UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

女性泌尿生殖道瘘

Authors
Alan D Garely, MD
William J Mann, Jr, MD
Section Editor
Linda Brubaker, MD, FACOG
Deputy Editor
Kristen Eckler, MD, FACOG
Translators
颜笑健, 主任医师，副教授

引言

泌尿生殖道瘘是女性生殖道与膀胱、尿道或输尿管之间的异常通道。泌尿生殖道瘘的病因和发病率存在地域差异。在美国和其他发达国家，泌尿生殖道瘘并不常见，经常是妇科手术的后遗症，在较少情况下是由产伤、严重的盆腔病变或放疗引起的[1]。相比之下，在发展中国家，泌尿生殖道瘘是分娩期间梗阻性分娩的一种常见并发症[2,3]。在发达国家，当成功修复膀胱和输尿管瘘后，患者通常没有后遗症。在发展中国家，由于膀胱颈和尿道括约肌损伤、逼尿肌活动异常、阴道狭窄、膀胱纤维化，患者经常存在持续性尿失禁[4]。

发达国家中的女性泌尿生殖道瘘将总结在此。资源有限情况下的产科泌尿生殖道瘘将单独讨论。 (参见“Obstetric fistulas in resource-limited settings”)

泌尿生殖道瘘的类型

泌尿生殖道瘘是根据连接管道的解剖学位置对进行分类的(图 1)。膀胱阴道瘘的发生率约为输尿管阴道瘘的3倍，输尿管膀胱阴道瘘非常罕见。临床医生极少遇到膀胱子宫瘘、膀胱宫颈瘘、膀胱腹膜瘘、膀胱结肠瘘，这些瘘通常只在存在结肠憩室或癌症时发生。

流行病学和危险因素

在美国，估计泌尿生殖道瘘的发生率从单纯子宫切除术后的不到0.5%，至根治性子宫切除术后的10%不等。虽然根治性子宫切除术使泌尿生殖道瘘的发生率升高，但目前尚不明确当采用腹腔镜及机器人技术时，瘘管形成的总体发生率是否会显著升高[5-7]。根据美国国家医院出院登记系统的数据，在2007年进行的2,329,000例女性泌尿生殖系统手术中，膀胱阴道瘘修补术少于5000例[8]。

多数泌尿生殖道瘘发生于因良性疾病而进行子宫切除术后。英国的一项研究显示，在所有类型的子宫切除术后，膀胱阴道瘘的发生率为0.12%[9]。根治性子宫切除术后的发生率最高，为1.14%；因盆腔器官脱垂进行阴式子宫切除术后的发生率最低为0.02%。在因良性指征进行子宫切除术的女性中，50岁以上患者瘘形成的发生率低于40岁以下的患者[10-12]。

