腹腔镜下膀胱癌根治术36例报告

目的探讨腹腔镜下全膀胱切除术治疗膀胱癌的手术方法和临床效果。方法36例患者,男性28例,女性8例;年龄56～75岁。36例病理证实为浸润性膀胱移行细胞癌Ⅱ～Ⅲ级,TNM分期：T2N2M0 22例,T3aN0M0 10例,T3bN0M0 4例。行腹腔镜下膀胱癌根治术,其中25例行原位乙状结肠代膀胱术,11例输尿管造口术,观察手术时间、术中出血量、术后肠道功能恢复、术后并发症及手术效果。站杲手术时间5～10h,术中失血200-1000mL,术后约72h肠道功能恢复,术后2周拔输尿管导管,术后3周拔尿管后腹压排尿正常,术后3个月IVU未见。肾积水,未出现腹腔并发症。结论腹腔镜下全膀胱切除术具有微创、出血少、恢复快等特点,随着技术的进步,该术式将成为治疗浸润性膀胱癌的较好方法之一。     

Management of benign ureteral strictures following radical cystectomy and urinary diversion for bladder cancer

PURPOSE: Ureteral obstruction due to benign strictures is a significant complication of radical cystectomy and urinary diversion for bladder cancer that can lead to renal function loss and infection related morbidity. Treatment may be performed surgically or with minimally invasive techniques. We describe the 10-year experience at our department with various treatment modalities for post-cystectomy benign strictures. MATERIALS AND METHODS: The study group consisted of 28 patients treated for benign ureteral strictures following radical cystectomy for bladder cancer. Their medical records were reviewed for clinical presentation, diagnostic procedures, treatment and long-term outcome. RESULTS: The study group represented 12.7% of all 221 patients treated at our department with radical cystectomy for bladder cancer in 1994 to 2004. Ureteral strictures were asymptomatic in 71.4% of cases. Median time to diagnosis was 7.0 months and 75% of the patients were diagnosed within year 1 after cystectomy. Treatment consisted of stenting, dilation and open surgical revision with removal of the strictured segment and reanastomosis. Median followup was 62.5 months. The stenting procedures served as the long-term definitive treatment in 45% of cases, whereas balloon dilation uniformly failed. Although open surgical revision was technically challenging, it had a long-term success rate of 93%. CONCLUSIONS: Benign ureteral strictures commonly occur during postoperative year 1 and they are usually asymptomatic. Early diagnosis and prompt drainage are required to prevent consequent renal parenchymal loss and infectious complications. Although minimally invasive procedures are viable treatment alternatives, open surgical revision is still the preferred long-term definitive treatment.     

Significance of cancer involvement at the ureteral margin detected on routine frozen section analysis during radical cystectomy

INTRODUCTION: We investigated the clinical significance of preoperatively-unsuspected ureteral involvement of cancer detected on intraoperative frozen section analysis of ureteral margins during radical cystectomy. PATIENTS AND METHODS: We performed a retrospective study of 115 patients who received radical cystectomy for locally-advanced but node-negative transitional cell carcinoma of the bladder between 1995 and 2002 by reviewing their records. RESULTS: Of 115 total patients, 5 (4.3%) demonstrated carcinoma in situ at the ureteral margin with 2 of 5 having a positive margin on final pathologic analysis. Meanwhile, only 3 of 115 total patients (2.6%) later showed upper urinary tract recurrence at a median interval of 30 months after cystectomy. And all 3 patients had intramural or juxtavesical ureter involvement of disease (p = 0.006), while not demonstrating carcinoma in situ in ureteral margins resected during cystectomy. On multivariate analysis, only the stage and grade of bladder cancer along with pathologic feature of vascular invasion were observed to be independent prognostic predictors of disease-specific survival. CONCLUSIONS: Cancer involvement of the distal ureteral margin detected through intraoperative frozen section analysis may not be a significant factor regarding upper tract recurrence and survival of patients with locally-advanced bladder cancer after radical cystectomy. Upper tract recurrence may be more prone to occur in patients with cancer involvement at the intramural or juxtavesical ureter.     

