经腹腔路径腹腔镜膀胱底纵切口膀胱阴道瘘修补术:单中心10年经验总结

Laparoscopic vesicovaginal fistula repairs though inferior of bladder longitudinal incision:summary of surgical experiences over ten years

目的总结经腹腔路径腹腔镜膀胱底纵切口膀胱阴道瘘修补术的手术技巧和经验,探讨该术式的可行性和疗效。方法回顾性分析2010年1月至2019年10月浙江省人民医院收治的54例膀胱阴道瘘患者的病例资料。中位年龄49.5(8~80)岁。主诉均为尿液经阴道流出。膀胱阴道瘘病因分别为良性病变子宫切除术后14例(25.9%),妇科恶性肿瘤术后23例(42.6%),症状出现时间为拔除尿管后11(1~20)d;宫颈恶性肿瘤放疗11例(20.4%),症状出现时间为放疗后10(5~25)个月;其他原因6例(11.1%),症状出现时间为治疗原发病后21(3~50)d。54例中,合并直肠瘘1例、输尿管损伤1例、膀胱挛缩6例。膀胱挛缩6例行膀胱造影检查均提示膀胱容量缩小,其中2例出现双侧输尿管轻度反流;术前CT检查示4例无明显上尿路积水,2例合并双侧肾轻度积水。瘘口直径0.5~4.0 cm。单发瘘口50例,多发瘘口4例。尿垫试验评估患者漏尿程度为轻度7例,中度42例,重度5例。37例初次行膀胱阴道瘘修补术,13例既往有1次膀胱阴道瘘修补术史,2例既往有2次膀胱阴道瘘修补术史,既往有3次、4次膀胱阴道瘘修补术史者各1例。所有患者均全麻下行经腹腔路径腹腔镜膀胱底纵切口膀胱阴道瘘修补术,其中8例采用达芬奇机器人手术系统。手术要点:①寻找膀胱阴道瘘口,正确评估瘘口大小、数量、位置,以利于术者采取正确的手术方式;②为保护双侧输尿管口,双侧输尿管置入单J管;③充分游离膀胱及阴道壁,去除瘢痕组织,低张力或无张力缝合膀胱切口;④松解一段带蒂大网膜填塞并覆盖在膀胱后壁与阴道之间的间隙。对低位、复杂性及混合性膀胱阴道瘘患者术中分别采用膀胱壁转瓣法(6例)、膀胱扩大术(3例)以及输尿管再植术(6例)等技术。分析影响患者治愈率的因素。结果本组54例手术均顺利完成,术中均无肠道损伤,均未中转开放手术。中位手术时间85(60~240)min。术中出血量(33.3±26.5)ml。术后住院时间(11.3±8.2)d。术后均未发生切口感染等手术并发症。术后随访6个月,一期治愈50例,失败4例,治愈率为92.6%。单因素分析结果显示,既往有膀胱阴道瘘修补术史的患者,再次手术的治愈率较低(P=0.00)。多发瘘口(≥2)患者相较于单发瘘口患者的治愈率较低(P=0.00)。瘘口位于膀胱三角区以上的患者比瘘口位于膀胱三角区以及尿道内口以外的患者治愈率高(P=0.00)。年龄(P=0.79)、手术时间(P=0.06)、术中出血量(P=0.78)、术后住院时间(P=0.73)、留置导尿时间(P=0.30)、瘘口大小(P=0.31)对修补手术治愈率均无明显影响。结论经腹腔路径腹腔镜膀胱底纵切口膀胱阴道瘘修补术是一种可行的手术方式,具有损伤小、恢复快、成功率高等特点。该术式疗效确切,可用于绝大多数膀胱阴道瘘的修补,并可同期处理混合瘘和膀胱挛缩等问题。

Objective To discuss the effect and experience of laparoscopic vesicovaginal fistula repairs though inferior of bladder longitudinal incision.Methods 54 patients were included in this study.Clinical data of patients collected from our hospital since January 2010 to October 2019 who underwent laparoscopic vesicovaginal fistula repair.The median age is 49.5(8-80)years old.Main complaints were urine flows out through the vagina.14 cases(25.9%)and 23 cases(42.6%)were post-hysterectomy of benign lesions and gynecological malignant tumors.The symptoms presented at 11(1-20)days post urinary catheter removal.There were 11 cases(20.4%)of cervical malignant tumors,symptoms presented at 10(5 to 25)months after radiotherapy.The symptoms of rest of cases 6(11.1%)presented at 21(3 to 50)days.One of them had rectal fistula,another had ureteral injury,6 had bladder contracture,2 patients had bilateral hydronephrosis.Preoperative CT examination revealed that 4 cases had no obviously hydroureter at upper urinary tract,and 2 cases had mild hydronephrosis in bilateral kidneys.The diameter of the fistula was 0.5-4.0 cm.There were 50 cases of single fistula and 4 cases of multiple fistula.The urine pad test evaluated the degree of urine leakage in patients reveals that 7 and 42 cases with mild and moderate,rest of 5 cases presented with severe result.37 cases performed with vesico-vaginal fistula repair for the first time;13 and 2 cases had once and twice vesico-vaginal fistula repair history and there were other two patients had vesico-vaginal fistula repair history for three and four times.All patients underwent general anesthesia under the laparoscopic bladder bottom longitudinal incision bladder vaginal fistula repair,8 cases performed with Da Vinci robotic assist surgery system.Main steps of the operation include:①search for bladder and vaginal fistula,assessed the size,number,and location of the fistula;②To set single J stents in the bilateral ureter;③Fully separated the bladder and vaginal wall,remove scar tissue,and suture the bladder incision with low or no tension way;④To use great omentum;for patients with low,complex,and mixed bladder vaginal fistulas,recommend to use bladder wall flaps(6 cases),bladder enlargement(3 cases),and ureteral replantation(6 cases).The clinical data of the patients were collected,and a univariate analysis was performed on the cure rate.Results The mean of blood boss and duration in operation were(33.3±26.5)ml and 85(60-240)minutes.Mean of hospitalization was(11.3±8.2)days.The postoperative urinary indwelling time were(20.8±8.3)days.50 cases were completed recovered and 4 cases failed,the curative ratio was 92.6%(50/54).It revealed that the curative ratio of vesicovaginal fistula repair had correlation with history of surgical interventions before operation.The curative effect was reduced(P=0.00)when the patient had previous laparoscopic vesicovaginal fistula repairs.Patients with multiple fistulas(≥2)had a lower cure rate than single fistulas(P=0.00).In addition,patients with fistulas above the triangle of the bladder had a higher cure rate than fistulas outside the triangle of the bladder and the urethra(P=0.00).There was no statistically significant difference in the cure ratio of Age(P=0.79),operation time(P=0.06),intraoperative bleeding(P=0.78),post-operative hospitalization(P=0.73),indwelling catheterization time(P=0.30),and size of fistula(P=0.31).Conclusions The operation could be effective with fewer complications procedure,which could fix mixed fistula and bladder contracture at the same time.