The anatomical relationship between the female reproductive system and the urinary system is closely adjacent. In gynecological surgery, due to the invasion of malignant tumors, severe adhesions of pelvic organs, or large tumors in the pelvic and abdominal cavity, they can cause variations in the anatomical position of the urinary system and unclear tissue levels. Easy to cause damage to the urinary system. Although there is no systematic review of the incidence of urinary tract injury between laparotomy and laparoscopic surgery.
In the clinic, more and more benign and malignant gynecological operations can be performed under laparoscopic surgery. However, with the expansion of gynecological laparoscopic surgery applications and the increasing difficulty of operations, the incidence of intraoperative and postoperative complications is also showing an upward trend. Severe irreversible damage will have a serious impact on the quality of life of patients after surgery.
Causes of urinary system damage
Urinary system injury is one of the most common complications in laparoscopic surgery.
Because laparoscopic surgery often uses electrocoagulation and electrocutting to treat blood vessels and tissues, the local temperature can be as high as 300°C, especially when a single-stage electric hook is used for electrocoagulation and electrocutting near the ureter, the heat conduction effect can spread to the surroundings as far as possible The range of 2cm causes avascular necrosis of the ureter. This kind of thermal injury is often not easy to find during surgery, but the corresponding symptoms and signs appear for a period of time after surgery. Once an abnormal increase in drainage is found, the possibility of urinary system fistula should be considered. Thinking is usually divided into two steps. First, it is necessary to determine whether there is a urinary system fistula, and secondly, to determine the location of the fistula. After surgery, the pelvic drainage fluid creatinine and urea nitrogen can be checked to determine whether there is a urinary system fistula; the bladder methylene blue test is used to determine whether it is a vesicovaginal fistula or a ureterovaginal fistula; further cystoscopy and CT urography (CTU) are performed. Can clarify the side of the injury and the location of the fistula. Need to pay attention to whether there is a compound fistula, that is, there are both ureteral fistula and bladder fistula, bilateral ureteral fistula, and more than 2 bladder fistulas.
Intraoperative and postoperative treatment of ureteral injury
When the tubular cord is found to be cut or injured during the operation, or there is more exudate in the surgical field, the source of the exudate should be carefully searched to identify the ureteral injury. If it is confirmed that the ureter is mistakenly tied or clamped, it should be removed immediately. If the clamp or suture time is short and the damage is not obvious, the ureter can be placed for a period of time to observe the ureteral peristalsis. The ureteral peristalsis is good, and it does not need to be treated. If the damage is obvious and the peristalsis function is lost, it should be treated as appropriate. In the mild cases, a double "∵J" ureteral catheter can be placed, and in the severe cases, ureter-end-end anastomosis or uretero-vesical anastomosis can be considered after cutting.
If the ureter is severely cut or damaged during the operation, if the position is higher, end-to-end ureteral anastomosis is possible. Drainage is placed next to the anastomosis. At the same time, a double "J" ureteral catheter is placed in the ureter, and the upper end to the lower end of the renal pelvis is placed in the bladder. The catheter was taken out through the cystoscope 2 weeks after the operation. If the location of the injury is low, ureterocystostomy is feasible, and the double "J" ureteral catheter is also placed, and the catheter is taken out through the cystoscope 2 weeks later.
Choose different treatment methods according to the patient's general condition and injury site, defect area, local blood supply, infection or not, etc., for IVU obstruction, and smooth retrograde intubation, no chills, fever, and not much urine leakage. Built-in double "J" tube drainage and anti-infection conservative treatment for 10-14 days. Once ureteral dilatation occurs, ureteral bladder replantation or other treatments should be performed in time to save renal function. For severely injured patients, the injured site should be removed decisively, ureter-to-end anastomosis or transplantation to the bladder should be performed, and the double J tube should be placed for 4-6 weeks. Early ureteral fistula with small postoperative urinary fistula can be continuously drained by placing a ureteral catheter for 10-14 days, and healing may be possible. When large fistulas or double "J"s are difficult to insert and conservative treatment is ineffective, ureteral stents or nephrostomy are given, and second-stage repairs are performed 3-6 months after surgery.