腹腔镜下全膀胱切除术的临床应用

目的 探讨腹腔镜下全膀胱切除术的手术方法和临床效果。方法 28例男性患者，58—73岁，26例病理证实为浸润性膀胱移行细胞癌Ⅱ一Ⅲ级，2例鳞状细胞癌；TNM分期：T2N0M0 16例，T3aN0M0 10例，T3bN0M0 2例。行腹腔镜下全膀胱切除，15例原位回肠代膀胱术，10例Sigma直肠膀胱术，3例输尿管造口术，观察手术时间、术中出血量、术后肠道功能恢复、术后并发症及手术效果。结果 手术时间7—10h，术中失血600—1500mL，术后约72h肠道功能恢复，术后2周拔输尿管导管，术后3周拔尿管后腹压排尿正常，术后3月IVu未见肾积水，未出现腹腔并发症。结论 本组共28例行经腹全膀胱切除术，均取得满意效果，无腹腔并发症；15例原位回肠代膀胱术，应注意保护盆腔神经丛和尿道外括约肌，尤其应防止尿道外括约肌受损，避免发生术后尿失禁和排尿功能障碍。该术式具有微创，出血少，恢复快等特点，随着技术的进步，该术式将成为治疗浸润性膀胱癌的较好方法之一。     

二次手术腹腔镜全膀胱切除的临床回顾性研究（附18例报告）

目的：探讨腹腔镜下根治性膀胱切除回肠膀胱术在膀胱部分切除术后复发的膀胱癌患者治疗中的应用价值。方法：回顾性研究18例二次予术腹腔镜全膀胱切除患者的临床资料,其中男14例,女4例。年龄44～76岁,平均年龄59．1岁,均曾经接受膀胱部分切除手术。在全身麻醉下行解剖性腹腔镜根治性膀胱切除,取下腹正中4～5cm切口取出标本,行回肠膀胱术13例,输尿管皮肤造瘘术5例。结果：手术时间240～360min,平均300min,其中腹腔镜下操作时间120～180min,平均142min。出血量100～1500ml,平均332ml。2例患者因术中出血较多给于输血,术后平均住院天数12．6天。术后随访6～24个月,1例患者术后1个月复查发现输尿管吻合口狭窄,1例患者术后行局部适形放疗,其余患者肾功能均正常,IVU检查未发现输尿管回肠吻合口狭窄或输尿管反流。结论：解剖性腹腔镜下膀胱根治性切除术治疗膀胱部分切除术后复发的膀胱癌患者临床效果满意,操作精确,创伤小,恢复快,安全性好,适于具有较高腹腔镜水平的单位开展。     

Contemporary cystectomy and urinary diversion

Radical cystectomy has emerged as the standard therapy for patients with invasive bladder cancer. Controversy is related to the indication, i.e. a low or high threshold. Meticulous pelvic lymphadenectomy can cure 20%-30% of patients with lymph node metastases, particularly those with limited node involvement. Unilateral nerve-sparing surgery is feasible in most patients without compromising oncological outcome and, besides erectile function, has an impact on the continence status after orthotopic bladder substitution. The excellent local control rates following radical cystectomy indicate that the weight of the problem in the future lies in reducing distant metastases. Orthotopic bladder substitution with a low-pressure ileal reservoir is currently the preferred method to reconstruct the lower urinary tract for both sexes following cystectomy. Long-term experience with follow-ups exceeding 10 years demonstrates a sustained favourable voiding outcome with slightly increasing incontinence rates as patients age.     

腹腔镜下全膀胱切除术(附50例报告)

目的:探讨腹腔镜下全膀胱切除术的手术方法和临床效果。方法:50例患者中男41例,女9例,52～76岁;经病理证实为浸润性膀胱移行细胞癌Ⅱ～Ⅲ级,TNM分期:T2N0M028例,T3aN0M014例,T3bN0M08例。行腹腔镜下全膀胱切除术,其中34例行原位乙状结肠代膀胱术,16例行输尿管造口术,观察手术时间,术中出血量,术后肠道功能恢复、并发症及手术效果。结果:手术时间5～10h,术中出血200～1000ml,术后约72h肠道功能恢复,术后2周拔输尿管导管,术后3周拔尿管后腹压排尿正常,术后3个月IVU未见肾积水,未发生腹腔并发症。结论:经腹腹腔镜全膀胱切除术,具有微创、出血少、恢复快等特点,随着技术的进步,该术式将成为治疗浸润性膀胱癌的较好方法之一。     

