女性下尿路阴道瘘治疗术式的选择

Selection of procedures for the treatment of female low urovaginal fistulas

目的探讨女性下尿路阴道瘘治疗术式的选择与效果。方法1999年1月至2012年12月收治94例女性下尿路阴道瘘患者。年龄5～58岁，平均28岁。病程1～23年，平均4年。病因为创伤性损伤57例，医源性损伤34例，局部炎症2例，先天性1例。其中尿道狭窄合并尿道阴道瘘（尿道组）61例，膀胱阴道瘘（膀胱组）33例。尿道组61例中伴有回肠阴道瘘2例，伴有直肠阴道瘘3例，伴阴道狭窄8例；膀胱组33例中单纯性或初发患者15例，复杂性或修复失败者18例。尿道组中采用带蒂阴唇皮瓣尿道成形术30例，外阴部岛状皮瓣尿道成形术4例，阴道壁瓣尿道成形术18例，尿道端端吻合术6例，膀胱壁瓣尿道成形术3例。在尿道成形的同时行膀胱颈重建术治疗尿失禁6例，5例伴肠道阴道瘘的患者同时行瘘道修复。膀胱组中18例采用经腹途径修补，15例采用经阴道途径修补。结果本组术后均无严重并发症，术后随访5～140个月，平均45个月。尿道组中采用带蒂阴唇皮瓣或外阴皮瓣重建尿道的34例中3例尿道阴道瘘复发，1例尿道狭窄，3例有尿频和压力性尿失禁，术后3～8个月均恢复控尿；采用阴道前壁重建尿道的18例全部达到尿道解剖修复成功，15例可控尿，3例有压力性尿失禁；采用尿道端端吻合术的6例全部达到尿道解剖修复成功，5例可控尿，1例有压力性尿失禁；采用膀胱前壁瓣重建尿道的3例术后1例排尿通畅，控尿好，1例有压力性尿失禁，1例排尿困难。排尿困难患者经膀胱颈部电切后排尿通畅。尿道组中56例（91．8％）尿道解剖修复成功，51例（83．6％）尿道功能修复成功。膀胱组中一次修复成功率为87．9％（29／33），膀胱阴道瘘复发4例。结论女性下尿路阴道瘘治疗术式的选择应根据患者病变的部位、严重情况、狭窄的长度和阴道的条件。术中应用各种带蒂组织瓣做屏障非常重要，可有效防止瘘的复发。

Objective To evaluate the selection and outcome of procedures for the treatment of female patients with low urovaginal fistulas. Methods Between Jan. 1999 and Dec. 2012, a total of 94 low urovaginal fistula patients with mean age 28 （5-58） years and the duration of the condition for mean 4 （ 1- 23） years were treated using a variety of procedures. Of the 94 patients, the etiology was trauma in 57 patients, iatrogenic injuries in 34, local inflammation in 2 and congenital in 1. Urethral stricture was associated with urethrovaginal fistulas in 61 patients （ Group of urethra） and vesicovaginal fistula in 33 （ Group of bladder）. Of the group of urethra, it was associated with ileovaginal fistula in 2 patients, rectovagina｜ fistula in 3 and veginal strictures in 8. Of the group of bladder, the fistula was simple or incipient in 15 cases and complex or recurrent in 18 cases. In group of urethra, pedicle labial skin grafs urethroplasty was used in 30 cases, island flap of vulva urethroplasty in 4 cases, vaginal wall flap urethroplasty in 18 cases, end to end anastomotic urethroplasty in 6 cases, and anterior bladder flap urethroplasty in 3 cases. At the same time of urethroplasty, bladder neck reconstruction was performed in 6 cases with pre-existing traumatic sphincter incompetence, intestovaginal fistula repair was performed in 5 cases. In the group of vesicovaginal fistula, the fistula repairing was performed by transabdominal approach in 18 cases and by transvaginal approach in 15 cases. Results There were no serious complications postoperatively. Patients were followed up with mean 45 （5-140） months. Of the 34 eases underwent pedicle labial or an island flap of vulva urethroplasty, fistulas was recurrent in 3 cases and urethral strictures was happened in one ease, 3 eases had frequent and stress incontinence, however, all 3 eases achieved urinary continence in 3-8 months postoperatively; of the 18 cases underwent urethroplasty using vaginal flap repairs, all patients achieved anatomical success, and continence in 15 patients and stress incontinence in 3 patients; of the 6 patients underwent urethral end to end anastomosis, all patients achieved urethral anatomical repair success and the continence was achieved in 5 patients, stress incontinence in one patient; and the left 3 patients underwent bladder anterior wall urethroplasty, urethral anatomical repair success was in all 3 patients and continence in one, stress incontinence in one and dysuria in one. Endoscopic resection was performed in the patient with voiding difficulty, after which the patient could void smoothly. In the group of urethra, successful urethral anatomical recovery rate was 91.8% （ 56/61 ） and successful functional recovery rate was 83.6% （ 51/61 ）. In the group of bladder, the fistulas were successfully repaired by one procedure in 29 patients （87.9%） and recurrence in 4 patients. Conclusions The selection of procedures for treatment of female patients with low urovaginal fistulas should be determined by stricture characteristics, including location, length and vaginal condition. It is very important to prevented fistulas reformation during operation by using tissue flaps as a bulk.