改良可控性回肠膀胱控尿机制的临床研究

目的探讨改良可控性回肠膀胱临床应用的效果。方法膀胱癌行根治性膀胱切除尿流改道患者12例,采用改良的回肠乳头瓣作为输出道,外口与脐孔作皮瓣嵌入防狭窄吻合,去管化回肠浆膜下隧道抗返流技术。结果12例随访14~50个月,昼夜控尿满意,尿动力学显示:储尿囊容量350~720(435±88)m l,充盈时内压15~32(20±5)cm H2O,储尿囊充盈时输出道最大闭合压力74~142(98±23)cm H2O,空虚时为49~105(68±20)cm H2O,2者差异有统计学意义(t=8.82,P<0.01);充盈过程中无收缩波出现。结论改良回肠乳头瓣输出道及去管化回肠浆膜下隧道抗返流技术是比较理想的可控技术改进。     

体外可控性回肠膀胱术的实验研究及临床应用

目的　提高体外可控性回肠膀胱术的治疗效果。　方法　距回盲部约 2 0cm处切取一段回肠 ,中间部分折叠成N形并缝制成贮尿囊 ;近端回肠为输入道 ,近贮尿囊 4～ 5cm回肠纵形折叠缝合以缩窄管腔 ;远端 8～ 10cm回肠从腹壁造瘘口处穿出体外 ,于造瘘口处取双片梯形皮瓣包绕外露肠管缝制成皮管 ,构建输出道。将尿液控制器置于皮管外 ,利用气囊控制排尿。 12只犬应用研究后对 5例膀胱癌患者采用此术式治疗。　结果　 10只犬手术顺利 ,术后 3个月时贮尿囊平均最大容量 (15 0± 4 0 )ml,最大充盈压 (2 4 .4± 5 .3)cmH2 O。 5例患者术后随访 3～ 14个月。术后 3个月时贮尿囊平均最大容量 (2 90± 80 )ml,最大充盈压 (36 .3± 8.2 )cmH2 O ,最大尿流率 (2 0 .3± 4 .7)ml/s ,无剩余尿。影像学检查肾脏显影良好 ,输尿管通畅。尿液控制器气囊充气后无尿液流出 ,气囊消气后尿线粗。　结论　该尿流改道术式可达到体外控尿效果 ,不必佩戴集尿袋及导尿 ,手术操作比较简单、并发症少。     

可控性膀胱术与回肠新膀胱术(附68例报告)

目的　评价不同术式可控性膀胱术及回肠新膀胱术的疗效。　方法　对 6 8例膀胱全切除术后患者采用 4种可控性尿流改道及回肠新膀胱术式 ,术后对患者控尿、导 (排 )尿 ,贮尿囊容积、内压 ,影像学及血生化资料进行比较。　结果　回肠套叠式输出道 3例中有 2例部分脱套致术后尿失禁 ,需再次手术 ;缩窄末端回肠式输出道 44例控尿均良好 ,除 1例插管困难外余均能用 16～ 2 0F尿管自行导尿。去管折叠式贮尿囊 39例 ,其中回肠贮尿囊 3例、结肠 2 2例、回结肠 14例 ,能达到低压贮尿囊要求 ,但早期有 8例发生贮尿囊过度扩张 ,容量 1470～ 16 5 0ml;去带结肠贮尿囊 8例 ,容量 430～6 0 0ml,充盈压 30～ 45cmH2 O(1cmH2 O =0 .0 98kPa) ,有蠕动波 ,术后早期有 2例尿漏。回肠新膀胱2 1例 ,容量 35 0～ 46 0ml,充盈压 12～ 2 0cmH2 O ,日间尿失禁 1例 ,夜间尿失禁 2例 ,其余无尿失禁。　结论　盲升结肠 30cm剖开对折成形可控性膀胱可满足低压贮尿囊要求 ,去带结肠贮尿囊由于易发生术后尿漏或粘连 ,内压较高 ,不够理想。缩窄末段回肠式输出道控尿效果好、内腔大、插管顺利、并发症少 ,明显优于回肠套叠输出道。回肠新膀胱术贮尿排尿功能良好 ,术后生活质量高 ,但应严格选择手术适应证。     