Peritonealkarzinose nach roboterassistierter radikaler Zystektomie

Among patients with metastatic urothelial cancer of the bladder, 16-25% develop peritoneal carcinomatosis. In the majority of cases peritoneal carcinomatosis is associated with multiple metastatic sites. Peritoneal metastases as the single site of metastatic deposits are rare and they have been described following laparoscopic radical nephroureterectomy or cystectomy. We report on a patient who developed peritoneal carcinomatosis as the single site of metastases 8 months after robotic-assisted radical cystectomy, extended pelvic lymphadenectomy and extracorporeal formation of an ileal neobladder for organ-confined, muscle-invasive and poorly differentiated bladder cancer. The indication for robotic-assisted radical cancer surgery for urothelial carcinoma of the upper or the lower urinary tract in patients with locally advanced or poorly differentiated cancer should be made with caution.     

Pulmonary diagnosis with use of iodized oils

Eleven cases of cystectomy for cancer of the bladder are herein reported. Of the II cases, there were 3 surgical deaths, or 27.27 per cent mortality.In 2 cases, women on whom the operation was done in two stages, first ureteral transplantation, second cystectomy, the patients are alive and well. Two women with far advanced carcinoma of the bladder which had been treated on numerous occasions by radiation and fulguration, died as a result of an attempt to do the combined operation of transplantation and cystectomy at one sitting. In one of these cases it was poor judgment to do an operation at all. The difficulties encountered in these 2 cases revealed special problems which indicate that the combined operation is impractical in women, even if the cases are favorable for operation.In seven men the cystectomy was performed with transplantation of the ureters at the same operation. Of this number, there was one surgical death, 14.28 per cent. One patient died five and one-half months after operation without the presence of a doctor and evidence obtained from the family indicated that death may have been due to something entirely foreign to the operation or to the disease. The other 5 men are alive and well. All have been seen or heard from within a month of the presentation of this paper. All have been examined within five months.We are now able to report 7 symptomatically cured patients following cystectomy for cancer of the bladder with no evidence of recurrence four years, six months; three years, four months; two years, nine months; two years, five months; two years, four months; one year, six months and one year respectively after operation. Aside from being perfectly well and comfortable, these patients are unusually happy and well satisfied with the results as contrasted with patients afflicted with carcinoma of the rectum who are frequently more or less morbid because of the inconvenience of a colostomy opening. This spirit of optimism and gratitude was recently manifested when six of the seven living patients came from their homes, some of them long distances, to present themselves for examination and questioning at a clinic held for the western division of the American Urological Society, July 1, 1932. These patients were all very happy to come and pay their own expenses. One of them came more than 700 miles to be present. The one who did not come was more than a thousand miles away.These results compare favorably with the results of treatment of cancer in any other part of the body. Indeed, this very limited experience coupled with the knowledge that as a rule cancer of the bladder remains a local process for a long time before it metastasizes, leads one to hope that cancer of the bladder may yet be the most curable of all the cancers which invade the body, and that the operation, with added experience, performed at an earlier stage of the disease will be no more formidable than any of the other major operations for internal cancer.One may very pertinently ask: “What is the state of the kidneys after ureteral transplantation?” Several hundred patients are now living upon whom transplantation of the ureters into the large intestine by the submucous implantation method has been done. Many different surgeons have employed this operation during the last twenty years for various conditions. Intravenous urography and blood chemistry have put into the hands of the profession accurate agencies of investigation. Many cases have been thus carefully studied subsequent to transplantation. In some of these, normal kidneys and ureters have been demonstrated and the patients are in perfect health. In others, a variable amount of dilatation of the ureters and pelves of the, kidneys is found and yet the blood urea is not elevated and the patients are in perfect health. In still other cases, decidedly damaged kidneys, increased blood urea, low visualization by intravenous urography are revealed and still the patient is seemingly in good health. It is noteworthy that the condition of the patients in this latter class tends to improve as the years go by, so that from the standpoint of the physical state of these patients as manifested in ordinary life, most of them may be considered normal in health. It is well to consider and discuss these purely urological matters when dealing with ordinary fistulae occurring in young women but the discussion is not so pertinent when we are dealing with cancer of the bladder.The problems involved in the treatment of cancer of the bladder vary in the two sexes. The generative organs in the female separate the transplantation operative field and that of the cystectomy so that it is necessary or at least advisable to do the operation in two stages. At the first operation the ureters are transplanted, the uterus and broad ligaments are stitched to the anterior parietal peritoneum and the quarantine drain is placed in the pelvis. This insures that the cystectomy operation to be performed later will be entirely extraperitoneal. Because the bladder is thus walled off from the peritoneal cavity and also because the vaginal canal intervenes between the rectum and bladder, tremendous doses of radium may be used within the vagina as well as within the bladder without doing damage to other organs. The radium may be used within a few days of the transplantation operation and will at least hold the cancer in check until a favorable time for doing cystectomy. In some cases, no doubt, such heroic doses as will be possible in this way may produce a permanent cure. Impressions gathered on a recent visit to the Curie Institute in Paris, however, deepen the conviction that cancer of the bladder is rarely cured by radium and should be classed as a surgical disease, even in women. For, notwithstanding the unfortunate results in two of the cases reported, the operative mortality in women should be no higher than in men if the operation is done in two stages.In the operation for cancer of the bladder in the male, the anatomical fields of ureteral transplantation and cystectomy are intimately connected. The cystectomy can be performed much more easily while the abdomen is wide open for ureteral transplantation than at a second operation when a small incision made through a recently healed operative field makes the operation much more difficult and less thorough. The gauze pack, furthermore, which fills the vesical space after the bladder has been removed also drains the area of the transplantation and thus avoids intraperitoneal drainage. The objection has been raised that the operation of bilateral transplantation of the ureters by Technique 2 is too complicated for general use. It will be conceded that it is quite a formidable operation. Urology is possibly the most highly developed of the major specialties and carcinoma of the bladder is susceptible of very early diagnosis by a skilled urologist. The fields of specialism have been so sharply defined in recent years that a most distinguished urologist may be unskilled in the practice of intraperitoneal surgery. The result is that he is loath to abandon the more conservative measures in treating carcinoma of the bladder for a very radical operation fraught with danger. An effort has been made therefore to develop a transplantation operation which is simple and safe enough to justify the use of radical means at an early and hopeful stage of the disease. Technique 3, while yet in the experimental stage, gives considerable promise in this regard.     

