腹腔镜下膀胱根治性切除-原位回肠新膀胱术108例分析

目的 报道108例腹腔镜下膀胱根治性切除-原位回肠新膀胱术手术资料及术后并发症、性功能、控尿功能和肿瘤根治情况.方法 2002年12月至2007年5月,108例膀胱癌患者施行了腹腔镜下膀胱根治性切除-原位回肠新膀胱术,其中男96例,女12例.采用5孔经腹入路,首先进行完全腹腔镜下标准的双侧盆腔淋巴结清扫及根治性膀胱切除,然后行体外回肠新膀胱的构建和输尿管新膀胱吻合,最后在腹腔镜下进行新膀胱尿道吻合,其中26例患者施行保留勃起神经步骤.结果 平均手术时间为330 min,出血量为320 ml,无中转开放手术.无围手术期死亡,手术并发症发生率为18.5%,所有患者手术切缘均为阴性.术后6个月日间尿控率90.7%,夜间尿控率82.6%.术后6个月,26例行保留勃起神经患者中10例有性功能.术后随访1～53个月,局部肿瘤复发5例,套管穿刺口种植转移1例,远处转移6例,随访期间死亡11例.结论 腹腔镜下膀胱根治性切除-原位回肠新膀胱术是可行的,具有低并发症和较好的新膀胱功能.     

腹腔镜根治性膀胱切除及回肠原位新膀胱术（附9例报告）

目的总结腹腔镜根治性膀胱切除加回肠原位新膀胱术的经验。方法对9例膀胱癌患者施行腹腔镜根治性膀胱切除及回肠原位新膀胱术,采用完全腹腔镜下标准的双侧盆腔淋巴结清扫加根治性膀胱切除,然后体外行回肠新膀胱构建和输尿管新膀胱吻合,最后在腹腔镜下行新膀胱尿道吻合。结果9例手术均成功,无中转开腹,无围手术期死亡,平均手术时间为370min,平均出血量为650ml,所有患者手术切缘均为阴性。术后9例日间尿控均良好,2例存在夜间尿失禁。术后随访2—8个月,1例出现新膀胱腹壁瘘,1例发生新膀胱前假性尿液囊肿,2例出现肾盂肾炎。结论腹腔镜根治性膀胱切除加回肠原位新膀胱术具有切口小、损伤少、疼痛轻、出血少、术后恢复快等优势,将成为肌层浸润性膀胱癌的标准手术方式。     

尿道途径辅助下经脐单孔腹腔镜根治性全膀胱切除术

目的 :评价经尿道途径辅助下经脐单孔腹腔镜根治性全膀胱切除术的可行性及其优势。方法 :2014年10~12月,2例男性膀胱癌患者采用多通道套管,在经尿道途径辅助下,行经脐单孔腹腔镜根治性全膀胱切除、双侧盆腔淋巴结清扫及单乳头双输尿管一侧腹壁造口术。操作全部在单孔腹腔镜下进行。收集围手术期及术后资料进行分析。结果:2例手术均顺利完成,无中转常规腹腔镜或开放手术。单孔平均手术时间为4.15 h。术中平均出血量为150 ml,平均术后住院时间为15 d。围手术期内无严重并发症发生。术后病理示2例手术标本切缘均为阴性,平均清扫淋巴结16.5个,前者3/15阳性,后者0/18阳性。结论:经尿道辅助的经脐单孔腹腔镜行全膀胱根治性切除术安全可行。该术式减少了腹腔镜与操作器械之间的相互干扰,降低了手术难度和风险,手术并发症发生率低。     

