改良全膀胱切除和原位新膀胱术重建下尿路功能

背景与目的:全膀胱切除原位新膀胱术是治疗浸润性膀胱癌最有效的手段.但由于手术繁杂、时间长、出血和并发症较多,以及相当一部分患者控尿不佳等缺点,我们对全膀胱切除和原位新膀胱术进行了反复改良,获得了比较满意的效果,本文报告我们的经验.方法:采用改良的全膀胱切除和原位新膀胱术治疗119例临床诊断为浸润性膀胱癌的患者.男性109例,女性10例.年龄33～78岁,平均55岁.统计手术时间、术中出血和输血量,对新膀胱功能、并发症、肿瘤控制和生存情况进行随访分析.结果:对全膀胱切除和原位新膀胱术一共进行了八处改良.从2000年1月至2007年2月用改良术治疗119例,无围手术期死亡.手术时间150～330 min,平均245 min.输血39例(32.8%).术后病理分期浅表性膀胱癌(T1N0M0) 9例,浸润性110例(其中T2N0M0 102例、T3aN0M0 3例、T3aN1M0 2例、T3bN1M0 2例,、T4N1M0 1 例).随访6～72个月,平均45个月,108例生存,10例因肿瘤死亡,1例非肿瘤原因死亡.术后白天控尿良好113例(95%),夜间控尿良好97例(81.5%).主要并发症有切口裂开5例,二次缝合后治愈;输尿管新膀胱吻合口漏1例,经再次手术作输尿管再植治愈;肠梗阻3例需住院处理.输尿管末端粘连引起肾积水8例,经内镜下切断粘连后积水消退.无肠瘘和新膀胱尿道吻合口瘘或狭窄,无膀胱输尿管返流.结论:全膀胱切除后采用改良原位新膀胱术重建下尿路功能,手术时间短、出血少和并发症少,新膀胱控尿和排尿满意,是目前全膀胱切除后最理想的下尿路重建方式.     

男性全膀胱切除后下尿路功能重建——附120例报告

目的 改良全膀胱切除和原位新膀胱术治疗浸润性膀胱癌的临床经验.方法 采用改良全膀胱切除和原位新膀胱术治疗局部浸润性膀胱癌患者120例,均为男性,平均年龄55.6岁.120例中移行细胞癌113例,鳞癌3例,腺癌4例.TNM临床分期T2N0M0101例、T3N0M0 7例、T3N1M0 2例.统计手术时间、术中出血和输血量,对新膀胱功能、并发症、肿瘤控制和病人生存情况进行随访分析.结果 120例患者无手术死亡,手术时间185～332分钟,平均254分钟.术中出血150～1270 ml,输血40例.病理分期T1N0M0 3例,T2N0M0 111例,T3aN0M0、T3aN1M0和T3bN1M0各2例.随访4～71个月,平均37个月.111例无瘤生存,因肿瘤死亡9例.新膀胱白天控尿良好112例(93.3%),夜间控尿良好95例(79.2%).残余尿量0～100 ml 112例,101～250 ml 8例.主要并发症:切口裂开3例,二次缝合治愈;输尿管吻合口漏1例,再吻合后治愈;输尿管口狭窄4侧,2侧经内镜下切开和扩张纠正,2侧行输尿管新膀胱再吻合治愈.输尿管口粘连4侧,经内镜下手术纠正;严重肠梗阻3例和慢性酸中毒低钾2例,均经内科处理纠正.结论 改良全膀胱切除和原位新膀胱术后严重并发症少、肿瘤控制满意,重建的新膀胱功能良好,能较好保持患者的生活质量,是目前治疗浸润性膀胱癌最理想的方法之一.     