Lymphadenectomy in bladder cancer: How high is “high enough”?

PURPOSE: The role of a regional lymphadenectomy in the surgical treatment of high-grade, invasive transitional cell carcinoma of the bladder has evolved over the last several decades. Although the application of a lymphadenectomy for bladder cancer is not significantly debated, the absolute extent or level of proximal dissection of the lymphadenectomy remains a controversial issue. MATERIAL AND METHODS: A review of the literature should help elucidate the rationale and extent of an appropriate lymphadenectomy in patients undergoing radical cystectomy for bladder cancer. Various surgical issues of lymphadenectomy as well as prognostic factors in patients undergoing radical cystectomy for bladder cancer are examined. RESULTS: A growing body of evidence, spanning from early autopsy and cadaveric studies to recent retrospective series and multicenter prospective trials, suggests that an extended lymph node dissection (cephalad extent to include the common iliac arteries) may provide not only prognostic information but also provide a therapeutic benefit for both patients with lymph node-positive and lymph node-negative disease undergoing radical cystectomy for bladder cancer. Although the absolute boundaries of the lymphadenectomy remain a subject of controversy, historical reports confirmed by recent lymphatic mapping studies suggest the inclusion of the common iliac as well as possibly presacral nodes in the routine lymphadenectomy for transitional cell carcinoma of the bladder. The need to extend the dissection higher to include the distal para-aortic and paracaval lymph nodes may be important in select individuals but remains more controversial. The extent of the primary bladder tumor (p-stage), number of lymph nodes removed, the lymph node tumor burden (tumor volume), and lymph node density (number of lymph nodes involved/number of lymph nodes removed) are all important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastases. Systemic adjuvant chemotherapy remains a mainstay of treatment of patients with lymph node metastases. CONCLUSIONS: Radical cystectomy with an appropriately performed lymphadenectomy provides the best survival outcomes and lowest local recurrence rates. Although the absolute limits of the lymph node dissection remain to be determined, evidence supports a more extended lymphadenectomy to include the common iliac vessels and presacral lymph nodes at cystectomy in patients who are appropriate surgical candidates. When feasible, adjuvant chemotherapy is warranted in patients with positive nodal metastasis.     

