膀胱全切术后阴茎勃起障碍调查及西地那非治疗效果分析

目的探讨膀胱全切术后男性患者勃起功能障碍及西地那非治疗效果。方法回顾性分析1997年6月～2005年2月53例膀胱全切患者临床资料。年龄35～62岁,平均51岁。32例行原位回肠膀胱术,21例行Bricker回肠膀胱术。保留血管神经束者28例,未保留血管神经束者25例。采用勃起功能国际问卷-5(IIEF-5)评估术前、术后及西地那非治疗前后勃起功能状况。结果随访16～47月,53例膀胱全切患者ED发生率为73.6%,其IIEF-5评分由术前(21.6±3.8)下降至(4.3±5.1)(P<0.05)。保留血管神经束膀胱全切ED发生率为57%,而未保留血管神经束者ED发生率为92%。39例ED患者中,13例应用西地那非治疗,其中9例保留血管神经束者治疗前后IIEF-5评分分别为(5.3±1.2)和(20.6±2.3)(P<0.05);而未保留血管神经束者治疗前后IIEF-5评分分别为(2.0±1.4)和(2.6±1.7)(P>0.05)。结论勃起功能障碍是膀胱全切术后常见并发症。保留血管神经束可保留部分患者的勃起功能,同时也是应用西地那非治疗成功的关键。     

机器人辅助腹腔镜下保留性神经全膀胱切除术临床应用及疗效分析

目的:初步探讨机器人辅助腹腔镜下保留性神经全膀胱切除术临床应用的可行性及疗效。方法:回顾性分析2016年3月至2018年5月12例施行保留性神经的机器人辅助腹腔镜下全膀胱切除术患者的临床资料。患者年龄45～65岁,术前均有勃起功能, IIEF-5评分17.0分。手术范围包括膀胱前列腺切除和盆腔淋巴结清扫,术中注意保留双侧神经血管束,副阴部内动脉和耻骨膀胱复合体。术后推荐患者进行规律PDE5抑制剂药物治疗,并利用IIEF-5量表随访评估其术后性功能。结果:12例手术均顺利完成,手术切缘阴性,术后病理均为浸润性高级别尿路上皮细胞癌或原位癌,其中11例T_2N_0M_0期及以下,1例T_(3a)N_0M_0期肿瘤,无严重术中、术后并发症。术后随访时间超过12个月[(20.7±8.0)个月],无肿瘤复发转移。术后第3、6、12个月进行IIEF-5评分,分别为(10.9±6.9)分、(12.3±6.9)分和(14.1±8.0)分。随访第12个月时,其中有5例(41.7%)患者在药物辅助下可保持足以获得满意性交的勃起功能,3例(25%)有勃起但无法进行满意性交,4例(33.3%)无勃起功能。结论:对于经过严格筛选的渴望保留性功能的膀胱癌患者,机器人辅助腹腔镜下全膀胱切除术可以最大限度地保护患者的勃起功能。     

勃起神经保留性膀胱全切Roux-y乙状结肠新膀胱的临床结果

目的:观察勃起神经保留性膀胱全切和Roux-y乙状结肠新膀胱术后患者阴茎勃起功能、尿控、排尿和肿瘤复发情况。方法:共有18例患者进行了勃起神经保留性膀胱全切和Roux-y乙状结肠新膀胱术,评价肿瘤复发情况和功能性结果(尿控、排尿、勃起功能)。结果:平均随访41个月,2例分别于术后10个月和15个月死于癌症广泛性转移,这2例均为盆腔淋巴结阳性的患者。白天和夜间尿控率均为100%,11例患者有阴茎勃起功能,勃起率达61.1%,2例患者勃起功能受损,5例无勃起功能,手术前后ⅡEF-5评分为(13.72±6.39)、(10.83±8.25)分,差异有显著性(P<0.05)。结论:勃起神经保留性膀胱全切和Roux-y乙状结肠新膀胱术后患者阴茎勃起功能和尿控情况良好,肿瘤复发情况尚可接受,但仍需要长时间随访和大样本患者证实。     

