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妇科手术中的尿路损伤：评估和处理

Author
Donna Gilmour, MD, FRCSC
Section Editors
Linda Brubaker, MD, FACOG
Howard T Sharp, MD
Deputy Editor
Kristen Eckler, MD, FACOG
Translators
陈友国, 主任医师，副教授

引言

据报道，接受盆腔手术的女性中约有1%会发生尿路(或泌尿系)损伤[1]。术中发现损伤可及时修复。尿路损伤诊断延迟的情况需引起高度重视，因为可能导致泌尿生殖器瘘管形成或严重的肾脏并发症。

本文将总结妇科手术中尿路损伤的评估和处理。尿路损伤的预防，以及尿失禁、盆腔脏器脱垂或妇科恶性肿瘤的手术治疗中及分娩过程中的尿路损伤将单独讨论。 (参见“妇科手术中泌尿道损伤的预防”和“根治性子宫切除术”和“Cesarean delivery: Surgical technique”和“Operative vaginal delivery”)

术中评估

以膀胱镜筛查尿路损伤 — 现已提出对接受妇科大手术的女性术中常规行膀胱镜检查，以作为尿路损伤的二级预防措施[2,3]。膀胱镜检查所发现的损伤多于尿路肉眼观察。肉眼观察发现的膀胱损伤多于输尿管损伤。2项常规使用了膀胱镜的前瞻性子宫切除术(经腹部、阴式或腹腔镜)病例系列研究(n=839和471例)说明了这一点[2,4]。尿路损伤的肉眼观察未能发现87%-93%(7/8和14/15)的输尿管损伤和62%-65%的膀胱损伤(15/24和11/17)—这些随后通过膀胱镜检查得以诊断[2,3]。每项病例系列研究中仅有1例损伤未被肉眼观察和膀胱镜检查发现，这2例患者术后都出现了泌尿生殖道瘘。

膀胱镜检可发现需要修复的损伤和其他很可能不会造成临床后果的损伤[例如，可吸收的膀胱透壁缝合(若保留原位)]。虽然有可能存在过度检查，但似乎常规膀胱镜检出的大多数损伤都颇有临床意义。前述前瞻性研究中的大多数输尿管损伤(几乎均仅能通过膀胱镜检出)都很可能需要修复，而不能自愈(横断伤、挤压伤、结扎：9/15和7/8 vs 扭转：6/15和1/8)。其中仅一项研究详细说明了哪些膀胱损伤仅能通过膀胱镜检出[3]。这些损伤中的大多数也很可能需要治疗(膀胱切开：9/11 vs 擦伤或透壁缝合：2/11)。膀胱镜检出的所有5例膀胱损伤均为膀胱切开，而非较微小的创伤。

术中常规使用膀胱镜检时，术后发现的尿路损伤发生率似乎减少。一项针对47项妇科手术回顾性研究的系统评价评估了术中常规使用膀胱镜检对尿路损伤诊断的影响[1]。术中常规使用膀胱镜检的研究中术后诊断的尿路损伤发生率低于术中未常规使用膀胱镜的研究：膀胱损伤为0.8例/1000例手术 vs 2.2例/1000例手术，输尿管损伤为1.0例/1000例手术 vs 2.2例/1000例手术。该发生率系几种不同手术(如，子宫切除术、脱垂修补术)的数据联合得出，可能掩盖了手术特异性差异。该分析也可能受限于其使用的回顾性数据—可能遗漏了并发症(例如，去其他机构就诊的患者)。

                      

