Xiong S W, Yang K L, Ding G P, Hao H, Li X S, Zhou L Q, Guo Y L
Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China.
Beijing Da Xue Xue Bao Yi Xue Ban. 2019 Aug 18;51(4):783-789. doi: 10.19723/j.issn.1671-167X.2019.04.034.
Ureteral injury can be classified as iatrogenic or traumatic, which represents a rare but challenging field of reconstructive urology. Due to their close proximity to vital abdominal and pelvic organs, the ureters are highly susceptible to iatrogenic injury, while ureteral injury caused by external trauma is relatively rare. The signs of ureteric injury are difficult to identify initially and often present after a delay. The treatment of ureteral injury, which is depended on the type, location, and degree of injury, the time of diagnosis and the patient's overall clinical condition, ranges from simple endoscopic management to complex surgical reconstruction. And long defect of the ureter presents much greater challenges to urologists. Ureterotomy under endoscopy using laser or cold-knife is available for the treatment of 2-3 cm benign ureteral injuries or strictures. Pyeloplasty is an effective treatment for ureteropelvic junction obstruction and some improved methods showed the possibility of repairing long-segment (10-15 cm) stenosis. Proximal and mid-ureteral injuries or strictures of 2-3 cm long can often be managed by primary ureteroureterostomy. When not feasible due to ureteral defects of longer segment, mobilization of the kidney should be considered, and transureteroureterostomy is alternative if the proximal ureter is of sufficient length. And autotransplantation or nephrectomy is regarded as the last resorts. Most of the injuries or strictures are observed in the distal ureter, below the pelvic brim, and are usually treated with ureteroneocystostomy. A non-refluxing technique together with a ureteral nipple or submucosal tunnel method, is preferable as it minimizes vesico-ureteral reflux and the risk of infection. In order to cover a longer distance, ureteroneocystostomy in combination with a psoas hitch (covering 6-10 cm of defect) or a Boari flap (covering 12-15 cm) is often adopted. Among various ureteral replacement procedures, only intestinal ureteral substitution, which includes ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance when urothelial tissue is insufficient. Ileal ureter can be used to replace the ureter of >15 cm defect and even to replace the entire unbilateral ureter or bilateral ureter. Laparoscopic and robotic-assisted techniques are increasingly being employed for ureteral reconstruction and adopted with encouraging results.
输尿管损伤可分为医源性或创伤性损伤，这是重建泌尿外科领域中一个罕见但具有挑战性的领域。由于输尿管与腹部和盆腔重要器官毗邻，极易发生医源性损伤，而外部创伤导致的输尿管损伤相对少见。输尿管损伤的体征最初难以识别，往往会延迟出现。输尿管损伤的治疗取决于损伤的类型、位置和程度、诊断时间以及患者的整体临床状况，范围从简单的内镜处理到复杂的手术重建。输尿管长段缺损对泌尿外科医生来说挑战更大。内镜下使用激光或冷刀进行输尿管切开术可用于治疗2 - 3厘米的良性输尿管损伤或狭窄。肾盂成形术是治疗输尿管肾盂连接部梗阻的有效方法，一些改进方法显示出修复长段（10 - 15厘米）狭窄的可能性。输尿管上段和中段2 - 3厘米长的损伤或狭窄通常可通过一期输尿管输尿管吻合术处理。当因输尿管长段缺损而不可行时，应考虑游离肾脏，如果近端输尿管长度足够，可选择输尿管间置吻合术。自体肾移植或肾切除术则被视为最后的手段。大多数损伤或狭窄发生在输尿管远端，即骨盆边缘以下，通常采用输尿管膀胱吻合术治疗。采用非反流技术并结合输尿管乳头或黏膜下隧道法较为可取，因为它能将膀胱输尿管反流和感染风险降至最低。为了覆盖更长的距离，常采用输尿管膀胱吻合术联合腰大肌悬吊术（覆盖6 - 10厘米缺损）或鲍里皮瓣术（覆盖12 - 15厘米）。在各种输尿管替代手术中，只有肠道输尿管替代术，包括回肠代输尿管术、阑尾间置术和重构结肠替代术，在尿路上皮组织不足时获得了广泛认可。回肠代输尿管术可用于替代超过15厘米缺损的输尿管，甚至替代整个单侧输尿管或双侧输尿管。腹腔镜和机器人辅助技术越来越多地用于输尿管重建，且取得了令人鼓舞的效果。