                               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2016-07-26.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Tancer ML. Observations on prevention and management of vesicovaginal fistula after total hysterectomy. Surg Gynecol Obstet 1992; 175:501.
  2. Waaldijk, K. The surgical management of bladder fistula in 775 women in Northern Nigeria. Benda BV, Nymegen, 1989.
  3. Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004; 190:1011.
  4. Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006; 368:1201.
  5. Mann WJ, Arato M, Patsner B, Stone ML. Ureteral injuries in an obstetrics and gynecology training program: etiology and management. Obstet Gynecol 1988; 72:82.
  6. Kobayashi E, Nagase T, Fujiwara K, et al. Total laparoscopic hysterectomy in 1253 patients using an early ureteral identification technique. J Obstet Gynaecol Res 2012; 38:1194.
  7. Magrina JF, Kho RM, Weaver AL, et al. Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol 2008; 109:86.
  8. Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Report 2010; :1.
  9. Hilton P, Cromwell DA. The risk of vesicovaginal and urethrovaginal fistula after hysterectomy performed in the English National Health Service--a retrospective cohort study examining patterns of care between 2000 and 2008. BJOG 2012; 119:1447.
  10. Hilton P. Urogenital fistula in the UK: a personal case series managed over 25 years. BJU Int 2012; 110:102.
  11. Methfessel HD, Retzke U, Methfessel G. [Urinary fistula after radical hysterectomy with lymph node excision]. Geburtshilfe Frauenheilkd 1992; 52:88.
  12. Emmert C, Köhler U. Management of genital fistulas in patients with cervical cancer. Arch Gynecol Obstet 1996; 259:19.
  13. Duong TH, Taylor DP, Meeks GR. A multicenter study of vesicovaginal fistula following incidental cystotomy during benign hysterectomies. Int Urogynecol J 2011; 22:975.
  14. Bai SW, Huh EH, Jung DJ, et al. Urinary tract injuries during pelvic surgery: incidence rates and predisposing factors. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:360.
  15. Karram MM. Lower Urinary Tract Fistulas. In: Urogynecology and Reconstructive Pelvic Surgery, 3rd ed, Walters MD, Karram MM. (Eds), Mosby Inc, Philadelphia 2007. p.450.
  16. MOIR JC. Personal experiences in the treatment of vesicovaginal fistulas. Am J Obstet Gynecol 1956; 71:476.
  17. Abou-El-Ghar ME, El-Assmy AM, Refaie HF, El-Diasty TA. Radiological diagnosis of vesicouterine fistula: role of magnetic resonance imaging. J Magn Reson Imaging 2012; 36:438.
  18. Afifi K, Tudor G, Nagrani R. Vaginal discharge: an unusual presentation of degenerated uterine fibroid. J Obstet Gynaecol 2010; 30:69.
  19. Raassen TJ, Verdaasdonk EG, Vierhout ME. Prospective results after first-time surgery for obstetric fistulas in East African women. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:73.
  20. Singh O, Gupta SS, Mathur RK. Urogenital fistulas in women: 5-year experience at a single center. Urol J 2010; 7:35.
  21. Hadley HR. Vesicovaginal fistula. Curr Urol Rep 2002; 3:401.
  22. Garza Cortés R, Clavijo R, Sotelo R. Laparoscopic treatment of genitourinary fistulae. Arch Esp Urol 2012; 65:659.
  23. Liao CY, Tasi RS, Ding DC. Gynecological surgery caused vesicovaginal fistula managed by Latzko operation. Taiwan J Obstet Gynecol 2012; 51:359.
  24. Demirci U, Fall M, Göthe S, et al. Urovaginal fistula formation after gynaecological and obstetric surgical procedures: clinical experiences in a Scandinavian series. Scand J Urol 2013; 47:140.
  25. Hoch WH, Kursh ED, Persky L. Early, aggressive management of intraoperative ureteral injuries. J Urol 1975; 114:530.
  26. Boateng AA, Eltahawy EA, Mahdy A. Vaginal repair of ureterovaginal fistula may be suitable for selected cases. Int Urogynecol J 2013; 24:921.
  27. Schlossberg SM. Ureteral healing. Semin Urol 1987; 5:197.
  28. Aungst MJ, Sears CL, Fischer JR. Ureteral stents and retrograde studies: a primer for the gynecologist. Curr Opin Obstet Gynecol 2009; 21:434.
  29. Tomlinson AJ, Thornton JG. A randomised controlled trial of antibiotic prophylaxis for vesico-vaginal fistula repair. Br J Obstet Gynaecol 1998; 105:397.
  30. Latzko, W. Postoperative vesicovaginal fistulas: genesis and therapy. Am J Surg 1992; 48:211.
  31. Yarmohamadi A, Asl Zare M, Ahmadnia H, Mogharabian N. Salvage repair of vesicovaginal fistula. Urol J 2011; 8:209.
  32. Farahat YA, Elbendary MA, Elgamal OM, et al. Application of small intestinal submucosa graft for repair of complicated vesicovaginal fistula: a pilot study. J Urol 2012; 188:861.
  33. Mohr S, Brandner S, Mueller MD, et al. Sexual function after vaginal and abdominal fistula repair. Am J Obstet Gynecol 2014; 211:74.e1.
  34. Mackenrodt, A. Die operative Heilung grosser Blasenscheiden-fistein. Zentralbl Gynakol 1894; 8:180.
  35. Elkins TE, DeLancey JO, McGuire EJ. The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990; 75:727.
  36. Tran VQ, Ezzat M, Aboseif SR. Repair of giant vesico-vaginal fistulae using a rotational bladder flap with or without a gracilis flap. BJU Int 2010; 105:730.
  37. Eilber KS, Kavaler E, Rodríguez LV, et al. Ten-year experience with transvaginal vesicovaginal fistula repair using tissue interposition. J Urol 2003; 169:1033.
  38. Altaweel WM, Rajih E, Alkhudair W. Interposition flaps in vesicovaginal fistula repairs can optimize cure rate. Urol Ann 2013; 5:270.
  39. Ezzat M, Ezzat MM, Tran VQ, Aboseif SR. Repair of giant vesicovaginal fistulas. J Urol 2009; 181:1184.
  40. Lee UJ, Goldman H, Moore C, et al. Rate of de novo stress urinary incontinence after urethal diverticulum repair. Urology 2008; 71:849.
  41. Kliment J, Beráts T. Urovaginal fistulas: experience with the management of 41 cases. Int Urol Nephrol 1992; 24:119.
  42. Papanikolaou A, Tsolakidis D, Theodoulidis V, et al. Surgery for ureteral repair after gynaecological procedures: a single tertiary centre experience. Arch Gynecol Obstet 2013; 287:947.
  43. Guerriero, WG. Ureteral trauma. In Guerriero WG (ed): Management of Acute and Chronic Urologic Injury. Appleton-Century-Crofts, E. Norwalk, CT, 1984.
  44. Hurd WW, Chee SS, Gallagher KL, et al. Location of the ureters in relation to the uterine cervix by computed tomography. Am J Obstet Gynecol 2001; 184:336.
  45. Guerriero WG. Ureteral injury. Urol Clin North Am 1989; 16:237.
  46. Yip SK, Leung TY. Vesicouterine fistula: an updated review. Int Urogynecol J Pelvic Floor Dysfunct 1998; 9:252.
  47. Porcaro AB, Zicari M, Zecchini Antoniolli S, et al. Vesicouterine fistulas following cesarean section: report on a case, review and update of the literature. Int Urol Nephrol 2002; 34:335.
  48. Novi JM, Rose M, Shaunik A, et al. Conservative management of vesicouterine fistula after uterine rupture. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:434.
  49. Leng WW, Amundsen CL, McGuire EJ. Management of female genitourinary fistulas: transvesical or transvaginal approach? J Urol 1998; 160:1995.
  50. Nardos R, Menber B, Browning A. Outcome of obstetric fistula repair after 10-day versus 14-day Foley catheterization. Int J Gynaecol Obstet 2012; 118:21.