输尿管医源性损伤的部位和修复效果

Analysis of diagnosis and treatment effect of iatrogenic ureteral injury and the vulnerable sites

目的探讨输尿管易发生医源性损伤的部位和修复效果。方法回顾性分析2019年5月至2022年5月新疆医科大学第一附属医院收治的43例输尿管医源性损伤患者的病例资料,男20例,女23例。中位年龄39(16,64)岁。损伤位于左侧26例(60.5%),右侧16例(37.2%),双侧1例(2.3%);输尿管上段8例(18.6%)、中段8例(18.6%)、下段27例(62.8%)。损伤长度(5.9±2.4)cm。7例于术中诊断,表现为输尿管管腔结构破损、离断或被结扎,术区出现广泛渗液,输尿管镜下可见脂肪组织。36例延迟诊断,表现为腰腹部疼痛13例,发热12例,腹膜刺激征9例,阴道流液9例,血尿5例;泌尿系增强CT或静脉尿路造影检查示造影剂外溢10例,肾积水或输尿管扩张27例,发现患侧肾肿瘤1例;行引流液肌酐检查7例;行肾动态显像检查发现单侧肾无功能1例。妇科手术损伤13例均行Boari皮瓣输尿管膀胱再植手术。结直肠外科手术损伤12例,术中诊断7例行Boari皮瓣输尿管膀胱再植手术;5例延迟诊断,先行肾造瘘术,其中4例于6个月后完成Boari皮瓣输尿管膀胱再植手术,1例行输尿管膀胱重吻合。泌尿外科手术损伤18例,其中10例行Boari皮瓣输尿管膀胱再植手术,2例行肾输尿管切除术,3例行自体肾移植术,1例行阑尾代输尿管手术,2例应用口腔黏膜补片修补。43例中,29例发生在7处易损伤部位,妇科手术损伤部位常见于输尿管与髂外动脉、骨盆漏斗韧带、子宫动脉交汇或毗邻处,分别为4、5、3例;结直肠外科手术损伤部位分别为输尿管与肠系膜血管平行段4例,输尿管与结肠毗邻处2例,输尿管与输精管交汇处3例;泌尿外科手术损伤部位分别为输尿管与髂外动脉交汇处和肾盂输尿管连接处各4例。其余14例损伤部位不具有规律性,与上述易损伤部位不重合结果本研究43例术后随访18(11,47)个月,其中41例能正常排尿,无血尿、尿外渗、胁腹疼等症状,尿常规、尿素氮、血肌酐检查均正常。泌尿系B超检查示轻度肾积水13例,随访中积水程度未见缓解或加重。1例自体肾移植术后出现输尿管膀胱吻合处再狭窄,行球囊扩张后积水缓解。1例先行肾穿刺造瘘,6个月后术中探查发现左输尿管末端被Hem-o-lok夹夹闭3/5管壁,右输尿管与乙状结肠形成内瘘,取左右侧膀胱皮瓣各3cm行双侧输尿管膀胱再植手术,术后恢复良好。结论医源性输尿管损伤易发生部位共7处,妇科手术易发生于输尿管与骼外动脉、骨盆漏斗韧带、子宫动脉交汇或毗邻处;结直肠外科手术易发生于输尿管与肠系膜血管平行段、与结肠毗邻处、与输精管交汇处;泌尿外科手术损伤易发生于输尿管与髂外动脉交汇处和肾盂输尿管连接处。输尿管损伤的治疗需根据损伤原因、位置和长度综合考虑。对于长度较短而程度较重的输尿管损伤,行输尿管吻合或输尿管膀胱吻合术。对于长度较长的损伤,行自体肾移植、其他组织代输尿管手术或采用Boari皮瓣、颊/口腔黏膜移植等。修复手术中最重要的是保证无张力吻合,不过度破坏输尿管的血供,输尿管应裁剪到血供较好的部位。

ObjectiveeTo examine the location and the reparative impact of iatrogenic ureteral injury.Methods Retrospectively analyzed the clinical data of 43 patients with iatrogenic ureteral injury admitted from May 2019 to May 2022.The median age of the patients was 39 years.The injuries were predominantly on the left side in 26 patients(60.5%),in addition,there were 16 patients(37.2%)on the right side,and 1 patient on(2.3%)bilateral sides.The types of injuries were upper ureteral(8 patients,18.6%),middle ureteral(8 patients,18.6%),and lower ureteral(27 patients,62.8%).The average injury length was 5.9 cm with a standard deviation of 2.4.During intraoperative diagnosis,7 cases were found to have damage,transection,or ligation of the ureteral luminal structure.Surgical areas displayed extensive exudation and the presence of adipose tissue was observed during ureteroscopy.There were 36 cases manifested symptoms such as lumbar and abdominal pain(13 cases),fever(12 cases),peritoneal irritation sign(9 cases),vaginal discharge(9 cases),or hematuria(5 cases).Among these cases,10 showed contrast agent spillage on urinary enhanced CT or intravenous urography,while 27 exhibited hydronephrosis or ureteral dilatation.Additionally,one case presented a renal tumor on the affected side,and creatinine examination was performed on drainage fluid in 7 cases.Furthermore,a unilateral renal nonfunction was identified in 1 case through renal ECT examination.Results Out of the 43 patients followed up for a median of 18 months(range 11-47),41 patients had no urinary symptoms such as hematuria,urine extravasation,or hypochondriac pain.Their urine tests(routine,urea nitrogen,and serum creatinine)were normal.Thirteen patients showed mild hydronephrosis on urinary ultrasonography,which remained stable during the follow-up period.One patient experienced restenosis at the ureterovesical anastomosis after renal autograft transplantation,but symptoms improved after balloon dilatation.Another patient underwent nephrostomy puncture and was found to have a clamped left ureteral end and a fistula in the sigmoid colon.This patient successfully underwent bilateral ureteroneocystostomy with a bladder flap and had a positive postoperative outcome.Conclusions Iatrogenic ureteral injuries occur at seven specific sites,with gynecological surgeries posing a higher risk of injury at the ureter and external iliac artery,pelvic infundibulum ligament,and uterine artery intersection or adjacent areas.Similarly,colorectal surgeries can result in injury at the parallel segment of the ureter and mesenteric vessels,colon adjacent region,and vas deferens intersection.Urological surgeries are more likely to cause injury at the intersection of the ureter and external iliac artery,as well as the ureteropelvic junction.When treating ureteral injuries,it is important to consider the cause,location,and length of the injury.For short and deep injuries,options such as ureteral anastomosis or ureterovesical anastomosis may be considered.In cases of longer injuries,alternatives like renal autograft transplantation,ureteral surgery involving other tissues,or techniques such as the Boari flap or buccal/oral mucosal transplantation can be explored.The primary focus during repair surgeries should be on achieving tension-free anastomosis while maintaining sufficient blood supply to the ureter and placing it in an area with betterblood circulation.