全膀胱切除和原位新膀胱术治疗女性浸润性胱膀癌患者(附8例报告)

背景与目的全膀胱切除和原位新膀胱广泛用于治疗男性浸润性膀胱癌,效果良好,但用于女性浸润性膀胱癌的经验很少。本研究的目的是探讨女性全膀胱切除和乙状结肠原位新膀胱的临床效果。方法回顾性分析2002年1月至2003年10月中山大学肿瘤防治中心应用全膀胱切除和乙状结肠原位新膀胱术治疗的8例女性浸润性膀胱癌的临床资料。结果手术均获成功。随访6～24个月(平均18个月),6例无瘤生存,2例分别于术后6个月和12个月出现盆腔复发。全部患者均能自主排尿。4例昼夜完全控尿,另4例白天完全控尿,夜间有少许漏尿。1例术后3个月发现肾输尿管轻度积水,观察3个月后自然消退。血电解质和肾功能均正常。结论女性膀胱癌患者行全膀胱切除和乙状结肠原位新膀胱术后,肿瘤控制及新膀胱功能良好,但夜间控尿能力较差。     

腹腔镜全膀胱切除术加回肠原位膀胱术的临床疗效观察 （附15例报告）

目的：总结腹腔镜下膀胱肿瘤根治术加回肠原位膀胱术的经验。方法：15例患者中男11例, 女4例, 年龄46～72岁,平均61.8岁, 采用5点穿刺法, 腹腔镜由脐部下缘导管进入, 手术者经左侧2个套管操作, 助手经右侧2个套管操作。从右到左分别游离输尿管中下段并进行盆腔淋巴结清扫, 输尿管暂不离断。男性患者先游离并离断输精管、 精囊, 前列腺后壁及前壁, 紧贴前列腺尖部离断尿道, 再行膀胱前列腺全切; 女性患者在行膀胱全切除的同时作子宫及附件切除。在下腹正中线上作长4～5 cm切口, 取出标本, 回肠拉出切口外, 取回盲部交界15 cm近侧隔离50 cm回肠段纵行剖开该肠后M形折叠形成贮尿囊, 将输尿管末段1 cm插入贮尿囊后顶部作吻合。贮尿囊最低位开口与尿道断端行6针吻合。结果：手术耗时5～8 h, 平均6.3 h, 出血量400～800 mL, 平均447 mL, 术后所有患者3～4 d肠道功能开始恢复,1个月行B超、 IVU及新膀胱造影检查示： 双肾显影良好, 无输尿管返流及梗阻, 新膀胱充盈良好, 容量约300 mL,15例患者均于术后4～6周内均恢复控尿能力, 无排尿困难及尿失禁症状。结论：腹腔镜下行膀胱全切除视野清楚, 有助于精确地处理盆底深部的重要结构, 术中出血少, 尿道括约肌损伤概率较小, 有助于减少术后肠粘连, 保护身体的免疫机制, 减少术后感染, 小切口取出标本, 体外构建贮尿囊, 吻合输尿管, 可缩减手术时间, 减少腹腔内污染。     

保留前列腺远端包膜及精囊对改善原位新膀胱功能及勃起功能的作用

背景与目的:膀胱全切是浸润性膀胱癌的主要治疗手段,膀胱全切后尿流改道方法很多,其中原位新膀胱下尿路重建在近年得到广泛应用.本研究旨在探讨改良根治性全膀胱切除术中保留前列腺远端包膜及精囊对改善原位新膀胱功能及勃起功能的作用.方法:选择2000年1月至2006年12月应用改良根治性膀胱全切及新回肠膀胱术治疗膀胱癌患者27例,同期应用经典术式治疗9例.观察两组患者术后并发症、新膀胱(术后6个月)的储尿、排尿、控尿功能及患者的勃起功能并进行比较.结果:术后随访3～84个月.术后6个月改良和经典组新膀胱容量[(385±68)mL vs.(388±71)mL]、最大充盈压[(24±16)cmH2O vs.(25±15)cmH2O],两组比较差异无统计学意义(P＞0.05).但在最大尿流率[(18±5)mL/s vs.(14±7)mL/s]、剩余尿[(35±16)mL vs.(97±35)mL]、完全控尿率[(24/27)vs.(3/9)]、夜间尿失禁[(3/27)vs.(6/9)]、新膀胱-尿道吻合口狭窄[(4/27)vs.(3/9)],以及患者正常勃起功能术后得以保留[(19/23)vs.(3/7)]方面,两组比较差异有统计学意义(P＜0.05).结论:在改良根治性膀胱全切术中保留远端的前列腺包膜及精囊,可明显改善患者术后的储尿、排尿、控尿功能,保护阴茎的勃起功能,同时可有效防止新膀胱-尿道吻合口狭窄的发生.     

