经阴道联合腹腔镜下根治性女性全膀胱切除原位回肠新膀胱术

目的 探讨经阴道联合腹腔镜下根治性女性全膀胱切除及原位回肠新膀胱的手术方法.方法浸润性膀胱癌患者6例,平均年龄61(55～73)岁.5孔法先行腹腔镜下手术:游离输尿管后分侧清扫盆腔淋巴结;举宫器配合下,用血管闭合器LigaSure切断子宫相关韧带及膀胱两侧血管蒂;电凝钩分离子宫直肠陷窝及膀胱前间隙;LigaSure切断阴蒂背血管复合体;超声刀切开膀胱颈尿道后游离膀胱颈后壁至阴道前穹窿部.阴道手术:直视下剪开阴道前后穹窿,于阴道取出标本,缝合阴道.回肠新膀胱术:下腹正中4～5 cnl切口,将回肠拉出切口外,游离30～40 cm回肠,剖开后w形折叠缝合形成贮尿囊;插入法植入输尿管后将贮尿囊还纳腹腔.缝合切口后重新开启气腹,腔镜下行新膀胱尿道吻合. 结果 手术时间平均6.2(4～8)h;出血量平均665(400～1200)ml.术后1～3个月患者均恢复较满意的控尿功能,IVU显示双肾功能良好,无膀胱输尿管反流及梗阻.新膀胱最大容量平均427(300～600)ml.无新膀胱阴道瘘等需要手术处理的严重并发症.术后平均随访16(9～30)个月,6例均存活.1例术后8个月发现肝转移. 结论 经阴道联合腹腔镜下根治性女性全膀胱切除回肠新膀胱术治疗女性浸润性膀胱癌可行、有效,应用举宫器及经阴道直视下手术可一定程度上降低腹腔镜下全膀胱切除术的手术难度、缩短手术时间.由于阴道切口整齐、缝合确切,新膀胱阴道瘘等并发症的发生机会减少.     

腹腔镜下全膀胱切除原位回肠新膀胱术(5例报告)

目的 探讨在基层医院采用腹腔镜下全膀胱切除原位回肠新膀胱术的临床应用.方法 浸润性膀胱癌患者5例,年龄60 ～ 65岁,男3例,女2例.采用OLYMPUS腹腔镜根治性切除膀胱后通过腹壁小切口形成回肠新膀胱,然后在腹腔镜下将新膀胱与尿道吻合.结果 5例患者手术均成功.手术平均时间8 h,出血量平均280 ml.术后2周拔除输尿管支架管,术后3周拔除导尿管.术后随访时间5 ～ 19个月,除1例女性患者外均能控制排尿,肾功能电解质大致在正常范围,未见肿瘤复发及远处转移.结论 腹腔镜下全膀胱切除原位回肠新膀胱术使传统的膀胱癌根治手术实现微创化,术中出血少,术后恢复快,在基层医院开展已成为可能.     

腹腔镜下全膀胱切除原位回肠新膀胱重建术(附5例报告)

目的:介绍腹腔镜下全膀胱切除原位回肠新膀胱重建术的经验。方法:采用腹腔镜下全膀胱切除原位回肠新膀胱重建术治疗浸润性膀胱癌患者5例。方法是经腹壁小切口取出切除物,行回肠去管成形新膀胱,然后在腹腔镜下将新膀胱与尿道连续吻合。结果:5例患者手术成功,手术时间4.5~7.2h。腹腔镜手术中以超声刀及双极电凝行膀胱侧韧带、前列腺血管蒂及前列腺尖部切断止血,未使用钛夹、术中出血量180~550ml,平均输血400ml。术后4~5天恢复饮食,3周拔除输尿管支架管,4周拔除尿管。患者白天可完全控制排尿,2例夜间偶有尿失禁。1例术后尿漏,经引流治愈。结论:腹腔镜下全膀胱切除术具有创伤小、出血少、恢复快等优点;而回肠新膀胱和尿道连续吻合具有操作方便、省时、缝合紧密、可防止尿漏等优点。     

腹腔镜下膀胱全切除原位回肠代膀胱术(附15例报告)

