Clinical analysis of different surgical repair procedures for vesicovaginal fistula after gynecologic surgery

目的:分析探讨不同术式膀胱阴道瘘修补术治疗妇科手术后膀胱阴道瘘的疗效.方法:回顾性分析北京大学第三医院泌尿外科2009年4月至2015年11月收治的12例膀胱阴道瘘患者的临床资料.12例患者均有妇科手术史:其中行子宫全切术10例,行盆腔肿物切除术1例,行膀胱电切术1例.从手术损伤致出现阴道漏尿的病程为5 ～12个月,平均8.4±2.9个月.膀胱镜检查测量瘘口直径0.3～ 2cra,平均(1.1±0.6)cm.12例均为单发瘘口.结果:6例患者行经阴道途径膀胱阴道瘘修补术.平均手术时间为(105.0±32.0) min,平均术中出血(4.5±1.2)mL,平均术后住院时间(3.0±1.5)d.6例患者术后6个月未见复发;3例患者行经腹腔镜途径膀胱阴道瘘修补术.平均手术时间为(345.3±192.3)min,平均术中出血(83.3±28.9) mL,平均术后住院时间(10.3±3.2)d.2例随访6月未见复发,1例术后6月发生膀胱阴道瘘复发,行二次手术修补;1例患者采用开放经腹腔途径膀胱阴道瘘修补术.手术时间为234min,术中出血200mL,术后住院时间40d.术后出现伤口脂肪液化,予定期换药治疗后好转,随访6月未见复发;1例患者发生Studer原位新膀胱阴道瘘,采用经腹经阴道联合途径的手术方式,手术时间为224min,术中出血100mL,术后住院时间20d,随访6月未见复发;1例患者因瘘口较小采用膀胱镜下膀胱阴道瘘口电凝术,手术时间为10min,术中出血2mL,术后住院时间2d,术后出现不自主漏尿,复查膀胱镜仍可见膀胱后壁瘘口,遂留置尿管1月,1月后行经阴道膀胱阴道瘘修补术,随访6月未见复发.结论:妇科手术导致的膀胱阴道瘘可以通过手术修补治愈.经阴道修补手术成功率高,术后恢复较快.对于能够经阴道显露、分离及缝合的膀胱阴道瘘尽可能行经阴道修补手术.Objectives:To compare the outcome of different surgical repair procedures for vesicovaginal fistula after gynecologic surgery.Methods:The clinical data of 12 patients with vesicovaginal fistula after gynecologic surgery from April 2009 to November 2015 in Peking University Third Hospital were analyzed retrospectively.All the 12 cases had a history of gynecologic operations:10 cases underwent hysterectomy,1 case underwent pelvic mass resection and 1 case underwent transurethral resection of the bladder.The duration from gynecologic operation to vaginal leakage was 5 to 12 months,with an average of 8.4 ± 2.9 months.The diameter of the fistula was 0.3 ～2cm,with an average of 1.1 ±0.6 cm.All the 12 cases were single fistula.Results:Six cases were repaired by a vaginal approach.The average operation time was 105.0 ± 32.0 min;average intraoperative bleeding was 4.5 ± 1.2 ml;average postoperative hospital stay was 3.0 ± 1.5 d.No recurrence was found in 6 months after the repair operation.Three cases underwent laparoscopic transabdominal repair.The average operation time was 345.3-± 192.3 min;average intraoperative bleeding was 83.3 ± 28.9 ml;average postoperative hospital stay was 10.3 ± 3.2 d.No recurrence was found in 6 months after the repair operation within 2 patients.One patient experienced two times of surgical repair treatment because of fistula recurrence.One case underwent open transabdominal repair.The operation time was 234 min;operation bleeding was 200 ml,and postoperative hospital stay was 40 d.Fat liquefaction occurred in wound after operation,cured by conservative treatment.No recurrence was found during follow-up.Studer neobladder vagina fistula occurred in 1 patient,who underwent operation in a combined abdominal and vaginal approach.The operation time was 224 min;operation bleeding was 100 ml,and postoperative hospital stay was 20 d.No recurrence was found.One case underwent electric coagulation due to the smaller diameter of fistula.The operation time was 10 min;operation bleeding was 2 ml,and postoperative hospital stay was 2 d.The patient experienced second transvaginal repair treatment because of recurrence.Condusion:The vesicovaginal fistula caused by gynecologic surgical procedures can be cured by surgical repair operation.Transvaginal repair is a feasible and effective procedure with less blood loss and shorter recovery time.As far as vagina is able to be revealed,separated and sutured,transvaginal repairs can be used as a minimal invasive procedure and provide favorable outcomes.765-682