腹腔镜根治性膀胱切除术的早期临床应用（附15例报告）

目的：探讨腹腔镜根治性膀胱切除术的临床价值。方法：对具有手术指征的15例膀胱癌患者施行腹腔镜根治性膀胱切除术治疗。常规建立5个工作通道,在腹腔镜下行双侧盆腔淋巴结清扫及膀胱全切除,自下腹切口取出标本。4例行回肠膀胱术,11例行原位回肠新膀胱术。观察手术时间、术中出血量、输血量、术后肠道功能恢复、尿外渗、尿瘘及术后腹腔并发症发生以及手术后效果。结果：15例手术成功。腹腔镜下根治性膀胱切除手术时间150～300 min;腹腔镜下新膀胱与后尿道吻合手术时间30～100 min;手术总时间300～660 min,术中出血500～1 200 mL;术中输血0～800 mL。2例术后出现急迫性尿失禁,经锻练后控尿满意;其余患者恢复良好。无腹腔并发症发生。结论：腹腔镜根治性膀胱切除术具有创伤小、术中操作精细、盆腔淋巴结清扫彻底、术后恢复快、并发症少的优点。     

世界首例单孔腹腔镜根治性膀胱切除、全去带乙状结肠原位新膀胱术

目的 报告世界首例单孔腹腔镜(LESS)根治性膀胱切除术,并采用全去带乙状结肠构建原位膀胱.方法 患者为74岁男性,因血尿2月人院,活检病理确诊为膀胱癌.行LESS根治性膀胱切除术,于下腹正中取3.5 cm纵形切口,置入单孔多通道套管(R-port)建立手术入路.手术过程包括双侧盆腔淋巴结清扫.根治性膀胱切除术完成后,开放构建全去带乙状结肠原位新膀胱.结果 手术总时间9.5 h,LESS部分5.5h.术中采用传统腹腔镜器械,没有增加其它通道,最终病理结果为尿路上皮癌.术中失血约600ml,输注红细胞400ml.清扫的盆腔淋巴结均为阴性.尿道及输尿管切缘未见肿瘤侵犯.围手术期未发生水电平衡紊乱及酸碱失衡.术后3月复查,未见肿瘤复发和远处转移,新膀胱容量约280ml.残余尿10ml,最大尿流率11.1 ml/s.结论 尽管LESs手术有着更长的学习曲线,但有望成为治疗浸润性膀胱肿瘤的更加微创更美观的手术方法.     

腹腔镜下根治性膀胱切除术治疗肌层浸润性膀胱癌7例体会

目的 探讨腹腔镜下根治性膀胱切除术治疗肌层浸润性膀胱癌的临床疗效.方法 回顾性分析黄山市人民医院2015年6月至2016年8月行腹腔镜下根治性膀胱切除+回肠膀胱术7例患者的临床资料,患者经病理证实为肌层浸润性膀胱尿路上皮癌Ⅱ~Ⅲ级.腹腔镜下行盆腔淋巴结清扫,膀胱切除,男性患者切除前列腺及精囊腺,女性患者子宫次全切除.结果 7例患者手术均获得成功,手术时间390~570 min,平均(451.47±103.03)min;术中出血量200~1100 mL,平均(514.28±318.48)mL;术后3~6 d肠道功能恢复,未出现尿瘘及肠道并发症;患者随访5~19个月,生存率为100.0%,肾功能检查均正常,无复发或转移.结论 腹腔镜下根治性膀胱切除+回肠膀胱术,是治疗肌层浸润性膀胱癌的一种安全、有效的手术方法.     

