目的 探讨妇科手术导致输尿管损伤行输尿管镜和腹腔镜治疗的安全性及有效性。方法 回顾性分析2008年1月~2016年6月妇科手术发生输尿管损伤并微创治疗的33例患者临床资料。平均年龄45(20~69)岁。术中发现输尿管损伤5例,即刻使用腹腔镜或膀胱镜置入双J管,腹腔镜下输尿管修补缝合或输尿管端端吻合;术后延迟发现输尿管损伤28例,其中1例为孤立肾患者,术后8 h发现引流液量异常多并行输尿管镜检查,见输尿管下段局部缺损,予置入双J管并腹腔镜下修补输尿管。其余均在术后7~35 d出现阴道残端漏尿。先行输尿管镜直视下置入双J管,置管成功16例,予以留置2~3个月。失败11例患者行腹腔镜探查。若损伤位置低,输尿管与膀胱直接插入吻合。若损伤位置高,则游离裁剪膀胱壁瓣并缝合成管状与输尿管吻合。结果 16例术后延迟发现输尿管损伤并成功置入双J管,有1例患者长期漏尿,3个月后再行腹腔镜手术成功,其余膀胱镜下拔除双J管无漏尿的发生。11例置管失败的患者均一期行腹腔镜修复手术成功。手术耗时110~160 min,平均132 min。术后住院5~8 d,平均6 d,予以保留导尿3~4周,术后4~8周膀胱镜下拔除双J管。全部病例术后3~6个月行B超检查提示轻度肾积水。结论 妇科手术致输尿管损伤可置入双J管,置管成功经保守治疗效果理想。置管后保守治疗失败可行腹腔镜治疗,虽然具有一定挑战,但安全有效,相比传统手术具有创伤小、瘢痕少、术后恢复快等优势,可最大限度地减少患者心理负担,避免医患纠纷的发生。

Objective: To investigate the safety and efficacy of ureteroscope and laparoscopic surgery for the treatment of ureteral injury caused by a gynecological operation.Methods: In the study, 33 cases of ureteral injury in gynecologic operation, with mean age being 45 (20 to 69) years. 5 cases of ureteral injuries were found during the operation and immediate laparoscopic-aided D-J stent insertion was done through ureteral lesion. Repair and suture or end to end anastomosis of ureter was followed. Delayed ureteral injury was found in 28 cases, including 1 case of solitary kidney patients. In this case, abnormal drainage fluid was found 8 hours after operation, the partial lesion of the lower ureter were examined by ureteroscopy, and D-J stent insertion and laparoscopic repair were done. Vaginal stump leakage was found 7 to 35 days after operation in the rest 27 cases. Then cystoscopic-aided or ureteroscopic-aided D-J stent insertion succeeded in 16 cases, and the D-J stent retained for 3 to 2 months. Laparoscopic exploration was done in the other 11 cases of patients with D-J stent insertion failure. Low lesion location, Direct insertion of ureter and bladder was done in the cases of low lesion location. If lesion location was high, free cutting of bladder wall flap and synthesis of tubular in order we do ureteroneocystostomy by free cutting of bladder wall flap and the synthesis of tubular.Results: One of the 16 patients who did successfully D-J stent insertion had long term urinary fistula. This patient recovered after undergoing laparoscopic surgery successfully after 3 months. The 11 cases of patients with D-J stent insertion failure were also healed after one-stage laparoscopic repair. In these cases, operating time was 110-160 min (mean,132 min); ostoperative hospitalization was 5 to 8 days (mean, 6 days); retention catheterization time was 3 to 4 weeks. We removed D-J stent under the cystoscope 4 to 8 weeks after operation. B-us were carried out 3 to 6 months after operation, and mild hydronephrosis was seen in all cases.Conclusions: Ureteral injury caused by gynecological surgery can be cured by inserting the D-J stent. If the conservative treatment failed, patients can be treated by laparoscopy. Although some challenges existed, there are the advantages of safe and effective, less trauma, less scar and faster postoperative recover. And laparoscopy operation can reduce the psychological burden of patients, to avoid the occurrence of medical disputes.