保留勃起和射精功能的改良全膀胱切除术的临床应用

目的探讨保留勃起和射精功能的改良全膀胱切除术在膀胱良、恶性病变患者的临床应用价值。方法本组18例男性患者,年龄18~38岁,平均30.5岁。结核性挛缩膀胱4例,腺性膀胱炎5例,晚期神经原性膀胱5例,复发的多发性非肌层侵犯膀胱移行细胞癌4例,均需行全膀胱切除术,但患者强烈希望保留勃起和生育功能。行改良单纯性全膀胱切除术,保留输精管、精囊、前列腺和双侧神经血管束,以回肠新膀胱(13例)或回结肠新膀胱(5例)替代。结果平均手术时间350min,术中平均出血量420ml,7例患者输血。1例发生尿漏,无其他围手术期并发症。拔除导尿管后均能自行排尿,每次尿量300~500ml,剩余尿量25~65ml。2例神经源性膀胱患者需间歇自家导尿。白天无尿失禁,3例患者晚上有遗尿。平均随访46个月(18~68个月)。17例(94.4%)患者术后阴茎勃起功能恢复良好,均有遗精(未婚者)或顺行射精。尿路造影上尿路功能和新膀胱形态良好,1例轻度肾积水。肿瘤患者无复发。结论对选择性膀胱良、恶性病变患者行保留勃起和射精功能的改良全膀胱切除和原位膀胱术,安全有效,效果满意。尿动力学检查对神经源性膀胱患者的选择至关重要。     

保存勃起神经的根治性膀胱切除术(附32例报告)

目的:探讨保存阴茎勃起神经的根治性膀胱切除术临床应用价值。方法:2000年1月~2005年1月我院对32例男性患者施行了保存勃起神经的根治性膀胱切除术。患者年龄38~78岁,病程2d~20年,术前勃起功能正常。术中膀胱全切采用顺行逆行相结合的方法,保留神经血管束。结果:随访6~54个月。术后性功能达到Ⅰ级者3例;Ⅱ级者6例;Ⅲ级者23例,时间为2~14个月,平均4.5个月。结论:保存勃起神经的根治性膀胱切除术治疗效果肯定。     

保留前列腺远端包膜在全膀胱切除肠代膀胱术中的应用

目的探讨膀胱癌患者根治性全膀胱切除术中保留前列腺远端包膜的价值.方法56例患者均为男性,平均年龄62岁.其中膀胱移行细胞癌53例,鳞状细胞癌3例;原发肿瘤40例,复发肿瘤16例.浅表性肿瘤27例,浸润性肿瘤29例.常规盆腔淋巴清扫术后,行保留前列腺远端包膜的全膀胱前列腺切除术.分别应用去管化回结肠或回肠作原位代膀胱20例和36例.随访观察手术效果和生活质量.结果回结肠代膀胱和回肠代膀胱的平均手术时间分别为350和380 min,术中出血量分别为580和540 ml.病理报告pT1N028例,pT2N025例,pT3N+3例.平均随访42个月(4～102个月),3例T3N+者分别于术后8、11、19个月死于癌肿,死于其他病变者5例.随访1年时,两种代膀胱白天控尿率分别为94%(17/18)和100%(30/30),夜间排尿1～2次后,保持干燥者占96%(46/48).术后最大尿流率分别为(15.8±2.6)ml/s和(14.7±3.2)ml/s.随访5年以上者28例,肿瘤特异5年生存率T1N0为94%(15/16),T2N0为83%(10/12).术前勃起功能正常31例中,术后维持正常勃起23例(74%).结论保留前列腺远端包膜的膀胱癌肠代膀胱术,能有效保留神经和括约肌功能,提高术后控尿和勃起能力,不影响肿瘤切除原则,值得临床推广应用.     