腹腔镜下膀胱前列腺全切除-原位回肠新膀胱术初步报告

【目的】探讨腹腔镜下膀胱前列腺全切除-原位回肠新膀胱手术方法。【方法】为4例52～65岁男性膀胱癌患者施行了手术。采用5个套管针,腹腔镜由脐上或脐下套管针进入,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。游离输精管、精囊,剪开狄氏筋膜分离前列腺后面;游离输尿管下段在其末端切断;剪开前腹壁腹膜反折,游离膀胱前壁;缝扎阴茎背深静脉复合体;游离膀胱侧韧带及前列腺侧韧带;在结扎线近端剪断阴茎背深静脉复合体,紧贴前列腺尖端离断尿道;下腹正中耻骨上作6cm切口,取出切除的膀胱前列腺,将回肠拉出切口外,隔离50cm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。【结果】手术时间平均约为8h,出血量平均为650mL。术后3周作腹部平片、静脉尿路造影,以及新膀胱造影检查,显示:新膀胱充盈良好,容量约300mL,无输尿管返流及梗阻,所有患者术后1个月内恢复控尿功能。无排尿困难及残余尿。【结论】腹腔镜下切除膀胱前列腺视野清楚,可减少出血,避免尿道括约肌损伤,保留神经血管束;可减少肠管暴露时间,有利用术后肠道功能恢复,减少肠粘连。作一小切口取出膀胱前列腺,并将肠管拉出体外形成贮尿囊,可大大缩减手术时间。回肠作贮尿囊有取材容易     

腹腔镜下膀胱前列腺全切除－原位回肠新膀胱术初步报告

【目的】探讨腹腔镜下膀胱前列腺全切除．原位回肠新膀胱手术方法。【方法】为4例52～65岁男性膀胱癌患施行了手术。采用5个套管针，腹腔镜由脐上或脐下套管针进入，手术经左侧2个套管针操作，助手经右侧2个套管针操作。游离输精管、精囊，剪开狄氏筋膜分离前列腺后面；游离输尿管下段在其末端切断；剪开前腹壁腹膜反折，游离膀胱前壁；缝扎阴茎背深静脉复合体；游离膀胱侧韧带及前列腺侧韧带；在结扎线近端剪断阴茎背深静脉复合体，紧贴前列腺尖端离断尿道；下腹正中耻骨上作6cm切口，取出切除的膀胱前列腺，将回肠拉出切口外，隔离50cm回肠剖开后“M”形折叠形成贮尿囊，将输尿管末段lcm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。【结果】手术时间平均约为8h，出血量平均为650mL。术后3周作腹部平片、静脉尿路造影，以及新膀胱造影检查，显示：新膀胱充盈良好，容量约300mL'无输尿管返流及梗阻，所有患术后1个月内恢复控尿功能。无排尿困难及残余尿。【结论】腹腔镜下切除膀胱前列腺视野清楚，可减少出血，避免尿道括约肌损伤，保留神经血管束；可减少肠管暴露时间，有利用术后肠道功能恢复，减少肠粘连。作一小切口取出膀胱前列腺，并将肠管拉出体外形成贮尿囊，可大大缩减手术时间。回肠作贮尿囊有取材容易，系膜较长，可无张力下与尿道吻合的优点。     

经尿道途径辅助下单孔腹腔镜猪全膀胱切除加回肠代膀胱术

目的尝试完成经尿道途径辅助下单孔腹腔镜猪全膀胱切除加回肠代膀胱术,探讨该操作的可行性,总结操作经验。方法体质量约为30kg的雌性香猪,全麻后仰卧位,平脐水平,经右侧腹直肌纵行切开2cm长皮肤切口,钝性分开腹直肌并切开腹膜。置入SILS单孔多通道平台后,建立气腹。超声刀配合可弯分离钳游离膀胱周围组织,并离断双侧输尿管。末端可弯电钩离断尿道,完成膀胱切除。在输尿管镜的引导下,经尿道置入12mm的普通腹腔镜套管。选择合适肠管后,经尿道套管置入直线切割器进行离断。单孔腹腔镜下完成小肠侧侧吻合和左侧输尿管小肠吻合。经尿道套管取出膀胱标本,缝闭尿道残端。取出SILS单孔多通道平台,一并将右侧输尿管及拟行造口的小肠输出袢带出。体外完成右侧输尿管和输出袢吻合,并将小肠黏膜外翻完成造口。结果完成3例动物试验,手术时间210～335min,平均(275±63)min,未增加额外套管。术毕,腹壁除正常肠造口外,无其他手术切口。结论经尿道途径辅助下有利于完成高难度的单孔腹腔镜猪全膀胱切除加回肠代膀胱重建术,但手术操作难度较大。     

