子宫动脉栓塞治疗妇产科良性疾病引起泌尿系统损伤的临床研究

Study of the injury to the urinary system caused by radiological vascular interventional therapy of obstetrical and gynecological benign diseases

目的探讨子宫动脉栓塞(uterine arterial embolization,UAE)治疗妇产科良性疾病引起泌尿系统损伤的原因、治疗及预防。方法对我院妇产科医学微创介入治疗中心收治的960例因妇产科良性疾病行UAE治疗患者的临床资料,进行回顾性分析,960例中,子宫肌瘤690例、子宫腺肌病244例、异位妊娠10例及产后出血16例。同时对损伤发生的血管解剖学、血管影像学及微导管的使用等问题进行分析总结。结果960例中,发生不同程度的泌尿系统损伤共5例,总发生率为0·5%(5/960)。其中中度损伤1例(0·1%),为一侧输尿管节段性部分狭窄致肾积水;轻度损伤4例(0·4%),为膀胱炎1例、膀胱黏膜部分坏死1例、一过性一侧肾轻度积水2例。5例中,子宫肌瘤4例、子宫腺肌病1例;5例均行双侧子宫动脉UAE术,术中均未使用微导管。行UAE引起泌尿系统损伤的原因,均为在栓塞动脉的过程中,栓塞剂进入子宫动脉中下段发出的输尿管支及膀胱支。结论对妇产科良性疾病进行UAE治疗,有发生泌尿系统损伤的危险;术中准确分辨血管及其分支、交通支,采用子宫动脉上行支进行栓塞,可以避免泌尿系统损伤的发生。

Objective To explore the injuries to the urinary system caused by uterine artery embolization （UAE） for treatment of obstetrical and gynecological benign diseases, including the classification,aetiology, therapy of the injuries and precaution methods. Methods The injuries of the urinary system were reviewed in 960 cases of obstetrical and gynecological benign diseases treated with UAE by our interventional centre. Of all 960 cases, 690 cases were myoma, 244 adenomyosis, 8 cervical pregnancy ,2 comus pregnancy, 14 postpartum hemorrhage, 2 late postpartum hemorrhage. Meanwhile, the correlative problems of the vascular anatomy, DSA and the embolization technics of microcatheter were analyzed. Results （ 1 ） Different degrees of urinary system injuries occurred in 5 of 960 cases ,the rate was 0. 5%. None was severe injury , one case （0. 1% ） was moderate injury, and the patient suffered of hydronephrosis caused by segmental necrosis of unilateral ureter. Mild injury occurred in 4 cases （0. 4% ）, including one case of inflammation of bladder, one case of partial necrosis of bladder mucosa membrane, 2 cases of transient slight unilateral hydronephrosis. Among all the injuries, 4 occurred in myoma patients, and one occurred in adenomyosis patient. The operation procedures of all five cases were bilateral uterine artery embolization, and none used microcatheter. （2） The ureter branch arising from the middle or lower part of the uterine artery supplied the middle or lower part of ureter and the lenght of this part of ureter is about 4 cm,the bladder branch arising from the middle or lower part of uterine artery supplied the bladder and communicated with the bladder vascular net. Correlative injuries could be caused by the retroflow of embolisms into the above arteries. （3）Placement of the catheter into the upper branch of the uterine artery or the tumor vascular net, using microcatheter if necessary and notation of the retroflow in the embolization process could avoid the embolization of bladder and ureter arteries. （4） Totally 506 cases used microcatheter, the ratio was 52.7%. The 5 cases of injuries did not use microcatheter. Conclusions Injuries to the urinary system could occur in UAE for treatment of obstetrical and gynecological benign diseases, which can be prevented by carefully differentiating the vascular communicating branch and the conditions of branches,and embolization of the upper branch of uterine artery can avoid the injury.