尿流改道新术式棗体外可控性肠代膀胱术

目的　探讨体外可控性回肠代膀胱术的临床应用效果。方法　距回盲部 2 0cm处 ,取 48cm回肠 ,中段 3 0cm折叠成N形并缝制成贮尿囊 ;远端 10cm经腹壁造瘘口处穿出体外 ,将此处皮瓣包绕外露肠管缝制成皮管 ,构建输出道。将尿控器置于皮管外控制排尿。结果　 6例患者术后恢复顺利 ,随访 3～ 18个月。术后肝肾功能、电解质均正常。术后 3个月时平均贮尿囊最大容量为 (2 90± 80 )ml,最大充盈压为 (3 4.7± 7.8)cmH2 O (1cmH2 O =0 .0 98kPa) ,最大尿流率为(2 1.2± 3 .9)ml/s ,无残余尿。X线影像学检查 ,肾输尿管显影良好 ,无梗阻。尿控器能控制尿液流出。结论　本术式可达到体外控制排尿的效果 ,既不戴集尿袋 ,又不必导尿 ,并发症少 ,是一种比较理想的尿流改道新方法     

贮尿囊与腹壁的壁外支持增强缩窄回肠控制机制的临床研究

目的：建立一种控尿可靠、导尿容易和手术方法简单的输出管。方法：选用缩窄后的回肠作为输出管,输出管的内口与贮尿囊作端侧吻合,其外口与脐孔作端端吻合,并将部分输出管固定在贮尿囊与腹壁之间的手术方法治疗10例膀胱癌患者。术后对输出管和贮尿囊作尿动力学和X线检查。结果：1例术后55d死于心脏疾病,余9例中8例白天和晚上均能控制排尿,术后尿动力学检查示贮尿囊充盈时输出管最大闭合压明显高于贮尿囊空虚时输出管最大闭合压,两者间比较差别有显著性意义（t=-7.14,P=0.000098)。结论：采用回肠贮尿囊与腹壁的壁外支持可明显增强缩窄回肠的控制能力。     

带蒂腹直肌瓣包绕缩窄回肠输出道增强控尿机制的实验研究

目的 改良可控输出道术式,增强可控输出道的长期控尿能力.方法 1～2岁杂种犬10只,雄性2只,雌性8只.分别截取30～40 cm末端回肠U形折叠制成储尿囊,另取2段6 cm回肠段缩窄为可通过12 F导管的输出通道.切取6 cm×3 em腹直肌,保留神经m管束,自1条缩窄同肠输出道的肠系膜血管间穿过,包绕十输出道外作为控制管;另1条输出道直接连接腹壁皮肤作为对照管.术后1、3、6个月分别测定储尿囊空虚和充盈时输出道压力(MIP)及功能性压力段长度(FPL).分析储尿囊充盈前后控制管与对照管MIP与FPL的差异.结果 1条犬术后6个月储尿囊允盈中液体经对照管溢出,无法完成实验.其余9条均行3次测压.储尿囊充盈前后,控制管MIP均70 cm H2O(1 cm H2O=0.098 kPa);对照管分别为<30、40<45 am H2O,均明显低于控制管.术后1、3、6个月,储尿囊充盈前后,控制管MIP平均值分别为(73.51±24.01)与(77.68±25.15)、(71.16±19.35)与(79.78±21.25)、(70.28±18.30)与(75.93±17.53)cm H2O,FPL平均值分别为(4.78±0.78)与(4.60±0.75),(4.71±0.61)与(4.61±0.54)、(4.49±0.65)与(4.24±0.97)cm,充盈前后差异均无统计学意义(P0.05);对照管MIP平均值分别为(29.04±7.02)与(42.90±7.66)、(28.10±8.09)与(41.63±8.98)、(26.63±6.89)与(43.36±9.79)cm H2O,FPL平均值分别为(5.04±0.44)与(4.59±0.53)、(4.98±0.82)与(4.42±0.85)、(4.63±0.69)与(3.97±0.53)cm,充盈前后差异均有统计学意义(P<0.05).术后6个月造影显示输出管与对照管形态无明显差异,无扭曲、狭窄或瘘道形成;组织学检查可见控制管回肠浆膜层外明显横纹肌组织结构.结论 带带腹直肌肌瓣翻转包绕输出道可有效提高输出道的控尿能力,凡有利于同定输出道,方便插管.     