世界首例小儿腹腔镜下根治性膀胱切除全去带乙状结肠原位新膀胱术

目的 世界首例小儿腹腔镜下根治性膀胱切除全去带乙状结肠原位新膀胱术的经验及疗效.方法 3岁男孩,确诊为膀胱横纹肌肉瘤,行腹腔镜下根治性膀胱切除术全去带乙状结肠新膀胱术.手术包括先行腹腔镜下双侧盆腔淋巴结清扫及膀胱切除,下腹部小切口取出标本,再行去带乙状结肠原位新膀胱术.结果 手术成功完成.手术时间为6h,其中腹腔镜根治性膀胱切除部分时间约3.5 h.术中出血量约50 ml,术中输入200 ml浓缩红细胞以确保手术安全性.双侧盆腔淋巴结各清扫6个,均为阴性,术中输尿管及尿道切缘均为阴性.患儿术后3 d恢复肠蠕动.盆腔引流管于术后7d拔除,新膀胱造瘘管于术后14 d拔除,术后25 d行经尿道膀胱造影,确定无造影剂外漏后拔除导尿管及双侧输尿管支架管.患儿拔除导尿管后1周左右基本恢复白天控尿及排尿功能.5个月后复查,提示新膀胱容量约为110ml,膀胱残余尿量约10ml,最大尿流率约12ml/s.围手术期未见明显水电解质及酸碱平衡紊乱,无尿漏、输尿管返流及肠梗阻发生.结论 随着手术经验的丰富和技术的发展,腹腔镜下根治性膀胱切除术具有损伤小,术中出血少,患儿恢复快等优点,有望成为治疗小儿膀胱癌的安全可靠的方法.     

腹腔镜下膀胱全切除原位乙状结肠代膀胱术(附12例报告)

目的:探讨腹腔镜下膀胱全切除原位乙状结肠代膀胱手术的方法与治疗效果。方法:对12例浸润性膀胱癌患者采用腹腔镜下全膀胱切除术,前列腺切除或子宫次全切除。经腹壁造口取出切除物,行乙状结肠去带原位新膀胱术。结果:12例手术成功,手术时间5~10 h,平均6.5 h;出血量200~1 000 ml,平均387 ml,代膀胱充盈良好,容量约300 ml,术后4~6周患者恢复控尿功能,无排尿困难及尿失禁。结论:腹腔镜下行膀胱全切除视野清晰,可减少出血,缩短手术时间。     

腹腔镜根治性膀胱切除术加原位T型回肠新膀胱重建的临床观察

目的 总结13例腹腔镜根治性膀胱切除、标准淋巴结清扫加T型原位回肠新膀胱重建的经验,评价此术式肿瘤学结果与功能性结果.方法 2005年8月至2009年7月,对首都医科大学附属北京朝阳医院13例肌层浸润性膀胱肿瘤患者实施腹腔镜根治性膀胱切除加下腹壁小切口行原位T型回肠新膀胱重建术,对手术时间、淋巴结数量、围手术期并发症、出血量、输血量、生存率、上尿路形态与功能、控尿情况进行分析.结果 平均手术时间为6 (5～8) h,平均出血量为480(100～800)ml,平均输血量133(0～400)ml,平均清扫淋巴结数16(8～22)个,无围手术期死亡,围手术期并发症发生率为15.4% (2/13).术后3周行膀胱造影检查,未发现明显造影剂外溢及反流.患者日间完全控尿率达84.6%(11/13);夜间完全控尿率为46.1%(6/13),夜间仅需要1块尿垫者占30.8%(4/13).上尿路检查提示,23.1%(3/13)术后45 d内出现双侧肾盂及输尿管的轻度暂时性扩张,但肾功能保持正常.随访24(16～63)个月,7.7% (1/13)于术后55个月死于急性心肌梗死,92.3%(12/13)无复发生存.结论 腹腔镜根治性膀胱切除、标准淋巴结清扫加下腹壁小切口行T型原位回肠新膀胱重建术取得了满意的肿瘤学与功能性结果;T型原位新膀胱输入袢的抗反流效果令人满意,能够充分保护上尿路形态与功能.

