经阴道无张力尿道吊带术引起下尿路损伤的原因分析及处理

The factors and treatments of lower urinary tract injury caused by tension-free vaginal tape procedure

目的探讨经阴道无张力尿道吊带术（tension—freevaginaltape，TVT）中引起下尿路损伤的影响因素和处理方法。方法回顾性分析2001年3月至2011年2月因SUI行TVT手术治疗的609例患者的临床资料，其中39例（6．4％）发生术中下尿路损伤。39例患者年龄39—78岁，平均年龄（52．74-18．3）岁，病程2—12年。术前分型：Ⅱ型尿失禁12例，Ⅱ／Ⅲ混合型尿失禁22例，Ⅲ型尿失禁5例。分析下尿路损伤的发生原因和影响因素，提出预防和处理方法。结果本组39例中34例（87．2％）有盆腔手术史，其中子宫全切18例（52．9％），剖宫产9例（26．5％），子宫肌瘤摘除术4例（11．8％），卵巢附件手术3例（8．8％）。36例（5．9％）膀胱穿孔患者术中均退出穿刺针后再次穿刺，留置导尿4～5d，术后均无尿外渗、出血和感染发生。3例（0．5％）尿道损伤患者尿道破口缝合后，均再次穿刺，留置导尿2周，术后均无继发尿瘘和感染发生。结论既往盆腔手术史是TVT术中发生下尿路损伤的影响因素之一，应引起术者重视。术中发现膀胱穿孔时应及时退出穿刺针，调整穿刺方向再次穿刺；如发现尿道损伤可以在缝合尿道后再次穿刺。

Objective To discuss the influent factors and managements of lower urinary tract injury caused by tension-free vaginal tape （TVT） procedure. Methods From Mar. 2001 to Feb. 2011, 609 stress urinary incontinence （SUI） patients were treated by TVT. Lower urinary tract injury appeared in 39 cases （6.4%）, which age from 39 to 78 years （ average age 52.7 -＋ 18.3）. The history of disease was 2 to 12 years. Preoperative SUI types were 12 cases of II type SUI, 22 cases of II/III type SUI and 5 cases of III type SUI. The patients who had low urinary tract injury were retrospective analyzed to figure out the causes and influent factors, and recorded the treatments and follow-ups. Results 39 patients （6.4%） suffered from low urinary tract injury, including 36 cases （5.9%） of bladder perforation and 3 cases of urethral inju- ry. In these 39 patients, 34 （87.2%） patients had history of pelvic surgeries, including 18 （52.9%） ca- ses of total hysterectomy, 9 （26.5%） cases of cesarean section delivery, 4 （11.8% ） cases of hysteromyo- mectomia and 3 （8.8%） cases of ovarian surgery. All of the 36 bladder perforation patients were re-punc- tured and the catheter was kept for 4 - 5 d. Three urethral injury patients were re-punctured after the urethral rupture was sutured and the catheter was kept for 2 weeks. All the 39 patients were cured and discharged. No urinary fistula, infection or other postoperative complications occurred. Conclusions The history of pelvic surgery may be an important risk factor of the lower urinary tract injury, which should pay attention. If the bladder perforation occurred, re-puncture should be taken by adjust the direction. If there was a urethral injury, the re-puncture should be taken after the suturing of the urethral rupture.