儿童医源性输尿管损伤19例临床分析

Clinical analyses of iatrogenic ureteral injury in children:a report of 19 cases

目的总结儿童医源性输尿管损伤的临床特点、处理方法及预后,为降低医源性输尿管损伤的发生率、减少远期肾功能的丢失提供参考。方法收集2005年1月至2020年12月首都医科大学附属北京儿童医院收治的非泌尿系统手术导致的医源性输尿管损伤19例患儿的临床资料,其中男14例,女5例;左侧7例,右侧12例;平均年龄为6岁(1~12岁)。对其损伤原因、分类、临床表现、诊断方法、处理原则以及远期随访结果进行总结分析。结果19例患儿中因腹膜后或盆腔肿瘤手术损伤输尿管的13例,因阑尾切除术、疝囊高位结扎术、巨结肠根治术导致输尿管损伤的各2例。术中即刻发现并处理者有6例,其中输尿管肾盂吻合2例、输尿管端端吻合3例、输尿管再植1例。术后延迟发现者13例,术后诊断时间从4 d至3年。13例中2例因疝囊结扎术所致的输尿管损伤直接行输尿管再植术;其余11例先行肾造瘘,二期行肾盂输尿管吻合术1例、输尿管端端吻合术3例、输尿管再植术1例、膀胱肌瓣成形术2例,阑尾代输尿管2例,剩余2例造影发现输尿管自行愈合,未再次手术。术后平均随诊时间为17个月(8~242个月),术中即刻修复的6例和因疝囊结扎术所致的输尿管损伤直接行输尿管再植术的2例肾盂输尿管未见明显积水,其余11例患儿肾脏均有不同程度积水,但随诊保持稳定。结论儿童医源性输尿管损伤多发生于腹膜后、盆腔及腹股沟区手术中。术中、术后如能及时发现,对症正确处理,远期肾脏功能多可保存。

Objective To summarize the clinical characteristics,treatments and prognoses of pediatric iatrogenic ureteral injury and lower the incidence of iatrogenic ureteral injury and the loss of long-term renal function.Methods A total of 19 cases of iatrogenic ureteral injury from January 2005 to December 2020 were reviewed.There were 14 boys and 5 girls with an average age of 6 years.The involved side was left(n=7)and right(n=12).The causes,classifications,clinical manifestations,diagnostic modalities,management principles and long-term follow-up outcomes were recorded.Results Among them,ureteral injury was caused by retroperitoneal or pelvic tumor operation(n=13)and appendectomy,high ligation of hernia sac and radical operation of Hirschsprung's disease(n=2).Six cases were treated promptly,including ureteropelvic anastomosis(n=2),end-to-end ureteral anastomosis(n=3)and ureteral replantation(n=1).Delayed diagnosis was made in 13 cases and time of postoperative diagnosis ranged from 4 days to 3 years.Two cases of hernia sac underwent ureteral reimplantation while the remainders had nephrostomy.After(3-6)months,pelvic ureteral anastomosis(n=1),ureteral end-to-end anastomosis(n=3),ureteral reimplantation(n=1),Boair surgery(n=2),appendix replacing ureter(n=2)and self-healing(n=2)were performed.During a follow-up period of(8-242)months,no obvious hydronephrosis was present in 2 cases of ureteral injury from ligation of hernia sac.The other 11 cases had varying degrees of hydronephrosis and remained stable during follow-ups.Conclusions Iatrogenic ureteral injury in children occurs frequently during retroperitoneal,pelvic and inguinal operations.If detected timely and treated properly,long-term renal function may be preserved.