Experiences in treating cancer of the bladder

Experience in the treatment of urinary bladder cancer based upon observation of 306 cases has been presented. Two hundred and thirteen patients were treated surgically by performing in 151 cases partial cystectomy and in 62 cases total cystectomy. Conservative treatment was applied in 75 patients. In the authors' opinion the best method of treating bladder cancer is its radical excision. A simple and easy method of implantation of the ureters into the rectum is described.     

THE STATUS OF BLADDER. P. RESERVING THERAPEUTIC STRATEGIES IN THE MANAGEMENT OF PATIENTS WITH MUSCLE–INVASIVE BLADDER CANCER

The recommended treatment for medically fit patients with muscle–invading bladder cancer is usually radical cystectomy. However, transurethral resection of the tumor, partial cystectomy, irradiation and systemic chemotherapy are each effective in some patients. These latter treatments allow bladder preservation and cure as an alternative to radical cystectomy although when used unselectively the survival rates are inferior to those of radical cystectomy. The updated results of conservative surgery, radiation therapy and systemic chemotherapy as monotherapy, as well as strategies of combined modality treatment were reviewed. Based on this review many areas of consensus were reached which include: 1. The primary goal of any treatment for a patient with muscle–invading bladder cancer is survival; bladder preservation in the interest of quality of life is a secondary objective. 2. Only a small proportion of carefully selected patients may be cured by transurethral surgery alone, or by partial cystectomy alone. 3. Radiation therapy is currently the standard bladder–preserving therapy against which all other bladder–preserving methods must be compared. 4. Systemic chemotherapy as monotherapy is inadequate and cannot be recommended. 5. The addition of cisplatin–containing systemic chemotherapy to radiation therapy or conservative surgery appears to improve local control. While no multi–modality therapeutic regimen has yet been shown to be clearly optimal with regard to local efficacy and minimizing toxicity, monotherapy for bladder preservation is probably not desirable as a routine approach. 6. Deferring the patient from immediate cystectomy does not appear to compromise survival, nor does the addition of primary systemic chemotherapy appear to significantly increase the morbidity of cystectomy or radiotherapy. 7. All patients treated by .bladder–preserving therapy must return to the urologist for regular cystoscopic follow–up so that additional therapy may be started at the earliest opportunity if relapse occurs. 8. Bladder substitution is suboptimal compared with a normally functioning, disease–free bladder. 9. If alternatives to cystectomy are not considered, little progress will be made in the treatment of muscle–invading bladder cancer. 10. Randomized phase III trials must be performed to establish the role of optimal combined modality treatment for bladder preservation, but patient recruitment into such trials may prove difficult unless urologists are prepared to open their minds to the possibility that cystectomy may not be the best treatment for all patients with muscle–invading bladder cancer. Further, urologists must be prepared to have their patients randomized into phase III protocols and investigators must not allow premature publication of findings.     

Management of concomitant ureteral carcinoma in situ at radical cystectomy

OBJECTIVE: We conducted a retrospective study to evaluate and define the management of concomitant ureteral carcinoma in situ (CIS) at radical cystectomy. METHODS: For 158 consecutive patients, who underwent radical cystectomy for invasive bladder cancer, ureteral CIS missed by preoperative examinations were evaluated by intraoperative analysis of frozen sections or postoperative histological analysis. The median follow-up period was 3.4 years. RESULTS: In total, 15 concomitant ureteral CIS were diagnosed by intraoperative (n=9) or postoperative analysis (n=6). Additional ureteral resection achieved no malignancies in the final ureteral margins of eight patients. During the follow-up period, five patients (3.6%) suffered from tumor recurrence in the upper urinary tract in total, as did three (20%) among the 15 patients with ureteral CIS missed by preoperative examinations. No recurrence was identified in the eight patients with no malignancy in the final ureteral margins after additional resection. Furthermore, multivariate analysis indicated that the presence of bladder CIS was a risk factor for the presence of concomitant ureteral CIS. CONCLUSIONS: Detection of concomitant ureteral CIS by intraoperative studies, in combination with complete resection of ureteral CIS, might be beneficial for patients with risk factors such as bladder CIS.     

Should prostate cancer status be determined in patients undergoing radical cystoprostatectomy?

