【评论】经肛全直肠系膜切除术术中的尿道损伤和其他泌尿系统损伤:一项国际合作研究  

Urethral injury and other urologic injuries during transanal total mesorectal excision:an international collaborative study

作　　者：王枭杰[1] Wang Xiaojie

机构地区：[1]福建医科大学附属协和医院结直肠外科,福建福州350001

出　　处：《结直肠肛门外科》2024年第1期87-89,共3页Journal of Colorectal & Anal Surgery

摘　　要：目的明确经肛全直肠系膜切除术(transanal total mesorectal excision,taTME)术中发生尿道损伤和其他泌尿系统损伤的危险因素,并评估患者的预后。背景尿道损伤是腹会阴联合切除术(abdominoperineal resection,APR)的一种罕见并发症,在经腹入路术中尚未见尿道损伤的报道。低位直肠癌发展计划(Low Rectal Cancer Development Program)taTME国际注册中心近来报告此类尿道损伤的发生率为0.8%,但是在很大程度上,其真实发病率和损伤机制仍未知。方法对taTME并发泌尿系统损伤的患者进行回顾性分析。分析内容包括患者的一般情况、肿瘤特征、术中细节、预后,以及术者在taTME方面的实践经验和培训情况。从外科医师的角度出发,围绕尿道损伤的原因及如何避免损伤的策略进行探讨。结果在7年多的时间里,共32个手术组报告了taTME术中发生泌尿系统损伤的病例,包括34例尿道损伤、2例输尿管损伤和3例膀胱损伤。其中,有20例损伤发生在各小组开展的前8例taTME实践中(“早期经验”),其余损伤发生在各小组开展的第12例至第101例taTME。泌尿系统损伤导致22%的中转开腹率和8%的非计划APR/Hartmann术手术率。中位随访27.6个月(范围3~85个月),尿道修复导致的并发症发生率为26%,尿道修复失败而需进行永久性尿路改道的概率为9%。在成功实现尿道修复的患者中,18%的患者出现持续性的排尿功能障碍。结论泌尿系统损伤导致较高的并发症发生率。我们的调查表明,实施结构化的taTME培训和监管可能是减少外科医师早期taTME实践中的泌尿系统损伤的最好途径。“早期经验”后出现的泌尿系统损伤多与患者个体的复杂性有关,或可通过更严格的病例筛选来避免。Objective To identify risk factors for urethral and urologic injuries during transanal total mesorectal excision(taTME)and evaluate outcomes.Background Urethral injury is a rare complication of abdominoperineal resection(APR)that has not been reported during abdominal proctectomy.The Low Rectal Cancer Development Program international taTME registry recently reported a 0.8%incidence,but actual incidence and mechanisms of injury remain largely unknown.Methods A retrospective analysis of taTME cases complicated by urologic injury was conducted.Patient demographics,tumor characteristics,intraoperative details,and outcomes were analyzed,along with surgeons’experience and training in taTME.Surgeons'opinion of contributing factors and best approaches to avoid injuries were evaluated.Results Thirty-four urethral,2 ureteral,and 3 bladder injuries were reported during taTME operations performed over 7 years by 32 surgical teams.Twenty injuries occurred during the teams'first 8 taTME cases("early experience"),whereas the remainder occurred between the 12th to 101st case.Injuries resulted in a 22%conversion rate and 8%rate of unplanned APR or Hartmann procedure.At median follow-up of 27.6 months(range,3-85),the urethral repair complication rate was 26%with a 9%rate of failed urethral repair requiring permanent urinary diversion.In patients with successful repair,18%reported persistent urinary dysfunction.Conclusions Urologic injuries result in substantial morbidity.Our survey indicated that those occurring in surgeons’early experience might best be reduced by implementation of structured taTME training and proctoring,whereas those occurring later relate to case complexity and may be avoided by more stringent case selection.

关 键 词：直肠切除术 直肠癌 经肛全直肠系膜切除术 尿道损伤 泌尿系统损伤 

分 类 号：R735.3[医药卫生—肿瘤]