目的　探讨腹腔镜下膀胱全切除原位回肠代膀胱手术方法。　方法　浸润性膀胱癌患者 15例 ,年龄 39～ 71岁 ,平均 5 9岁 ,男 14例 ,女 1例。采用 5个套管针 ,腹腔镜由脐部上缘套管针进入 ,手术者经左侧 2个套管针操作 ,助手经右侧 2个套管针操作。清扫双侧盆腔淋巴结 ;游离输尿管下段在其末端切断 ;男性患者行膀胱前列腺全切除 ,紧贴前列腺尖端离断尿道 ;女性行膀胱全切除的同时作子宫及附件切除。在下腹正中线上作 4～ 5cm切口 ,取出标本。将回肠拉出切口外 ,隔离 5 0cm回肠剖开后M形折叠形成贮尿囊 ,将输尿管末段 1cm插入贮尿囊后顶部作吻合。贮尿囊最低位开口与尿道断端 6针吻合 ,前 4例直视下作吻合 ,后 11例在腹腔镜下行尿道吻合。　结果　手术时间 5～ 10h ,平均 6 .5h ;出血量 2 0 0～ 10 0 0ml,平均 387ml。术后 3周KUB、IVU及代膀胱造影检查显示 :双肾显影良好 ,无输尿管返流及梗阻 ,代膀胱充盈良好 ,容量约 30 0ml,术后 4～ 6周内患者均恢复控尿功能。无排尿困难及尿失禁。　结论　腹腔镜下行膀胱全切除视野清楚 ,可减少出血 ,避免尿道括约肌损伤 ,保留海绵体神经血管束 ;减少肠管暴露时间 ,有利于术后肠道功能恢复 ,减少肠粘连。小切口取出标本 ,体外构建贮尿囊 ,吻合输尿管 ,可缩减手术时间     

腹腔镜下根治性膀胱切除Studer回肠新膀胱术

目的 介绍腹腔镜下根治性膀胱切除Studer回肠新膀胱术的方法.方法 膀胱癌患者8例.均为男性,年龄51～69岁,平均57岁.浸润性膀胱癌7例,腺癌1例.临床分期:T27例,T21例.经腹取5个穿刺点,腹腔镜下清扫双侧闭孔、髂内及髂外淋巴结;游离膀胱腹侧,剪开双侧盆筋膜,缝扎阴茎背静脉复合体;游离输精管和精囊,剪开狄氏筋膜,分离前列腺与直肠间隙;分离前列腺尖部尿道,切断尿道,将切下的膀胱和前列腺装入标本袋.下腹正中切口6～8 cm,取出标本,于该切口外距回盲部20 cm处截取45 cm回肠.取远端40 cm段对折,纵行切开对系膜缘肠壁,交叉折叠缝制新膀胱,将双侧输尿管吻合于新膀胱近端未剖开的5 cm肠管上.新膀胱颈部与保留尿道断端间断缝合.结果 8例手术顺利,手术时间 6～8 h,平均7.2 h;出血量200～800 ml,平均420 ml;无中转开放手术者.术后病理分期pT2 6例、pT31例、pT2N2M01例,切缘均为阴性.术后发生右侧输尿管套叠1例,经输尿管镜下还纳松解.8例随访3～12个月,生活质量良好.结论 腹腔镜下根治性膀胱切除术切11小、出血少,技术可行,Stueder原位膀胱技术简单、输入袢长、术后功能好.     

腹腔镜下根治性膀胱切除回肠新膀胱术（附15例报告）

目的介绍腹腔镜下根治性膀胱切除回肠新膀胱术的方法及经验。方法本组15例，均为男性，年龄45～62岁，平均54岁。术前均明确诊断为浸润性膀胱癌。采用腹腔镜下行膀胱癌根治性切除，然后取长约40cm回肠于体外缝制贮尿囊及输尿管贮尿囊吻合，体内行贮尿囊尿道吻合术。结果手术时间5．5～8h，平均6．5h；出血量200～1100ml，平均550ml。术后8周静脉尿路造影以及代膀胱造影检查显示：双肾显影良好，无输尿管返流及梗阻，代膀胱充盈良好，容量约300ml。术后3个月全部患者日间控尿良好，7例患者夜间控尿良好，夜间排尿2～3次。结论腹腔镜下膀胱全切除、体外建成贮尿囊及输尿管再植、体内贮尿囊尿道吻合术创伤小、出血少、术后尿控率高、恢复快。     

