切除106例,其中发生医源性输尿管膀胱损伤31例。现将其发生原因、预防和临床处理经验总结如下。

1　资料与方法

1.1　资料来源及患者临床情况　本组31例,年龄27～61岁,平均44岁。术中发现输尿管损伤7例,膀胱损伤15例;术后3d～2周发现输尿管损伤4例,包括输尿管下段梗阻2例,输尿管阴道瘘2例;术后1周～1个月发现膀胱损伤5例,均导致膀胱阴道瘘。良性疾病子宫全切术输尿管损伤2例,膀胱损伤3例;子宫癌前

病变扩大子宫切除术输尿管损伤3例,膀胱损伤2例;根治性子宫切除术输尿管损伤5例,膀胱损伤7例;剖宫产术损伤输尿管1例,膀胱损伤8例(均有下腹部手术史)。

1.2　治疗方法　术中发现输尿管损伤患者7例,其中输尿管断裂5例,输尿管壁部分撕裂伤2例,均留置双J管,4-0可吸收线间断缝合输尿管断端,缝合口周围留置引流管1条,留置导尿管1周,术后2周膀胱镜下拔出双J管。术后3d～2周出现腰痛,经CT、静脉肾盂造影、膀胱镜下插管造影检查证实输尿管下段梗阻伴患侧肾积水2例,后经手术探查发现输尿管下段被缝线结扎、坏死。2例术后2周出现阴道尿瘘,经静脉肾盂造影及膀胱镜下灌注美蓝确诊为输尿管阴道瘘,均

【作者简介】　段萍,医学硕士,副主任医师。主要从事妇科肿瘤方面的研究

【作者单位】　325000　浙江温州　温州医学院附属第二医院妇科(段萍、吕杰强、朱春丹),泌尿外科(饶大庞)