保留性功能的膀胱全切手术进展

根治性膀胱前列腺切除术是目前治疗浸润性和多发性膀胱肿瘤的标准术式,通常包括膀胱、前列腺、精囊和部分输精管的切除以及局部淋巴结的清扫,然而这种手术不可避免地对患者术后生活质量造成负面影响,包括勃起功能障碍和尿失禁等,文献报道即使在保留神经血管束(neurovascular bundles,NVB)的膀胱前列腺切除术后勃起功能恢复率也不超过50％,因此为了提高患者术后的生活质量,众多学者在肿瘤     

保留性功能全膀胱切除原位回肠新膀胱术(附19例报告)

目的探讨保留勃起和射精功能的全膀胱切除术对浸润性膀胱癌的疗效。方法收集2000年1月～2006年6月膀胱移行细胞癌19例，男性，平均年龄50.9岁，为保留性功能，改善控尿，行改良根治性全膀胱切除原位回肠新膀胱术，保留精囊、输精管、双侧神经血管束及大部分前列腺包膜，随访观察手术效果和生活质量。结果术后病理报告T2aN0M013例，T2bN0M06例。平均随访39个月（6～78个月），死亡率0，均未发现局部及远处转移;平均手术时间5h，平均出血400ml;白天控尿率100%（19/19），夜间尿失禁10.5%（2/19）;全部患者均保留勃起及逆行射精功能，IIEF-5平均22分;新膀胱储尿囊容量350～480ml，充盈压13～25cmH2O，残余尿量10～60ml。结论对有选择的病例采用保留性功能的全膀胱切除-原位回肠新膀胱术可以更好的保留阴茎勃起射精及控尿功能。     

保留性神经的根治性全膀胱切除术探讨(附6例报告)

本文报告我科1993.6～1995.2在为6例多发性或浸润性膀胱肿瘤患者行根治性全膀胱切除术中,有意识地保护支配阴茎勃起的性神经,并取得满意的效果。术后6例中有5例恢复了阴茎勃起功能。本文报告6例临床资料及手术方法的同时,结合文献复习着重介绍性神经血管束(Neuro-Vaocular Bundle,NVB)的解剖三维关系,及术中如何识别并有效地保护NVB的体会。     

保留勃起和射精功能的单纯膀胱切除术

目的 :探讨保留勃起和射精功能的单纯膀胱切除术的临床应用价值。　方法 :7例病人平均年龄 2 7岁。其中 ,结核性挛缩膀胱 2例 ,腺性膀胱炎 1例 ,晚期神经源性膀胱 4例 ,均需行全膀胱切除。为保留勃起和射精功能 ,病人做了改良的单纯性膀胱切除 ,保留输精管、精囊、前列腺和双侧神经血管束。　结果 :平均手术时间 5h 4 5min ,术中出血少 ,未发生围手术期并发症。随访 9～ 6 0个月 ,勃起功能良好 ,均有遗精或顺行射精。新膀胱术者无排尿困难 ,可控性膀胱者插管顺利。尿路造影示上尿路功能良好。病人自我评价生活质量满意。　结论 :对希望保留生育和勃起功能的病人 ,保留输精管、精囊、前列腺和双侧神经血管束的单纯膀胱切除术是一种简单、有效、实用的手术方法     

Neurovascular bundle block as predictor of postoperative erectile function after radical prostatectomy