腹腔镜膀胱根治性切除原位回肠新膀胱术

目的分析8例腹腔镜下膀胱根治性切除术加原位回肠新膀胱术的手术经验及术后效果。方法浸润性膀胱癌患者8例,均为男性,年龄61～76岁,平均68.5岁。腹腔镜下行根治性膀胱前列腺切除,延长脐下切口取出标本,于体外选择40cm回肠,对系膜缘切开后W形折叠形成新膀胱,双输尿管乳头状再植于新膀胱,腹腔镜下将新膀胱最低点与尿道残端行端端吻合。结果手术耗时4～7h,平均5.3h;出血量100～1100mL,平均250mL。术后平均肠道恢复时间3.9d。术后随访7～27个月（平均16.2个月）,患者排尿良好,行B超、IVU及新膀胱造影检查示：双肾显影良好,无输尿管返流及梗阻,新膀胱充盈良好,容量约300mL。结论腹腔镜下行膀胱全切原位回肠新膀胱术损伤小、出血量少、术后恢复快、生活质量高,短期随访临床效果满意。     

腹腔镜根治性膀胱切除术加原位回肠代膀胱术32例临床分析

目的 总结腹腔镜下根治性膀胱术加原位回肠代膀胱术的临床经验.方法 2005年5月至2012年5月对32例膀胱癌患者采用腹腔镜下行根治性膀胱切除术＋原位回肠代膀胱术.结果 全部患者术后随访4 ～60个月,平均34个月,均原位排尿,未发生水、电解质及酸碱平衡紊乱,肾功能正常,无肾积水及输尿管扩张.结论 腹腔镜下行根治性膀胱切除,创伤较小、术野清晰、操作方便、淋巴清扫彻底.原位回肠代膀胱通过负压和尿道的协同作用,可实现原位排尿,发生尿路损害及电解质紊乱的概率低,不失为膀胱根治性切除后尿流改道的较好方法.     

腹腔镜女性膀胱癌根治性切除-原位回肠新膀胱术初步报告

目的探讨腹腔镜女性膀胱癌根治性切除-原位回肠新膀胱术的可行性。方法2003年2月～2006年7月,为8例女性膀胱癌患者施行腹腔镜膀胱、子宫、附件全切除-原位回肠新膀胱术。全麻,仰卧位,头低15°,大腿外展,膝关节屈曲。下腹部置入5个trocar。在髂血管分叉处剪开腹膜,游离输尿管,切断子宫圆韧带、卵巢韧带。沿盆壁向下游离子宫阔韧带,清扫盆腔淋巴组织。离断主韧带、骶韧带、双侧输尿管及膀胱侧血管蒂。于阔韧带基底部切开腹膜,沿子宫颈两侧游离打开阴道穹隆。切开前腹膜反折,游离膀胱前间隙,切断阴蒂背深静脉复合体,膀胱颈下方0.5cm处切断尿道。靠近阴道穹隆处横断阴道并封闭残端。在下腹正中线上做4～5cm切口,取出标本。切口外构建"M"形去管回肠储尿囊,输尿管"插入式"种植于储尿囊。储尿囊回纳腹腔,在腹腔镜下做储尿囊与尿道吻合。结果8例手术时间(344.5±42.1)min,术中出血(373.9±81.3)ml。术后随访6～46个月,平均26个月,其中>12个月6例,半年内均能自主排尿,1例日间偶有尿失禁,1例夜间尿失禁,1例排尿困难。膀胱容量(333.6±40.4)ml。残余尿量0～183ml,(51.2±18.1)m...     

