螺旋状带蒂膀胱肌瓣输尿管成形术修复全程输尿管损伤的疗效分析(附6例报告)  

Curative effect analysis of spiral pedunculated bladder muscle flap ureteroplasty for reconstruction of whole-length ureteral defects

作　　者：李永伟[1] 杨嗣星[1] 吴天鹏[1] 宋超[1] 廖文彪[1] 熊云鹤[1] 

机构地区：[1]武汉大学人民医院泌尿外科,武汉430060

出　　处：《临床泌尿外科杂志》2014年第4期296-299,303,共5页Journal of Clinical Urology

摘　　要：目的：观察螺旋状带蒂膀胱肌瓣输尿管成形术修复全程或接近全程输尿管损伤的疗效，探讨膀胱肌瓣修复长段输尿管损伤（〉20cm）的手术方式。方法：回顾性分析6例因输尿管上段结石行输尿管镜下碎石术并发的全程或接近全程输尿管损伤患者的治疗过程：男4例，女2例；年龄37～59岁，平均49岁；左侧4例，右侧2例。其中输尿管黏膜全程撕脱2例，自肾盂至膀胱连接处输尿管完全离断4例；损伤长度21～25cm，平均22cm。6例均采用螺旋状带蒂膀胱肌瓣输尿管成形术。术中注意保护患侧膀胱上动脉的完整性，取瓣要循膀胱上动脉走行裁剪。其中5例术中同行肾脏下降固定术和膀胱腰大肌悬吊术，以缩短患侧肾和膀胱间距，1例切瓣卷管后直接与肾盂端吻合。酌情转移带蒂大网膜组织覆盖重建输尿管。结果：6例手术顺利，手术时间1～2h，平均1．5h。5例成形输尿管旁引流管术后第3天拔除，1例因漏尿于术后第10天拔除。6例切口均一期愈合。术后2周复查血肌酐和尿素氮正常，术后8周在膀胱镜下安全拔除双J管。1例术中未同行肾脏下降固定术和膀胱腰大肌悬吊术的患者术后3个月行静脉尿路造影（IVU）检查，发现重建输尿管明显狭窄且伴肾积水，重新置人双J管行保守治疗，2个月后复查ECT示患侧肾脏功能重度受损，于术后6个月行患肾切除术。1例术后6个月IVu复查时发现手术侧轻度肾积水及输尿管轻度扩张，但总肾功能正常。余4例随访2～4年，未见明显异常，IVU检查显示手术侧成形输尿管形态均正常，显影良好，均未发现明显的膀胱输尿管反流，因膀胱容量缩小导致的下尿路症状（LUTS）不明显。结论：螺旋状带蒂膀胱肌瓣输尿管成形术是长段输尿管损伤修复的理想术式，创伤小，并发症少，恢复快，尤其适用于缺损长度超过20cm乃至全程输尿管损伤�Objective： To observe the effects of spiral pedunculated bladder muscle flap ureteroplasty for the treatment of whole-length or nearly whole-length ureteral defects, and to investigate a suitable method for repai- ring long segment ureteral defects （〉20 cm）. Method：Retrospective analysis on the clinical effects of six patients encountered a long segment ureteral defects in the course of ureteroscopic lithotripsy. Six patients including four males and two females were from 37 to 59 years old（average age, 49）, in which four cases happened on the left and two cases occurred on the right. Two cases suffered from whole ureteral mucosal avulsion and four cases were found whole ureteral rupture from the pelvis to the bladder junction. Defect length was from 21 cm to 25 cm（mean length, 22 cm）. All six patients experienced emergency surgery of spiral pedunculated bladder muscle flap uretero- plasty. We paid attention to protect the superior vesical arteries while dissociation, and cut the shape S bladder flap following the tract of the superior vesical arteries. Five of them underwent kidney descent fixation and psoas blad- der simultaneously. The rest one were anastomosed the formed ureter and renal pelvis directly. Result： All opera- tions were successful and the operation time was ]-2 hours （average time, 1.5 hours）. Formed ureteral drainage tubes of the five patients were removed three days after operation, while drainage tube of another one patient was removed ten days after operation due to leakage of urine. Wounds of all patients healed by first intention. Review results of all patients serum creatinine and blood urea nitrogen were normal two weeks after operation. Double-J tubes were removed safely under cystoscope eight weeks postoperatively. Postoperative follow-up results showed one ease who didn＇t receive kidney descent fixation and psoas bladder fixation was found severe ureteral stenosis and hydronephrosis, then underwent nephrectomy after the failure of one month conservative treat

关 键 词：输尿管损伤 螺旋状带蒂膀胱肌瓣输尿管成形术 输尿管镜检查术 

分 类 号：R693[医药卫生—泌尿科学]