We assessed audiovisually induced erections after nerve block of the neurovascular bundle during prostate biopsy. We evaluated neurovascular bundle nerve block to mimic non-nerve-sparing radical prostatectomy in an experimental setup. Patients undergoing a transrectal ultrasound-guided prostate biopsy were randomized to bilateral injection of 5 ml ropivacaine hydrochloride 0.75% or NaCl 0.9% into the neurovascular bundle. The patients completed the International Index of Erectile Function 5-item questionnaire (IIEF-5) questionnaire, and a detailed patient history was obtained. A routine prostate biopsy was performed. Thereafter, patients were exposed to 60 min of audiovisual stimulation. Erections were recorded using a Rigiscan-Plus device. A total of 11 patients were randomized. Five patients received NaCl (group 1) and six patients ropivacaine (group 2). Patient characteristics were comparable in terms of age (group 1: 59.8 y; group 2: 61.8 y), mean PSA (4.1 vs 4.7 ng/ml), mean IIEF-5 score (20.5 vs 22) and risk factors for erectile dysfunction, respectively. Patients of group 1 showed significantly stronger and longer erections after audiovisual stimulation than patients in group 2. Patients with bilateral infiltration of saline solution to the neurovascular bundle showed significantly stronger erections than patients receiving local anesthesia of the neurovascular bundle. Thus, this experiment might serve as a model to assess postoperative erectile function after a unilateral nerve-sparing radical prostatectomy.     

Is laparoscopic unilateral sural nerve grafting during radical prostatectomy effective in retaining sexual potency?

OBJECTIVES: To present a pilot study of laparoscopic unilateral sural nerve grafting during radical prostatectomy, with the aim of preserving sexual potency. PATIENTS AND METHODS: Because they had localized prostate cancer, 29 men had a laparoscopic radical prostatectomy with deliberate wide unilateral neurovascular bundle resection and preservation of the contralateral bundle. Fifteen men (group A) had an interposition sural nerve graft on the sectioned bundle, and 14 (group B) had laparoscopic radical prostatectomy with preservation of the unilateral bundle only. The men were also involved in a rehabilitation programme, and erectile function was evaluated after surgery, and at 3, 8, 12 and 18 months, using the five-item version of the International Index of Erectile Function (IIEF-5) questionnaire. RESULTS: The two groups had similar clinical characteristics (age, prostate-specific antigen level, body mass index, prostate volume, clinical stage, Gleason score before and after surgery, postoperative stage). The follow-up was complete for 12 men in group A and 10 in group B. Group A had significantly higher erectile function scores on the IIEF-5 at 12 and 18 months than immediately after surgery (P < 0.01), whereas in group B the improvement was not statistically significant. Overall, by 18 months after surgery five of 12 men in group A had achieved spontaneous unassisted erection or erection assisted with sildenafil, while three of 10 in group B achieved an erection assisted with sildenafil (not significant). CONCLUSIONS: These data suggests that laparoscopic sural nerve grafting during radical prostatectomy is feasible and safe; nevertheless we cannot conclude that sural nerve grafting is more effective than preserving the neurovascular bundle alone in retaining sexual potency. More research is required to validate the effectiveness of this technique.     

Potency-sparing radical perineal prostatectomy

We evaluated the results of a unilateral nerve-sparing radical perineal prostatectomy in a prospective study. Thirty patients with histologically confirmed unilateral prostate cancer and adequate erectile function preoperatively underwent a nerve-sparing procedure. The criteria were a PSA of <10 ng/ml, prostate volume of <60 ml, and a Gleason score <7. In 29 patients the procedure was technically feasible. In one patient significant damage to the neurovascular bundle was seen at the end of the procedure. Bilateral tumors were present in 18 patients on final pathology. Positive surgical margins were observed in five patients (pT2: 2/20; pT3: 3/10). After a follow-up of 3-12 months, 15 of 29 patients (51%) reported some erectile function without additional medication. Of 14 patients, 2 had enough rigidity for penetration within 3 months.The short-term results after unilateral nerve-sparing perineal prostatectomy are encouraging. Since the neurovascular bundle can be exposed very well, interposition of sural nerve should be considered.     

