妇科腹腔镜手术输尿管损伤26例临床分析

Clinical Analysis of 26 Cases of Ureteral Injury in Gynecological Laparoscopic Surgery

目的 总结妇科腹腔镜手术输尿管损伤的诊治经验。方法 回顾性分析2017年1月~2021年12月24 097例妇科腹腔镜手术中26例(0.11%)输尿管损伤的临床资料。宫颈癌19例,子宫内膜癌3例,子宫腺肌症合并深部浸润型子宫内膜异位症2例,宫颈原位癌1例,卵巢癌1例。广泛性子宫切除术21例,其他子宫切除术3例,高位腹主动脉旁淋巴结切除术1例,肿瘤细胞减灭术乙状结肠切除时1例。术中发现输尿管损伤4例,术后发现22例。损伤部位为输尿管近膀胱入口处24例,腹段与盆段交界处1例,肠系膜下动脉起始处1例。4例术中发现损伤即行修复手术,术后发现损伤的22例中,放置双J管11例,输尿管膀胱再植术11例(一期手术6例,二期手术5例)。结果 除1例二期手术后继发输尿管狭窄定期更换双J管外,余25例拔除双J管后随访6~24个月(平均9个月),均无漏尿、中重度肾积水及输尿管扩张,肾功能正常。结论 妇科腹腔镜手术输尿管损伤常发生于宫颈癌广泛性子宫切除术及困难的全子宫切除术中,多为术后迟发性损伤,与电热损伤及过度游离输尿管有关,及时诊治预后良好。

Objective To summarize the experience of diagnosis and treatment of ureteral injury in gynecological laparoscopic surgery.Methods Clinical data of 26 cases of ureteral injury among 24097 cases of gynecological laparoscopic surgery from January 2017 to December 2021 were analyzed retrospectively.There were 19 cases of cervical cancer,3 cases of endometrial carcinoma,2 cases of adenomyosis with deep infiltrating endometriosis,1 case of cervical carcinoma in situ,and 1 case of ovarian cancer.The operations included 21 cases of radical hysterectomy,3 cases of other hysterectomy,1 case of high para-aortic lymphadenectomy,and 1 case of sigmoid resection of cytoreductive surgery.Ureteral injury was found during surgery in 4 cases and after operation in 22 cases.The injured sites included the ureter near the entrance of the bladder in 24 cases,the junction between the abdominal segment and the pelvic segment in 1 case,and the origin of the inferior mesenteric artery in 1 case.The 4 cases of ureteral injury found in operation were immediately repaired.And among the 22 cases of injury found after operation,a double J tube was placed in 11 cases and the ureterovesical replantation was performed in 11 cases(one-stage operation in 6 cases and two-stage operation in 5 cases).Results Except for 1 case requiring regular double J tube replacement due to ureteral stricture after secondary surgery,the other 25 cases were followed up for 6-24 months(mean,9 months)after double J tube removal,no leakage of urine,moderate and severe hydronephrosis,or ureteral dilatation during the follow-up period.The renal function was normal.Conclusions Ureteral injury in gynecological laparoscopic surgery most frequently occurs in radical hysterectomy of cervical cancer and difficult total hysterectomy,most of which are postoperatively delayed injury and closely related to electric heating injury and excessive ureteral dissociation.Favorable prognosis can be achieved by timely diagnosis and treatment.