腹腔镜全膀胱切除-原位回肠膀胱术（5例报告）

目的探讨腹腔镜全膀胱切除-新膀胱术的手术方法和临床效果。方法膀胱移行细胞癌患者5例，27-64岁（平均49．8岁）。均经腹腔镜下行全膀胱切除-原位回肠膀胱术，经腹壁切口取出标本，然后将回肠牵出切口截取40cm长回肠段，剖开建成“M”型贮尿囊，并与双侧输尿管吻合再置入腹腔与腹腔镜下行贮尿囊尿道吻合建成原位回肠膀胱。行回肠新膀胱术。结果5例手术均获成功，手术时间5-7h，平均6．0h。出血量200～510ml，平均340ml，无输血。术后2～3天恢复肠道功能。术后三个月随访时患者排尿良好，新膀胱无明显残余尿，容量200-350ml。结论腹腔镜全膀胱切除-原位回肠膀胱术创伤小、出血少、恢复快，很有前景，但还需要长时间随机对照和随访研究。     

Simplified laparoscopic radical cystectomy with orthotopic ileal neobladder creation in a porcine model

BACKGROUND AND PURPOSE: Laparoscopic radical cystectomy with orthotopic ileal neobladder creation is a technically challenging and lengthy surgical procedure. We present our experience with a simplified technique for laparoscopic cystectomy and neobladder creation in the porcine model. MATERIALS AND METHODS: Ten female minipigs underwent a purely laparoscopic radical cystectomy with orthotopic ileal neobladder creation. Nine ureterointestinal anastomoses were performed using a simplified "dunk" technique, where the ureter was prolapsed 5 mm into the afferent limb and the periureteral tissue was secured to the bowel serosa with three superficial sutures. Six ureters were not stented, and three had indwelling stents inserted. In 11 ureters, the anastomosis was performed using a running mucosa-to-mucosa technique (three with stents, eight without stents). The Lapra-Ty suture clip (Ethicon Endosurgery, Cincinnati, OH) was used to secure the running sutures on the urethra, ureters, and neobladder. Animals were harvested at 3 to 8 weeks (mean 6.5 weeks) after surgery. Serology, static cystogram, intravenous urography, and gross and histopathologic evaluations were performed. RESULTS: Of six unstented dunked ureterointestinal anastomoses, two (33%) were widely patent, two were strictured but patent, and two were completely obstructed. In the three stented ureters implanted using the dunk technique, one (33%) was widely patent, one was strictured, and one was completely obstructed. All ureterointestinal anastomoses performed with a mucosa-to-mucosa running anastomosis, whether stented (three ureters) or not stented (eight ureters), were widely patent. Lapra-Ty clip migration into the neobladder pouch caused urethral obstruction resulting in delayed bladder perforation in two animals. CONCLUSIONS: Laparoscopic cystectomy and ileal neobladder creation is technically feasible. Attempts to simplify the ureterointestinal anastomosis require further evaluation and modification. Stent placement appears to be unnecessary in the laparoscopic ureterointestinal anastomosis. Laparoscopic creation of the ileal neobladder remains a technically challenging procedure.     

腹腔镜下膀胱全切除-乙状结肠新膀胱术初步报告

目的 探讨腹腔镜下膀胱全切除-乙状结肠新膀胱手术方法。方法 浸润性膀胱癌患者4例。均为男性。年龄58—74岁，平均65岁。手术采用气管内全麻、膀胱截石位、头低15℃，下腹部置入5根套管，腹压设定12mmHg（1mmHg=0．133kPa）。在髂总动脉分叉处剪开腹膜，找到输尿管向下游离至膀胱，剪开髂血管鞘，行盆腔淋巴结清扫；游离输精管及精囊，切开狄氏筋膜分离狄氏间隙；分离膀胱前间隙，切开两侧盆筋膜反折和耻骨前列腺韧带，缝扎阴茎背深静脉复合体；切断输尿管及膀胱前列腺侧血管蒂；剪断阴茎背深静脉复合体及尿道，将前列腺及膀胱一并切除。距肛门15cm处切开乙状结肠，将标本经该开口从肛门取出；隔离15cm乙状结肠，将肠道吻合器经肛门插入，乙状结肠近远端作端端吻合。在隔离乙状结肠肠管的中点作一小切口，将该口与尿道断端吻合；插入Foley导尿管，左右输尿管种植在乙状结肠肠管两端，将输尿管末端插入乙状结肠内1cm，4-0可吸收线固定4—6针。关闭乙状结肠两端开口，用剪刀小心剪开前结肠带，形成去带乙状结肠膀胱。结果 手术时间7—9h，出血量200～350ml，术后第3天肛门排气，第2周拔除导尿管。术后1—3个月恢复控尿功能，膀胱容量200—300ml，无上尿路梗阻及返流，无明显围手术期并发症。结论 腹腔镜下膀胱全切除-乙状结肠新膀胱术技术可行，手术效果良好。     