膀胱移行细胞癌术后上尿路再发肿瘤(附7例报告)

膀胱移行细胞癌术后再发上尿路肿瘤临床上很少见 ,文献报道其发生率仅 1～ 2 %左右。现对我们 1978～ 1993年间因膀胱移行细胞癌手术后发生上尿路肿瘤的资料进行回顾性分析 ,探讨再发的有关因素和处理方法 ,以期有益于临床工作。临床资料自 1978年～ 1993年间我院收治了 2 83例无痛性肉眼血尿患者 ,血尿时间 1～ 2 6个月 (平均 7个月 ) ,年龄 2 2～ 78岁 (平均 52岁 ) ,经膀胱镜、Ｂ超及ＣＴ检查确诊为膀胱肿瘤 ,并且排除同时合并上尿路肿瘤。视肿瘤所在位置 ,浸润程度 ,单、多发性及全身状况选择膀胱癌黏膜下切除 ,膀胱部分切除或膀胱根治…     

甲状腺全切术后甲状旁腺功能减退的恢复时间分析(附13例)

目的:浅析甲状腺癌甲状腺全切术后甲状旁腺功能减退患者的恢复时长及其分布。方法:对我科2013年至2019年470例甲状腺癌甲状腺全切患者的病历资料进行了回顾,将其中有完整记录术前术后甲状旁腺激素(parathyroid hormone,PTH)水平的电子病历资料进行了随访分析。筛选出13例术后甲状旁腺功能先减低再恢复的病例。通过13例患者甲状旁腺激素从减低到恢复到正常低限的时长,分析甲状腺全切术后甲状旁腺功能恢复的时间分布。结果:术后发生甲状旁腺功能减退的患者在1月内恢复的占30.8%(4/13),2至3月内恢复的占30.8%(4/13),4至6月内恢复的占7.7%(1/13),超过6月恢复的占30.8%(4/13)。暂时性甲状旁腺功能减退的患者大部分于4月内甲状旁腺激素水平恢复正常,部分(30.8%)永久性(超过6个月)甲状旁腺功能减退的患者甲状旁腺激素水平可以恢复正常。结论:甲状腺全切术后暂时性甲状旁腺功能减退的患者,甲状旁腺激素水平恢复正常的时长主要分布在2至6月,即使超过6个月,通常被认为是永久性甲状旁腺功能减退的患者,仍有约1/3甲状旁腺功能恢复正常。并非所有永久性甲状旁腺功能减退的患者是真正的永久性甲状旁腺功能减退。     

汽化电切加黏膜下定期浸润注射吡柔比星预防膀胱癌复发(附56例报告)

目的探讨汽化电切膀胱肿瘤术后行肿瘤周围黏膜下定期浸润注射吡柔比星(THP)预防膀胱癌复发的效果。方法回顾分析56例膀胱肿瘤,经尿道汽化电切肿瘤术后行肿瘤周围黏膜下定期浸润注射THP患者的临床资料。结果56例中51例获随访,随访时间3~5年,平均3年10个月。术后1年复发率5.88%(3/51),2年复发率11.76%(6/51),3年复发率19.61%(8/51)。结论膀胱肿瘤汽化电切术后行黏膜下定期浸润注射THP,方法简单,预防膀胱癌术后复发安全有效。     

全胃切除缺8字空肠袢代胃术(附16例临床分析)

目的:分析全胃切除缺8字空肠袢代胃术的临床疗效.方法:对本院2002年5月至2005年12月间实施的16例全胃切除手术后行缺8字吻合重建消化道的病例作回顾性总结.结果:本组经腹行全胃切除术16例,全部采用缺8字吻合重建消化道,手术后均恢复良好,无手术死亡,肺部并发症1例,无吻合口瘘及返流性食管炎发生.结论:缺8字吻合操作方便,代胃的空间大,也有利于防止返流性食管炎,不失为一种较为理想的全胃切除术后消化道重建术式.     