INTRODUCTION: We estimate the frequency of prostate cancers detected incidentally in radical cystoprostatectomy specimens and discuss whether the prostate cancer status should be determined in patients undergoing radical cystoprostatectomy. MATERIALS AND METHODS: A total of 97 radical cystoprostatectomies without evidence of prostate cancer on digital rectal examination were performed for transitional cell carcinomas of the bladder between January 2001 and May 2004. The mean patient age at the time of surgery was 66.9 +/- 9.52 (range 49-75) years. RESULTS: The overall incidence of prostate cancer detected in radical cystoprostatectomy specimens was 21.6% (21/97 specimens). The mean tumor volume was found to be 0.93 +/- 0.81 ml. The tumor volume was >0.5 ml in 12 cases (57.1%). The surgical margin was negative in all cases, and the disease was organ confined in 20 patients (95.2%). Capsular invasion was evident in 2 patients (9.5%), 1 of whom had lymph-node-positive disease. CONCLUSIONS: Despite the high prevalence of incidental prostate carcinomas among patients with bladder cancer undergoing cystoprostatectomy, the vast majority of the cancers are organ confined. However, the prostate cancer status should be determined on the basis of digital rectal examination and prostate-specific antigen in patients undergoing radical cystoprostatectomy - especially if prostate-sparing cystectomy is planned.     

Standardization of radical cystectomy and pelvic lymph node dissection for bladder cancer: a collaborative group report

PURPOSE: We propose standards for radical cystectomy and pelvic lymph node dissection in the surgical treatment of patients with invasive bladder cancer. MATERIALS AND METHODS: We compiled the consecutive cystectomy experience of 16 experienced surgeons during the last 3 years (2000 to 2002) from 4 institutions. We evaluated patient, tumor and surgical variables of margin status, extent of pelvic node dissection, number of nodes examined and surgeon volume associated with bladder cancer outcomes. RESULTS: A total of 1,091 cystectomy cases were evaluated. Surgical margins and number of nodes retrieved correlated with patient age, prior treatments, pathological tumor stage and extent of node dissection, but not surgeon volume. CONCLUSIONS: Standards for radical cystectomy can be established and achieved by experienced surgeons operating on patients presenting with diverse clinical situations.     

A case of lung metastases of bladder cancer in which thoracotomy was performed following M-VAC therapy

A case of lung metastases of bladder cancer in which thoracotomy was performed following M-VAC is presented. A fifty-nine-year-old man underwent radical cystectomy and ileal conduit diversion for bladder cancer. Pathological diagnosis was TCC greater than AC much greater than SCC. After nine months, he was admitted because of lung metastases. Three courses of M-VAC therapy brought partial remission. A thoracotomy was performed on residual lung metastasis. Pathological diagnosis was AC much greater than TCC greater than SCC. Because M-VAC therapy has limited antitumor activity against mixed histological bladder cancer, we recommend not only M-VAC therapy but also surgical resection for the metastatic tumor the primary site of which has nontransitional components.     

Chemotherapy in the post-MVAC era: the case for adjuvant chemotherapy

Radical cystectomy for muscle invasive and locally advanced bladder cancer is the standard treatment modality in most of the Western industrialised countries. Rates of perioperative mortality from radical cystectomy have decreased to less than 2% over the past two decades due to advances in surgical technique and perioperative care. However, at least 40% of patients with pT3 bladder cancer and 70% of patients with lymph node-positive disease develop tumour recurrence after radical treatment within the first 5 years when treated with radical cystectomy alone. After the efficacy of combination chemotherapy for metastatic urothelial cancer using methotrexate, vinblastine, adriamycin and cisplatin (MVAC) was first described in 1985, several cisplatin-based systemic regimens have been investigated as adjunctive treatment before or after therapy for locally advanced bladder cancer by radical surgery or radiation therapy. Three randomised studies have reported superior results of postoperative adjuvant systemic chemotherapy compared to radical cystectomy alone for locally advanced bladder cancer. All three studies demonstrated a significant survival benefit for bladder cancer patients receiving adjuvant combination therapy. Studies have been criticised for small patient numbers and statistical shortcomings. New effective antineoplastic agents, such as paclitaxel and gemcitabine, have evolved during the past decade as promising substances for the treatment of urothelial cancer. This article reviews adjuvant studies from the era of MVAC combination chemotherapy, as well as contemporary studies that discuss new antineoplastic agents for systemic adjuvant chemotherapy of locally advanced bladder cancer.     