腹膜外入路腹腔镜下前列腺癌根治术41例

目的熟悉腹膜外入路腹腔镜下前列腺癌根治术的手术方法,降低前列腺癌根治术的手术并发症的发生率。方法对2005年11月至2012年6月的41例腹腔镜下前列腺癌根治术患者的临床资料进行回顾性分析,患者年龄65-78岁,平均72岁,所有患者术前均获确诊,前列腺特异性抗原3.4-45.6ng/ml,〈4.0ng/ml3例,4-20ng/ml30例,〉20ng/ml8例。结果除1例中转开腹手术,其余均由腹腔镜完成,手术时间65-240min,平均125min,术中出血量80-700ml,平均120ml。术后轻度尿失禁6例,通过尿道括约肌锻炼后1-3个月后可满意控尿,术中保留性神经26例,其中19例术后勃起功能恢复,可以完成性交。术后病理均证实为前列腺癌,Gleason评分4-9分,切缘阳性1例,术后加用内分泌治疗。术后随访2个月-6年,生化复发9例,予内分泌治疗后控制满意,1例因其他疾病死亡。结论腹膜外入路腹腔镜前列腺癌根治术是治疗前列腺癌的重要方法,把握好关键步骤,仔细操作,可以达到安全、有效、创伤小的目的。     

低温下筋膜内前列腺癌根治术对早期控尿及勃起功能的影响

目的：探讨低温下筋膜内前列腺癌根治术对早期控尿及勃起功能的影响。方法：选择穿刺活检证实的早期前列腺癌患者21例,其中有性生活者17例,在25℃生理盐水局部低温处理下行筋膜内前列腺癌根治术。结果：21例手术均顺利完成,出血量2001100（300±95）ml,平均留置尿管8（6～14）天。术后随访6个月,完全控尿18例（85％）;17例术前有性生活的患者中,术后6个月可完成性生活者13例（76％）。结论：局部低温的应用减轻了前列腺癌根治术的创伤性炎症后遗反应;低温下筋膜内前列腺癌根治术对早期控尿与勃起功能的恢复有益。     

3D腹腔镜与2D腹腔镜前列腺癌根治术的对比研究

目的 总结3D腹腔镜下前列腺癌根治术的手术方法,比较3D腹腔镜与2D腹腔镜下前列腺癌根治术的疗效。方法 回顾性分析2012年3月至2014年2月,我院66例行腹腔镜下前列腺癌根治术患者的临床资料,其中3D腹腔镜组43例,2D腹腔镜组23例,对比两种术式在手术时间、术中出血量、术后平均住院时间、术后尿失禁比例及保留勃起功能成功率等指标的差异。结果66例前列腺癌根治术均在腹腔镜下完成。3D腹腔镜组手术时间为65~125min,平均95min;术中出血30~150ml,平均60ml;术后平均住院时间为8d;术后轻度尿失禁7例（16.28%）;术中保留性神经27例,保留勃起功能成功率为37.04%。2D腹腔镜组手术时间为74~146min,平均112min;术中出血66~196ml,平均110ml;术后平均住院时间为8.5d;术后轻度尿失禁5例（21.74%）;术中保留性神经11例,保留勃起功能成功率为27.27%。66例术后病理均证实为前列腺癌,Gleason评分4~9分,无切缘阳性。术后随访2~23个月,5例生化复发。结论 与2D腹腔镜比较,在高清3D立体视野下完成的3D腹腔镜下前列腺癌根治术,解剖层次更加清晰,分离更为精细,缝合更为精确。     

Clinical impact of intraoperative frozen sections during nerve-sparing radical prostatectomy

Purpose

Enhanced surgical techniques and standardised selection criteria have led to a higher rate of nerve-sparing (NS) radical prostatectomy (RP) procedures. The aim of this study was to evaluate the clinical value of intraoperative frozen sections (IFS) during nerve-sparing radical prostatectomy (NSRP).