体外可控性回肠代膀胱术的实验研究

目的 探讨体外可控性回肠代膀胱术的可行性及效果。方法 距回盲部 20 cm处取35 cm回肠,中段折叠成 N形并将其对系膜缘纵形剪开,缝制成贮尿囊;近端回肠作为输入道,远端回肠作为尿流输出道,将此段回肠于下腹壁造瘘口处穿出体外,于造瘘口处取双片梯形皮瓣包绕外露肠管缝制成皮管,制成输出道。将尿液控制器置于皮管外,利用气囊控制排尿。结果 10例动物顺利度过手术期。术后6个月内肝肾功能、电解质、血糖及血脂均与术前差异无显著性(P>0.05)。尿动力学检查:术后 3个月时平均贮尿囊最大容量为(150±40)ml,最大充盈压为(24.4±5.3)cm H_2O(1 cm H_2O=0.098 kPa),贮尿囊顺应性好。X线影像学检查:肾脏显影良好,输尿管通畅,贮尿囊充盈良好,无输尿管逆流。尿液控制器的排尿效应:气囊充气后,无尿液流出;气囊消气后,尿液呈粗线条流出。结论 该尿流改道术式可达到体外控制排尿的效果,手术操作比较简单、并发症少。     

输出管悬吊增强缩窄回肠控制机制的实验研究

目的 设计探讨可靠、导尿容易、并发症少的可控性膀胱输出道的手术方法。方法 对8条成年杂种狗采用经裁剪后缩小管腔直径的回肠作为输出管,用宽1.5cm的涤纶带以400g的拉力将输出管固定于腹直肌上,术后12周作尿动力学和X线检查。结果 8条狗的腹壁造口可容易地插入14F导管,尿动力学检查示膀胱输出管最大闭合压为117-157cmH2O,平均137cmH2O。腹壁造口逆行造影示输出管被固定在腹壁下,无狭窄,膀胱造影示输出管内无造影剂。结论 输出管悬吊具有明显增强缩窄回肠控制机制和手术方法简单的优点。     

以阑尾为流出道的可控性回盲肠膀胱术远期疗效观察

目的 评价以阑尾为流出道的可控性回盲肠膀胱手术的远期疗效。方法 应用回盲肠及部分升结肠作储尿囊，以阑尾为流出道腹壁造口术治疗膀胱肿瘤患者46例，采用尿动力学方法随访5年以上21例。男15例，女6例，平均年龄57岁。G212例，G39例。T3aN0M011例，T3bN0M0 5例，T3bN1M03例，T3bN0M02例。结果 21例患者中能控尿者19例(95％)。白天导尿4～5次，夜间1～2次，每次量250～400ml。膀胱初始感觉压力平均28cmH2O，最大充盈压36cmH2O，储尿囊容量分别为265ml、450ml。阑尾流出道闭合压力45cmH2O。1例患者出现肺转移行手术切除，1例出现肝转移死亡。无输尿管返流，无高氯血性酸中毒。结论 以阑尾为流出道的回盲肠膀胱术储尿囊内压低、容量大、可控性好，是一种较理想的尿流改道方式。     

原位回肠新膀胱术15 例临床报告

目的 探讨膀胱全切除术后原位M形回肠新膀胱的疗效.方法 膀胱恶性肿瘤患者15例行膀胱全切除术,采用M形原位回肠新膀胱术进行尿流改道.结果 围手术期无1例死亡,随访3-20个月(平均12.4个月).膀胱容量(340±23.71)mL(210-430 mL),膀胱充盈压为(20.12±0.64)cmH2O(13.50-33.91 cmH2O),排尿膀胱压为(77.02±12.11)cmH2O(53.21-87.09 cmH2O),残余尿(15.43±34.33)mL(3-88 mL),最大尿流率(18.16±5.60)mL/s(11.38-19.17 mL/s).无明显输尿管梗阻及返流.未发现尿道残端复发肿瘤.无排尿困难者,白天均可控制排尿;术后大于6个月者无夜间遗尿,术后半年15例复查B 超无肾积水表现,复查生化指标,肾功能电解质在正常范围内,1例术前肾积水及肾功能异常者术后为正常.结论 原位回肠新膀胱术是较理想的膀胱全切术后的尿流改道方式.     