ORTHOTOPIC BLADDER SUBSTITUTION IN WOMEN: FUNCTIONAL EVALUATION

PURPOSE: Orthotopic bladder substitution following cystectomy in women has recently been introduced at some specialized centers. Studies of such a procedure should consider the oncological and functional outcomes. We analyzed only the functional results of orthotopic bladder substitution since followup is too short (about 2 years) for a valid oncological assessment. MATERIALS AND METHODS: From October 1994 to November 1997, 60 women with a mean age of 48.3 years underwent standard radical cystectomy and orthotopic diversion (ileal W-neobladder with subserous tunnel in 47 and hemi-Kock reservoir in 13). The oncological criterion was organ confined invasive bladder cancer. RESULTS: There was no perioperative mortality. Postoperative complications included fatal pulmonary embolism in 1 woman, deep vein thrombosis in 2, prolonged ileus in 1 and fistula of the vaginal pouch in 3, which was repaired successfully. Cancer recurred in the pelvis in 2 cases and as distant metastases in 5. Of the patients 43 had been followed for a mean of 20.2 months (range 6 to 36), and 32 were continent day and night, 1 was totally incontinent, 2 had daytime stress incontinence and 6 had nighttime incontinence. Six women had difficulty emptying the pouch spontaneously with concomitant residual urine due to acute angulation between the urethra and pouch. CONCLUSIONS: Orthotopic bladder substitution after standard radical cystectomy in select women provides a satisfactory functional outcome. Failure of complete emptying seems to be due to anatomical rather than functional reasons.     

腹腔镜膀胱癌根治加回肠膀胱术

目的:总结腹腔镜下膀胱癌根治加回肠膀胱术的手术方法及临床疗效。方法:2003年6月～2007年5月共行25例腹腔镜下根治性全膀胱切除、双侧盆腔淋巴结清扫加回肠膀胱术,患者平均年龄68岁,全膀胱切除和盆腔淋巴结清扫均在腹腔镜下完成,标本自下腹部小切口取出后,体外切取末端回肠10～15cm,近端闭合并与双侧输尿管吻合,远端造口于右下腹壁。结果:所有手术均顺利完成,手术时间210～320min,平均270min。术中出血220～1000ml,平均460ml。平均每例清扫淋巴结数10个,淋巴结阳性率16.2%,手术切缘均阴性。术后3～5天肠道功能恢复,1例因粘连性肠梗阻于术后1周再行手术探查松解粘连。术后2～3周拔除单J管,无肠漏及尿漏并发症发生。随访2～30个月,1例死于原发病转移,无腹壁造口狭窄发生,3例术后B超或造影显示单侧轻度肾积水和轻度输尿管扩张。结论:腹腔镜膀胱癌根治术具有创伤小,恢复快等优点,但手术难度较大,手术技术要求较高。回肠膀胱术手术操作相对简单,并发症少,可作为腹腔镜膀胱癌根治术后尿流改道可选方式之一。     

腺性膀胱炎伴肾积水并发症的治疗分析

目的:探讨腺性膀胱炎伴单、双侧肾积水并发症的治疗方法和效果。方法:回顾性分析32例腺性膀胱炎患者的临床资料。将患者分为两组:单侧肾积水组21例,双侧肾积水组11例,均进行积极的局部治疗,包括经尿道电切和激光切除膀胱内可见病变组织。如输尿管膀胱开口清晰,给予膀胱镜下放置输尿管支架,解除输尿管梗阻(10例);如输尿管膀胱开口无法明确判断,不能放置支架管,则给予开放手术行输尿管膀胱再植(22例)。术后治疗包括膀胱灌注及口服药物抗感染和预防复发。结果:32例随访12～45个月,伴单侧肾积水并发症的腺性膀胱炎在尿常规缓解、膀胱镜下缓解、肾积水缓解以及最终是否行膀胱全切治疗等方面的结果显著优于伴双侧肾积水并发症的结果(P<0.05)。14例患者最终行膀胱全切(回肠膀胱或输尿管皮肤造瘘),两组均未发生癌变。结论:对于并发单侧肾积水并发症的腺性膀胱炎患者,积极的局部治疗有效,缓解率高;对于并发双侧肾积水并发症的腺性膀胱炎患者,积极的局部治疗效果差,最终往往需要行膀胱全切除术。