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Literature review current through: 2017-06 . | This topic last updated: 2017-01-24.
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References
Top
  1. Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol 2006; 107:1366.
  2. Ibeanu OA, Chesson RR, Echols KT, et al. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol 2009; 113:6.
  3. Vakili B, Chesson RR, Kyle BL, et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol 2005; 192:1599.
  4. Jelovsek JE, Chiung C, Chen G, et al. Incidence of lower urinary tract injury at the time of total laparoscopic hysterectomy. JSLS 2007; 11:422.
  5. Visco AG, Taber KH, Weidner AC, et al. Cost-effectiveness of universal cystoscopy to identify ureteral injury at hysterectomy. Obstet Gynecol 2001; 97:685.
  6. Gold RS, Groutz A, Pauzner D, et al. Bladder perforation during tension-free vaginal tape surgery: does it matter? J Reprod Med 2007; 52:616.
  7. Kristensen I, Eldoma M, Williamson T, et al. Complications of the tension-free vaginal tape procedure for stress urinary incontinence. Int Urogynecol J 2010; 21:1353.
  8. Abouassaly R, Steinberg JR, Lemieux M, et al. Complications of tension-free vaginal tape surgery: a multi-institutional review. BJU Int 2004; 94:110.
  9. Dyrkorn OA, Kulseng-Hanssen S, Sandvik L. TVT compared with TVT-O and TOT: results from the Norwegian National Incontinence Registry. Int Urogynecol J 2010; 21:1321.
  10. Brubaker L, Norton PA, Albo ME, et al. Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study. Am J Obstet Gynecol 2011; 205:498.e1.
  11. Beer M, Kuhn A. Surgical techniques for vault prolapse: a review of the literature. Eur J Obstet Gynecol Reprod Biol 2005; 119:144.
  12. Johnson N, Barlow D, Lethaby A, et al. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials. BMJ 2005; 330:1478.
  13. Mäkinen J, Johansson J, Tomás C, et al. Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod 2001; 16:1473.
  14. Härkki-Sirén P, Sjöberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998; 92:113.
  15. Mäkinen J, Brummer T, Jalkanen J, et al. Ten years of progress--improved hysterectomy outcomes in Finland 1996-2006: a longitudinal observation study. BMJ Open 2013; 3:e003169.
  16. ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol 2007; 110:717.
  17. American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Number 372. July 2007. The Role of cystourethroscopy in the generalist obstetrician-gynecologist practice. Obstet Gynecol 2007; 110:221.
  18. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL Practice Report: Practice guidelines for intraoperative cystoscopy in laparoscopic hysterectomy. J Minim Invasive Gynecol 2012; 19:407.
  19. Chan JK, Morrow J, Manetta A. Prevention of ureteral injuries in gynecologic surgery. Am J Obstet Gynecol 2003; 188:1273.
  20. Gilmour DT, Baskett TF. Disability and litigation from urinary tract injuries at benign gynecologic surgery in Canada. Obstet Gynecol 2005; 105:109.
  21. Buchsbaum GM, Moll C, Duecy EE. True occult bladder perforation during placement of tension-free vaginal tape. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:432.
  22. Labin LC, Morse AN, Young SB. Vaginal revision of intravesical tension-free vaginal tape 44 h after initial placement: a case report. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:223.
  23. Hove LD, Bock J, Christoffersen JK, Andreasson B. Analysis of 136 ureteral injuries in gynecological and obstetrical surgery from completed insurance claims. Acta Obstet Gynecol Scand 2010; 89:82.
  24. Sorinola O, Begum R. Prevention and management of ureteric injuries. Hosp Med 2005; 66:329.
  25. Stanhope CR, Wilson TO, Utz WJ, et al. Suture entrapment and secondary ureteral obstruction. Am J Obstet Gynecol 1991; 164:1513.
  26. Manahan KJ, Fanning J. Peritoneal fluid urea nitrogen and creatinine reference values. Obstet Gynecol 1999; 93:780.
  27. Nguyen-Khac E, Thevenot T, Capron D, et al. Are ascitic electrolytes usable in cirrhotic patients? Correlation of sodium, potassium, chloride, urea, and creatinine concentrations in ascitic fluid and blood. Eur J Intern Med 2008; 19:613.
  28. Wong MH, Lim SK, Ng KL, Ng KP. Pseudo-acute kidney injury with recurrent ascites due to intraperitoneal urine leakage. Intern Med J 2012; 42:848.
  29. Charalampidis S, Petrides C, Charalampous C, Stavrou S. Hyponatremic renal pseudofailure and massive ascites following normal vaginal delivery: a diagnostic and therapeutic challenge. Ren Fail 2012; 34:237.
  30. Kim JS, Lee DH, Suh HJ. Double-J stenting: initial management of injured ureters recognized late after gynecological surgery. Int Urogynecol J 2010; 21:699.
  31. Kim JH, Moore C, Jones JS, et al. Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:531.
  32. Hastings JC, Van Winkle W, Barker E, et al. The effect of suture materials on healing wounds of the bladder. Surg Gynecol Obstet 1975; 140:933.
  33. Hanke PR, Timm P, Falk G, Kramer W. Behavior of different suture materials in the urinary bladder of the rabbit with special reference to wound healing, epithelization and crystallization. Urol Int 1994; 52:26.
  34. Hepperlen TW, Stinson W, Hutson J, Bartone FF. Epithelialization after cystotomy. Invest Urol 1975; 12:269.
  35. Bødker B, Lose G. Postoperative urinary retention in gynecologic patients. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:94.