Abstract：

Objective To summarize the preliminary experiences of 13 cases of laparoscopic radical cystectomy and construction of orthotopic T pouch ileal neobladder and evaluate the oncological and functional outcomes of this procedure. Methods From August 2005 through July 2009, 13 patients underwent radical cystectomy and standard lymphadenectomy followed by construction of orthotopic T pouch ileal neobladder via mini-laparostomy for muscular invasive bladder cancer. The data were analyzed according to procedure time, blood loss volume, transfusion volume, number of dissected lymph nodes, peri-operative complications, morphology and function of upper urinary tract and status of urinary continence. Results The mean operating duration was 6 (5-8) hours, estimated volume of blood loss 480 (100-800) ml, transfusion volume 133 (0-400) ml and the number of dissected lymph nodes 16 (8-22). There was no peri-operative mortality. The peri-operative complications were found in 15.4% (2/13) and included urine leak at neobladder-urethra junction managed by drainage (n=1) and urine leak at ureter-neobladder junction repaired (n=1). The complete daytime continence rate was 84.6%(11/13), complete nocturnal continence rate 46.1% (6/13) and <1 pad in 30.8% (4/13). No reflux into afferent limb of neobladder was observed by cystography. Temporary dilation of upper urinary tract was observed in 23.1% (3/13) at Day 45 post-operation and later it disappeared spontaneously. Serum creatinine remained in a normal range in all patients. Within a follow-up of 24 (16-63) months, 7.7% (1/13) died of myocardial infarction at Month 55 post-operation. And 92.3% (12/13) survived without a local relapse or a distal metastasis. Conclusion Within an intermediate follow-up period, the oncological and functional outcomes are encouraging after laparoscopic radical cystectomy and construction of orthotopic T pouch ileal neobladder via mini-laparostomy. The anti-reflux mechanism is effective to preserve the morphology and function of upper urinary tract.     

机器人辅助腹腔镜根治性膀胱切除联合原位回肠新膀胱术治疗膀胱癌22例

目的 总结机器人辅助腹腔镜根治性膀胱切除联合原位回肠新膀胱术治疗膀胱癌的临床经验,评估其疗效和安全性。方法 回顾性分析2019年1月至2019年12月接受机器人辅助腹腔镜根治性膀胱切除联合原位回肠新膀胱术治疗的膀胱癌患者的临床资料。共22例,均为男性,年龄为32~71岁（中位年龄63岁）。统计手术方法、手术时间、术后拔管时间、并发症等围手术期资料,术后病理结果,以及肿瘤控制情况和尿控效果等随访资料。结果 22例患者手术均顺利完成,无术中转开放手术者。其中4例行单孔手术,2例为全腔镜下原位回肠新膀胱术。手术时间为320~600（420±36）min,术中出血量为100~400（150±17）mL,围手术期均未输血。术后1~2 d（中位数2 d）下床活动,1~3 d（中位数2 d）恢复肠道通气,5~21 d（中位数10 d）拔除负压引流管,10~25 d（中位数14 d）拔除导尿管。本组患者均无术中肠道损伤、术后肠梗阻等肠道并发症,无切口感染。2例发生新膀胱漏尿,经延长留置导尿管后自行愈合。所有患者术后病理结果均为尿路上皮癌。术后随访3~15个月,未出现肿瘤复发,无患者死亡。术后2个月20例（90.1%）患者尿控满意。1例患者术后4个月因内疝而手术,2例患者术后6个月因排尿困难给予间歇自我导尿。结论 机器人辅助根治性膀胱切除联合原位回肠新膀胱术在临床上安全可行,短期肿瘤控制和尿控效果满意,远期疗效有待通过病例累积和长期随访进一步评估。     