改良原位螺旋构型回肠新膀胱术32例报告

目的 评价原位螺旋构型回肠新膀胱术的疗效.方法 1998-2008年对32例男性膀胱癌患者行原位螺旋构型回肠新膀胱术.采用40～45 cm回肠新建储尿囊,去管后用无水乙醇擦拭以清除、破坏黏液细胞,螺旋状构型缝合成低压储尿囊.两侧输尿管末端袖口状整形后分别行原位"插入式"置入新膀胱(Split-Cuff术式).新建储尿囊采用"四针法"低位与尿道缝合.结果 本组平均手术时间(281.2±48.7)min;平均失血量(545.4±181.9)ml,术中输血20例,平均输血(430.8±235.9)ml;平均住院时间(26.8±9.7)d.白天控尿良好30例(93.7%),夜间控尿良好26例(81.3%).23例于术后6个月复查尿动力学提示新膀胱初始尿意容量为270～420(315.0±33.4)ml,最大膀胱容量350～600(490.3±39.7)ml,充盈压(22.5±11.8)cm H2O,最大排尿压(78.3±14.7)cm H2O,最大尿流率(16.5±5.9)ml/s.术后随访22～132个月,平均58.4个月,术后2年内死于肿瘤转移4例.结论 原位螺旋形回肠新膀胱具有容量大、相对低压、顺应性好、肠管利用率高、消化道干扰小和术后排尿、控尿功能更接近正常生理等特点.新膀胱经无水乙醇处理后减少了分泌吸收功能,降低了尿路梗阻和代谢紊乱发生率.输尿管新膀胱Split-Cuff乳头"插入式"吻合可有效防止尿液反流,且方法简单,不易引起管口狭窄,有效地保护了肾功能.尿道以"四针法"吻合简单、实用,可减少吻合口狭窄的发生率.改良螺旋构型回肠新膀胱术是一种较为合理的原位膀胱替代方法.

Abstract：

Objective To assess the outcomes of modified spiral ileal orthotopic neobladder.Methods From January 1998 to January 2008, 32 patients (all male) underwent radical cystectomy and spiral ileal orthotopic substitution for muscle invasive bladder cancer. A segment of 40 to 45 cm ileal loop was isolated, detubularized, and reconfigured in spiral shape to form a pouch. Bilateral ureters were reimplanted by inserting the 1 cm distal segment into the pouch to form a Split-Cuff nipple.The bottom of the pouch was opened and anastomosed with the urethra (4 stitches). Results There were no perioperative deaths. The mean operative time was 281.2±48.7 min. Blood loss was 545.4±181.9 ml. Twenty cases required a blood transfusion, the mean volume of intraoprative blood transfusion was 430.8±235.9 ml. The average hospital stays were 26.8±9. 7 days. Rate of daytime continence was 93. 7% (30/32) while nighttime continence was 81.3% (26/32). Urodynamic studies were carried out in 23 cases 6 months after surgery. Neobladder capacity at first desire to urinate was 315.0± 33.4 ml(270-420 ml). The maximum neobladder capacity was 490. 3±39.7 ml(350-600 ml).The maximum flow rate (Qmax) was 16.5 ± 5.9 ml/s. Full resting pressure was 22. 5 ± 11.8 cm H2O. Peak voiding pressure was 78.3 ± 14.7 cm H2O. After mean 58. 4 months' follow up (range 22 to 132), 4 cases died of metastasis of bladder cancer. Conclusion Modified spiral ileal orthotopic neobladder is a reasonable option for treating invasive bladder cancer.     