Enhanced continent mechanism of tapered ileum by extramural support from the pouch and abdominal walls: a preliminary report of a clinical study

PURPOSE: We constructed a reliable continent tube that is easy to catheterize and surgically simple. MATERIALS AND METHODS: Eight patients with bladder cancer underwent a procedure in which ileal segment was tapered as an efferent tube, of which a part was placed between the back surface of the rectus muscle and the ileal pouch wall. The internal orifice of the tapered ileum was anastomosed to the ileal pouch and its external orifice was anastomosed to the umbilicus. Urodynamic and radiological studies were done postoperatively in 7 cases. RESULTS: The stoma was easily catheterized with a 16Fr catheter in all cases. One patient died of heart disease 55 days postoperatively, while 6 of the remaining 7 were completely continent day and night. Urodynamic study of the efferent tubes showed that maximum close pressure with the pouch full was significantly higher than with the pouch empty (p <0.001). Retrograde radiography of the efferent tubes demonstrated perfect canalization without stenosis. CONCLUSIONS: This study indicates that the continent mechanism of tapered ileum may be greatly enhanced by fixing it between the abdominal and pouch walls. This maneuver also provides easy catheterization and surgical simplicity.     

Efferent tube suspension as a continent diversion mechanism: a preliminary report of a clinical study

PURPOSE: We constructed a reliable continent tube that is surgically simple. MATERIALS AND METHODS: In 12 patients with malignant bladder tumor we performed radical cystectomy with isolation of a 50 cm. ileal loop with pedicle. The proximal segment (8 to 10 cm.) was tapered over a 16Fr catheter as an efferent tube, the remaining segment was detubularized to create a W-shape pouch and the tapered ileum was fixed to the back surface of the rectus muscle with 2 polyester tapers 1 cm. wide with a suspension tension of 500 g. The external orifice of the tapered ileum was anastomosed to the umbilicus. In 2 patients with neuropathic bladder a 15 cm. ileal loop with pedicle was isolated, the proximal segment (8 cm.) was tapered as an efferent tube with 500 g. suspension tension, and the remaining segment was detubularized and anastomosed to the bladder. RESULTS: The patients were followed for 6 to 17 months (mean 11.4) and were completely continent day and night. The stoma was easily catheterized with a 16Fr catheter in all cases. Urodynamic study of the efferent tubes revealed maximum pressure of 84 to 159 cm. water (mean 114). Retrograde radiography of the efferent tubes demonstrated perfect canalization without stenosis. CONCLUSIONS: This study suggests that the continent mechanism of the tapered ileum can be greatly enhanced by a suspension technique. This maneuver also provides easy catheterization and surgical simplicity.     

盲结肠膀胱术加强输出道可控机制的临床研究

目的　改进盲结肠膀胱术输出道手术方法 ,建立一种控尿可靠、插管方便、并发症少的可控输出道。　方法　对 4 7例膀胱癌患者行膀胱癌根治切除 ,37例采用去结肠带建立盲结肠贮尿囊 ,10例非管状化建立盲结肠贮尿囊 (改良Indianapouch) ,截取末端回肠 12～ 14cm ,剖开肠管重叠绕圈缝合成双层肠壁结构 ,回盲肠交界处浆肌层缝合 ,构筑回盲部小乳头状回肠套叠结构 ,建成长 12cm的输出道。盲肠端与盆腔腹壁缝合 ,远端与脐孔吻合 ,全长固定潜行于腹壁下贮尿囊和腹直肌之间。　结果　全部患者插管顺利 ,白天完全可控 4 5例 ,夜间完全可控 4 4例 ,术后 6个月输出道闭合压 4 0 .5～ 12 5 .6cmH2 O ,充盈状态输出道最大闭合压明显高于空虚状态 (P <0 .0 5 )。　结论　改进的缩窄末端回肠输出道是一种较理想的可控输出道。     

Study of efferent tube suspension as a continent diversion mechanism. an experimental study in dogs

PURPOSE: To construct a reliable continent tube, which is easy to catheterize and surgically simple. MATERIALS AND METHODS: 8 adult female mongrel dogs underwent a procedure in which an ileal segment was tapered as an efferent tube. The tapered ileum was fixed to the back surface of the rectus muscle with a polyester taper 1.5 cm in width and a suspension tension of 400 g. The internal orifice of the tapered ileum was anastomosed to the bladder and the external orifice of the tapered ileum was brought out to the abdominal skin. Urodynamic and radiological studies were carried out postoperatively in all dogs. RESULTS: All stomas in dogs could be easily catheterized with a 14-french catheter. Urodynamic study of the efferent tubes showed that the maximum closure pressure ranged from 117 to 157 (mean 136.75) cm water. Retrograde radiogram of the efferent tubes showed perfect canalization without stenosis. CONCLUSION: This study suggests that the continent mechanism of the tapered ileum can be greatly enhanced by a suspension technique.     