Materials and methods

Thousand and eighty-three patients with localised prostatic carcinoma were treated using retropubic RP (from 2004 to 2006). Two hundred and eighty-seven of the 1083 documented cases received NS. One hundred and thirty procedures were carried out with IFS from the area of the neurovascular bundles and 157 without IFS. The decision to use IFS was made intraoperatively and based on clinical suspicion of possible positive resection margins in the area of the bundles.

Results

In the NS group with IFS, the results revealed positive margins in nine (6.9%) out of 130 cases, resulting in subsequent resection of the ipsilateral neurovascular bundle. The final histological report on this group revealed four additional patients (3.1%) with positive margins, but only one (0.7%) in the area of the previous neurovascular bundle. The final histopathologic reports on the 157 NS cases without IFS showed that the positive margin was in the area of the previous neurovascular bundle in only one (0.6%) of the nine cases with positive margins (5.7%).

Conclusion

According to our data, there is no need for routine IFS during NSRP. The negative predictive value for infiltration of the NVB is high, and IFS can be dispensed with. Intraoperative biopsies should be taken in those cases where the surgeon is in doubt about the resection margins in the area of bundles.     

后腹腔镜手术治疗肾上腺髓质脂肪瘤的疗效观察(附12例报告)

目的:探讨后腹腔镜手术治疗肾上腺髓质脂肪瘤的疗效及临床意义。方法:回顾性分析12例肾上腺髓质脂肪瘤行后腹腔镜手术患者的临床资料。患者年龄33～72岁,平均53岁;左侧3例,右侧9例;偶发10例,因阵发性高血压、腰疼检查发现各1例。术前均诊断为肾上腺髓质脂肪瘤,肿瘤直径2～8 cm,平均4.9 cm;其中8例直径大于3.5 cm,4例小于3.5 cm。12例患者均在全麻下行后腹腔镜肾上腺肿物切除术。结果:12例患者手术均获成功,手术时间60～270 min,平均130 min。出血量10～660 ml,平均116 ml。术中无并发症。术后住院4～10天,平均5.6天。随访时间6个月～5年,平均2年,未出现肿瘤复发。结论:采用后腹腔镜手术治疗肾上腺髓质脂肪瘤安全有效,具有创伤小、出血少、住院时间短等优点,可以作为肾上腺髓质脂肪瘤的主要手术方法。     

Preliminary results of a monitoring system to confirm the preservation of cavernous nerves

BACKGROUND: It is important to preserve the neurovascular bundle (NVB) during nerve-sparing surgery. This article presents the preliminary results of our monitoring system for the postoperative preservation of erectile function. METHODS: In 15 patients undergoing radical prostatectomy and 20 patients undergoing radical cystoprostatectomy, intraoperative electrical stimulation along the NVB was performed to measure changes in intracavernous pressure before and after prostate removal. Seven of the radical prostatectomy patients and eight of the radical cystoprostatectomy patients underwent nerve-sparing surgery. Postoperative erectile function was evaluated in 25 patients not receiving adjuvant hormonal therapy. RESULTS: The NVB was judged to be preserved at least on one side electrophysiologically in 14 of 15 patients. Pathologically, three patients had pT3 cancer. Postoperatively, sufficient erectile function was demonstrated using the International Index of Erectile Function 5 in three patients, nocturnal penile tumescence in three patients, and a questionnaire or an interview in three patients. The other patients were incompletely erectile. None of the 11 patients not receiving adjuvant hormonal therapy, in whom NVB was not preserved, were erectile. CONCLUSION: If the successful criterion of nerve-sparing surgery is defined as a change in intracavernous pressure of 4 cm H2O or more being observed at least unilaterally, and the successful criteria of erectile function preservation includes being sufficiently erectile as revealed by an interview, the sensitivity of our system was 69.2% (9/13) and the specificity was 100% (12/12). Neither adverse reactions to the measurement, nor inadequacy of cancer excision accompanying NVB sparing, were observed. These results suggest that our system can predict postoperative erectile function fairly accurately.