女性保留内生殖器膀胱全切原位回肠新膀胱尿流改道术的临床疗效

目的:探讨女性保留内生殖器膀胱全切患者行原位回肠新膀胱尿流改道术的临床疗效。方法:回顾性分析我院2005年7月~2012年5月48例女性膀胱肿瘤患者的临床资料,均采取保留内生殖器的膀胱全切术并行原位回肠新膀胱尿流改道术。48例患者中移行细胞癌46例,腺癌2例;原发肿瘤32例,复发性肿瘤16例;多发性非肌层侵犯肿瘤17例,肌层浸润性膀胱肿瘤31例。结果:48例患者的平均手术时间260(210~360)min,平均输血量280(0~1200)ml。术后47例患者获得随访,随访6~84个月,平均36个月。术后12个月白天控尿率为97.9%(46/47),夜间控尿率为93.6%(44/47)。新膀胱尿道吻合口漏3例。术后6个月IVU检查输尿管狭窄2例。无子宫、子宫附件及阴道转移复发。结论:对于符合适应证的女性膀胱癌患者,保留内生殖器、阴道前壁、自主神经及完整尿道,行膀胱全切并行原位回肠新膀胱尿流改道术,临床疗效满意,术后患者生活质量高,可作为广泛开展的术式。     

正位可控去带盲结肠膀胱加回肠抗反流术

目的：探讨正位可控去带盲结肠膀胱加回肠抗反流术的临床效果。方法：采用膀胱全切正位可控去带盲结肠膀胱加末段回肠抗反流术治疗膀胱癌20例。结果：随访9～42个月，白天均可控制排尿，14例夜间能白控排尿，6例夜间有尿失禁。尿动力学检查：12个月贮尿囊平均最大容量350ml，平均最大囊内压3．16kPa，剩余尿量为16ml，平均最大尿流率19．2ml／s。贮尿囊造影及IVU显示2例有双侧输尿管反流，无输尿管狭窄和肾积水。血电解质及肾功能正常。结论：正位可控去带盲结肠膀胱加末段回肠抗反流术操作简单，并发症少，疗效好，是一种较理想的膀胱替代术。     

The ileal neobladder

An ileal neobladder for total bladder replacement was created in 11 patients. To achieve a low pressure system, disruption of directional bowel peristalsis with a longitudinal incision at the antimesenteric border of a 70 cm. ileal segment is performed. A spherical pouch, the neobladder, is fashioned and anastomosed to the urethra. The ureters are implanted according to the method of Le Duc and Camey. Videourodynamic studies during various postoperative phases demonstrate this neobladder to be a urinary reservoir with a capacity approximating that of a normal bladder, good compliance during filling by maintaining pressure lower than 30 cm. water and no reflux. Of the 11 patients with the neobladder 8 are completely dry day and night, while 3 have grade I stress incontinence. All 11 patients had recognizable sensations of bladder distension closely simulating those of normal bladders. The use of this ileal neobladder in male patients undergoing radical cystectomy offers an alternative free of a stoma to urinary diversion, resulting in a highly compliant, low pressure bladder.     

改良膀胱全切正位可控W形回肠代膀胱术(附10例报告)

目的:探讨改良膀胱全切正位可控W形回肠代膀胱术的疗效。方法:对10例膀胱癌患者采用改良膀胱全切正位可控W形回肠代膀胱术。膀胱全切时不切断耻骨前列腺韧带,切断前列腺尖部时紧贴精阜近端,并采用电刀紧贴膀胱及前列腺处理膀胱侧后韧带和前列腺侧韧带。截取末段回肠,排列成W形,褥式缝合制作贮尿袋,输尿管以乳头法种植。结果:10例手术时间平均240min,术中平均出血量600ml,术后随访12~24个月,平均16个月,日间控尿良好10人,夜间控尿良好9人,9例患者性功能恢复,未见一例尿失禁。结论:改良膀胱全切正位可控W形回肠代膀胱术手术时间短,操作简单,术中出血少,并发症少,术后患者控尿效果好,尿失禁发生率低,性功能恢复良好。