全膀胱切除137例临床分析

目的总结探讨全膀胱切除尿流改道不同术式的临床特点。方法回顾性分析137例行全膀胱切除术患者的临床资料,其中男117例,女20例;年龄36～88岁,平均65.2岁。经腹腔镜手术101例,其中9例术中改开放手术;传统开放术式36例。尿流改道方式:原位回肠新膀胱术86例,占62.8%;原位乙状结肠新膀胱术12例,占8.8%;回肠膀胱术20例,占14.6%;输尿管乙状结肠吻合术9例,占6.6%;输尿管皮肤造口术8例,占5.8%;胃代膀胱术2例,占1.5%。结果所有手术均获成功,手术时间为4～8h,术中出血400～1 600mL,随访3～60个月,术后早期并发症包括伤口感染、漏尿和肠梗阻等,严重并发症为肠瘘3例。围手术期死亡3例,死亡原因为呼吸、循环系统疾病。术后晚期主要并发症有泌尿系结石、尿路感染等。获随访的原位新膀胱术者51例,白天控尿良好48例(94.1%),夜间控尿良好43例(84.3%)。获随访的72例中男性67例,其中41例自诉阴茎可勃起,占61.2%(41/67)。术后无长期尿失禁,未发现尿道肿瘤。结论根治性全膀胱切除手术风险较高,术前应充分评估适应证;原位膀胱术是尿流改道的首选术式;全膀胱切除尿流改道严重并发症少,不易复发,患者生活质量高,是治疗浸润性膀胱癌的理想方法。     

Laparoscopic radical cystectomy with orthotopic ileal neobladder in the female: report of 14 cases

Background Bladder carcinoma is the most common malignant urological tumor in China. We present our preliminary experience and results of laparoscopic radical cystectomy （LRC） with orthotopic ileal neobladder in female patients with bladder carcinoma.
Methods From February 2003 to February 2008, 14 female patients with bladder carcinoma underwent LRC with orthotopic ileal neobladder. Nine of these patients underwent hysterectomy and ovariectomy, and the other 5 had preservation of the uterus and ovarian appendage. Standard bilateral pelvic lymphadenectomy was followed by radical cystectomy that was completed laparoscopically with hysterectomy and ovariectomy when needed. The tumor was removed by a 4-5 cm lower midline abdominal incision, followed by the construction of ileal neobladder and the extracorporeal anastomosis of ureter-neobladder. The neobladder was anastomosed to the urethral stump under a laparoscope.
Results The mean operative time and blood loss in the 14 patients were 350.2 minutes and 349.8 ml, respectively. Postoperative complications included uretero-pouch anastomotic stricture in 1 patient and pouch-vaginal fistula in 1 patient. Follow-up time of all patients ranged from 3 to 60 months, and 12 patients were followed up for more than 6 months and achieved micturition in half a year. One patient had occasional day-time urinary incontinence and 2 had night-time incontinence. Two patients who had undergone hystectomy and ovariectomy had voiding difficulties after one year, which was treated by intermittent self-catheterization. The mean volume of the neobladder and the residual urine were 333.6 ml and 31.2 ml, respectively. Surgical margins were tumor free for all patients. One patient had bone metastasis and died 11 months after the operation.
Conclusions LRC with orthotopic ileal neobladder in female patients is a technically feasible, safe and mini-invasive procedure with a low morbidity and acceptable neobladder function. Long-term follow-up is required to confirm the neobladder func     

Laparoscopic radical cystectomy with orthotopic ileal neobladder: report of 33 cases