Characteristics, prevention and treatment of bladder injury
The incidence of bladder injury is about 0.34%, and the injury sites are mainly at the top, bottom and triangle of the bladder. The causes of injury include: 1 poor technique, unclear anatomical level; 2) thermal injury of the device [6; 3) various factors that cause local adhesions, such as cervical tumor infiltration, cesarean section history, endometriosis, reproduction Systemic tuberculosis and inflammation not only increase the difficulty of the operation, but also increase the chance of bladder injury during the separation of the bladder, cervix, and vagina1. Hong et al [? retrospectively analyzed 118 patients with cervical cancer who underwent laparoscopic extensive hysterectomy, and 10 cases had bladder injury (8.47%), of which 5 cases had a history of cesarean section, which resulted in damage to the bottom of the bladder and bladder triangle. .
The bladder is composed of mucosal layer, muscle layer and adventitia. The adventitia is covered by peritoneum. The peritoneum is tightly connected with the adventitia at the tip of the bladder and the midline of the upper body, while the peritoneum and the adventitia on the side of the bladder are loosely combined. The peritoneum is easy to peel off. This is the anatomical basis for the lower uterine segment through extraperitoneal peeling. There is a thin layer of loose connective tissue space between the bladder and cervix, located between the triangle of the bladder and the cervix. The upper boundary is the bladder and uterus reflexed peritoneum, the lower boundary is the upper vaginal septum, and both sides are the inner lobes of the vesicocervix vaginal ligament, and the bladder vagina. The gap can be seen as a continuation of the gap between the bladder and cervix, which has fewer internal blood vessels and is easy to separate.
2.2 Matters needing attention
In patients with no obvious adhesions in the lower part of the uterus, after opening the bladder and the uterus and folding the peritoneum, lift the uterine cup forcefully to expose the bladder, cervix, and vaginal spaces, gradually push the bladder down along the gap, and separate and expand downward and on both sides to achieve sufficient surgery. level. If the level of adhesion is unclear, before the anatomical level of the bladder and cervix connective tissue gap is not clear, an ultrasonic knife can be used as close as possible to the cervix for sharp separation, combined with the blunt suction of the suction device to gently push down to feel the tension, resistance and bleeding. . If the tension and resistance are high, easy bleeding often means that the anatomical level is poor. At this time, you should not force it to avoid separation and bleeding. You should separate sharply and then find the correct boundary, and then perform blunt separation v avoid forced blunt separation to cause bladder muscle Layer blood vessel damage and bleeding or even bladder rupture; if the tension or resistance is small, and the bleeding is minimal, it often means that the anatomy is correct, and the white and smooth bladder cervical fascia can be seen. At this time, the blunt push down of the aspirator will be more effective until Stop when the resistance increases, and then perform sharp separation. Repeatedly, the bladder can be pushed down and there is less bleeding.Some patients with adhesions between the bladder and the lower part of the uterus may consider opening the bladder side fossa first, and then push the bladder down after the extraperitoneal path bluntly separates the adhesions from the side of the bladder, but pay attention to the anatomy of the bladder side fossa, and do not damage the side wall of the bladder. Although there is no exact mechanism for fistula formation, experimental studies by Cogan et al. in animals show that the formation of vesicovaginal fistula after laparoscopic total hysterectomy is related to unipolar heat damage, so it is best to use an ultrasonic knife when removing the vaginal wall. Instead of unipolar, reduce the possibility of thermal damage.
After the bladder is separated and moved, it should be checked in time. If bladder damage is found, it should be repaired immediately. If there is a high degree of suspicion but no obvious damage site can be seen, intraoperative injection of methylene blue solution or cystoscopy can be used to help diagnose R1. Only muscular layer injury can be sutured with 4-O absorbable synthetic thread intermittently. If the breach has been pierced, two layers of suture should be performed. After full-layer suture with 4-0 absorbable thread, another layer is sutured with inversion; the breach is located in the triangle of the bladder When suturing near the area, be careful not to hurt the ureteral opening; after adequate bladder drainage for 2 weeks and prevention of infection, it can usually heal at first stage. However, most bladder electrical injuries are difficult to find during surgery. It is usually manifested as a large amount of vaginal discharge or a small amount of vaginal discharge at about 1 week after surgery, but gradually increases and infection. At this time, methylene blue solution should be injected into the bladder and retrograde. Cystoureterography, cystoscopy, B-ultrasound, vaginal exudate and urine were tested for creatinine, urea nitrogen, and electrolytes to determine the presence or absence of urinary fistula and its location. As long as it is found, the urinary catheter should be indwelled for adequate bladder drainage, urinary tract infections should be controlled, and patients should try their best to adopt a position that can reduce urinary fistula exudates. Most bladder injuries and vesicovaginal fistulas can heal at first stage without leaving sequelae. For conservatively unsuccessful vesico-vaginal fistulas, secondary repairs are usually performed 3 to 6 months after surgery.