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

Laparoscopic Cystoprostatectomy and Ileal Orthotopic Neobladder

Objective] To report the method of laparoscopic radical cystoprostatectomy and ileal orthotopic neobladder. 4 males aged 52 to 65 years with bladder carcinoma underwent surgery from December 2002 to March 2003. Laparoscopic cysto prostatectomy was performed through 5 trocars and reconstruction of neobladder was performed through a small incision. With the technique of Montsouris, the ampullae of vas deferens, seminal vesicles, posterior aspect of prostate were divided, and ureters were dissected outside the bladder after clips. And then, anterial aspect of bladder and prostate were exposed. The endopelvic fascias and puboprostatic ligaments were separated bilaterally. The vesical and prostatic fibrovascular pedicles were coagulated and separated with harmonic scalpel. The dorsal vein complex was suture ligated and separated. The urethra was transected close to the prostate apex. A 6 cm suprapubic symphysis incision was made to remove the surgical specimens and construction of neobladder was performed. A 50 cm ileal loop was extracted from the abdominal cavity, isolated, detubularized and reconfigured into " M" shape pouch with running suture. The anti reflux ureter implantation was performed by means of inserting the 1 cm of distal ureter into the pouch and fixing with 4 to 6 suture. The urethra neobaldder anastomosis was completed with 6 absorbable sutures. The mean operative time was 8 hours. The mean blood loss was 650 mL. All patients could control urine on day and at night within one month after operation. The capacity of neobladder was about 300 mL. The intravenous urography and retrograde cystography in 3 weeks after operation showed no evidences of ureteric reflux, ureteral obstruction, and well filling neobladder without leakage. Conclusion] The procedure combines the advantages of minimally invasive laparoscopy with the speed and safety of open surgery. Ileal neobladder is suitable for construction through a small incision.