Background The laparoscopic radical cystectomy (LRC) with orthotopic ileal neobladder is now applied to treat invasive bladder cancer, however, it has not been well codified and illustrated. We describe in this paper a technique step by step that we have developed in 33 patients and achieved excellent results.Methods The surgical procedure can be divided into eight steps: laparoscopic pelvic lymphadenectomy and mobilization of the distal ureters; exposing Denonvillier’s space and the posterior aspect of prostate; exposing retropubic space and anterior surface of the bladder; dividing the lateral pedicles of the bladder and the prostate; dividing the apex of the prostate; extracorporeal formation of the ileal pouch; extracorporeal implantation of the ureters; and laparoscopic urethra-neobladder anastomosis. This operation was performed in 33 patients, 29 males and 4 females, with muscle invasive bladder cancer between December 2002 and September 2004.Results The operating time was 5.5-8.5 hours with an average of 6.5 hours; the estimated blood loss was 200-1000 ml with an average of 460 ml. The surgical margins of the bladder specimen were negative in all patients. There was no evidence of local recurrence at follow-up of 1-21 months in all the patients. However lymph node metastases were found in one case at 9 months postoperatively. Most of patients achieved urine control 1 to 3 months after surgery. The daytime continence rate was 94% (31 cases) and nighttime continence rate was 88% (29 cases). Urodynamic evaluation was performed between 3 and 6 months postoperatively for all cases. The mean value of neobladder capacity was (296±37) ml. The mean value of maximum flow rate was (18.7±7.1) ml/s. The mean residual urine volume was (32±19) ml. In all cases, excretory urography at 1 to 2 months postoperatively demonstrated slightly dilated upper urinary tracts without ureteral obstruction, which resolved at follow up. Cystography showed neobladders being similar in shapes to normal. Two small ureteral nipples with intermittently efflux of urine were observed at cystoscopy in most patients. Postoperative complications occurred in 6 of 33 patients (18%), including pouch leakage in 2 cases, pelvic infection in 1, partial small bowel obstruction in 2 and neobladder-vaginal fistula in 1.Conclusions The LRC with orthotopic ileal neobladder is a feasible option for bladder cancer when radical cystectomy is indicated. The extracorporeal formation of the ileal pouch and ureteral implantation through a small lower midline incision can simplify the complexity of the procedures, shorten the duration of surgery and reduce the medical expenses.     

女性膀胱癌腹腔镜根治性切除原位回肠新膀胱术术式改进

目的 探讨并改进腹腔镜女性膀胱癌根治性切除-原位回肠新膀胱术的手术方法,随访观察其治疗效果.方法 2003年2月至2008年9月,为19例女性膀胱癌患者施行了腹腔镜膀胱全切除-原位回肠新膀胱术,其中13例同时行子宫、卵巢及附件切除,6例行保留子宫、卵巢附件.主要手术步骤为:①行标准盆腔淋巴结清扫,②行膀胱全切除同时切除或不切除内生殖器,③在下腹正中线上作4～5 cm切口,取出标本,并构建"M"形去管回肠储尿囊,④输尿管末端形成半乳头,"插入式"种植于储尿囊;⑤储尿囊回纳腹腔,在腹腔镜下作储尿囊与尿道吻合.术后记录围手术期情况,并对患者进行定期随访,了解患者的生活质量、排尿情况,并检测患者的残余尿量、新膀胱压力等.结果 手术时间(340.5±43.1)min,术中出血(353.9±71.3)ml.术后随访2～69个月,半年内均能自主排尿,1例日间偶有尿失禁,2例夜间尿失禁,3例排尿困难.膀胱容量(333.6±45.4)ml,残余尿量0～210(41.2±18.1)ml.术后半年至1年,行静脉尿路造影,除1例单侧肾积液外,其余双肾显影良好,未见肾盂输尿管扩张.膀胱尿道造影,可见膀胱位于盆腔,其形状大小位置于正常膀胱相似,未见膀胱输尿管反流.术后输尿管新膀胱吻合口梗阻1例,新膀胱阴道瘘1例,肿瘤远处转移2例于随访期间死亡.结论 腹腔镜女性膀胱全切除-原位回肠新膀胱术,技术上可行,可根据患者情况采用保留或切除内生殖器的手术方法,术中出血较少,创伤较小,术后大部分患者能自主排尿,但尿失禁及排尿困难发生率略高于男性,术后中远期新膀胱功能及肿瘤根治效果还需进一步临床观察.