Continent vesicocutaneostomy. Preliminary experiments on dogs

A new operative technique for continent urinary diversion was designed as a continent vesicocutaneostomy and preliminary experiments were performed on 7 dogs. A U-shaped flap of anterior bladder wall (30 X 20 X 30 mm) was created, which was then rolled and sutured to an efferent duct. One-half to two-thirds in length of the efferent duct was placed between the muscular layer and mucosa of the bladder, and the distal end of the efferent duct was anastomosed to the cutaneous stoma made at the suprapubic area. In this urinary diversion, excretion of urine from the bladder was done by intermittent catheterization from the stoma through the efferent duct. The operation was successful on all of the experimented dogs, continence of the stoma was preserved and catheterization through the stoma was achieved easily. Urodynamic assessment of the efferent duct was performed, being focused on the mechanism of continence, at 3 and 6 months after the operation. The length of continence zone and maximum closing pressure through the entire efferent duct were 23.2 +/- 4.5 mm and 41.2 +/- 14.7 cmH2O respectively with empty bladder (intravesical pressure = 0). When the bladder was full (intravesical pressure = 20-40 cmH2O), these parameters were 21.4 +/- 4.7 mm and 36.0 +/- 7.0 cmH2O respectively. The length of continence zone and maximum closing pressure of only the submucosal part of the efferent duct were 12.8 +/- 4.3 mm and 18.5 +/- 5.2 cmH2O with empty bladder, 13.3 +/- 2.9 mm and 22.0 +/- 9.9 cmH2O with full bladder.(ABSTRACT TRUNCATED AT 250 WORDS)     

缩窄回肠输出道外支持可控腹壁尿流改道：5年随访报告

目的：评价缩窄回肠可控输出道外支持腹壁可控尿流改道的围手术期及远期并发症发生率及远期控尿效果。方法：对84例患者手术中采用两种方式加强缩窄回肠输出道的控尿能力：①39例通过两条1cm宽的涤纶补片以500g拉力将4～5cm的输出道悬吊于腹直肌下方;②45例以3—0尼龙线将一段4～5cm连接储尿囊的管状回肠贴合于腹直肌背侧,使输出道在腹直肌与管状回肠之间穿过,固定于腹直肌背侧。结果：本组1例术后55天死于心脏疾病,8例（9．6％）出现围手术期并发症,其中2例（2．4％）需再次手术,其余患者均经对症处理缓解。27例（32．5％）出现术后远期并发症,5例（6．0％）需再次手术纠正。在完成最近一次随访的52例患者中,43例可实现尿控,其中37例可日夜满意控尿。涤纶补片组与额外回肠段组的满意控尿率分别为77．3％和76．9％。结论：虽然缩窄回肠可控输出道外支持腹壁可控尿流改道的并发症仍较常见,但其发生率在可以接受的范围,且大多数并发症的处理都较为简单,再手术的概率并不高。长期随访结果显示该手术可使缩窄回肠输出道获得持久、可靠的控尿能力。     

去带盲升结肠可控膀胱术临床研究

目的建立一种操作简单、并发症少、较理想的可控性尿流改道术. 方法对26例膀胱癌等肿瘤患者行根治性膀胱切除术后,游离截取15～20 cm盲升结肠,间隔0.5～1.0 cm切断结肠带,建成去带盲升结肠可控膀胱并开口于脐部. 结果随访2～51个月,可控效果好,并发症少,术后6个月3～6 h放尿1次,每次尿量为350～600 ml.尿动力学显示最大充盈压为(59±24) cmH2O,输出道最大闭合压为(104±34) cmH2O. 结论去带盲升结肠可控膀胱术是一种比较理想的可控膀胱术.