Perioperative morbidity,bowel function and oncologic outcome after radical cystectomy and ileal orthotopic neobladder reconstruction: Studer-pouch versus I-pouch

Objective

To investigate whether the length of ileum used for ileal orthotopic neobladder (ONB) reconstruction (60 cm vs. 40 cm) after radical cystectomy (RC) for bladder cancer (BC) impacts on bowel function, postoperative complications or survival outcome.

An ileal neobladder for a female patient after a radical cystectomy to ensure voiding from the urethra: a case report.

An ileal neobladder construction realizing normal micturition was successfully performed after a total cystectomy, with preservation of the urethra, for a 69-year-old female patient with invasive bladder cancer. Approximately 60 cm of terminal ileum was selected, detubularized and re-sutured to create an oval-shaped intestinal pouch to which the bilateral ureters were anastomosed. The bottom of the pouch was anastomosed to the urethral remnant. Three months after surgery, the patient achieved daytime continence, and now enjoys almost the same lifestyle as before. This is the first case of successful neobladder construction to be precisely reported for a female patient. For normal micturition, the ileal neobladder will be one of the possible choices for urinary diversion in not only selected male, but also female, patients.     

Health related quality of life after radical cystectomy: Comparison of ileal conduit to continent orthotopic neobladder

Aims

To compare health related quality of life (HRQOL) between patients with two different types of urinary diversion, ileal conduit and orthotopic neobladder, and between them and an age-matched population of healthy subjects.

Materials and methods

Eighty eight patients treated with radical cystectomy for bladder cancer at our institutions between 2002 and 2007 were contacted for this survey. All of them had a follow-up of more than 12 months after surgery and were recurrence free. The SF-36 questionnaire was provided to each patient during a follow-up visit at outpatient clinics. Overall, 79 patients (90%) returned the questionnaire and were included in this analysis. They were divided into two groups: group 1 comprised 44 patients with an ileal conduit diversion, and group 2 included 35 patients with a neobladder. As a control, normative values of an age-matched healthy Italian population were considered.

Results

No significant difference was found in scale scores between the neobladder and ileal conduit groups. Scale scores for role-physical functioning, social functioning and role-emotional functioning in both the neobladder and ileal conduit groups were significantly below the Italian population norm. Patients with a neobladder 65 years old or older (n = 18) had significantly lower scores for role-physical functioning and role-emotional functioning than those younger than 65 years (n = 17; p < 0.05).

Conclusion

Few differences between ileal conduit and orthotopic bladder substitution have been detected. Thus, the assumption that continent reconstruction provides better HRQOL than ileal conduit diversion cannot be supported. Patient education and active participation in treatment decisions seem to be the key to postoperative satisfaction.     

Analysis of radical cystectomy and urinary diversion complications with the Clavien classification system in an Italian real life cohort

Introduction

Standardized methods of reporting complications after radical cystectomy (RC) and urinary diversions (UD) are necessary to evaluate the morbidity associated with this operation to evaluate the modified Clavien classification system (CCS) in grading perioperative complications of RC and UD in a real life cohort of patients with bladder cancer.

Materials and methods

A consecutive series of patients treated with RC and UD from April 2011 to March 2012 at 19 centers in Italy was evaluated. Complications were recorded according to the modified CCS. Results were presented as complication rates per grade. Univariate and binary logistic regression analysis were used for statistical analysis.

Results

Results and limitations: 467 patients were enrolled. Median age was 70 years (range 35–89). UD consisted in orthotopic neobladder in 112 patients, ileal conduit in 217 patients and cutaneous ureterostomy in 138 patients. 415 complications were observed in 302 patients and were classified as Clavien type I (109 patients) or II (220 patients); Clavien type IIIa (45 patients), IIIb (22 patients); IV (11 patients) and V (8 patients). Patients with cutaneous ureterostomy presented a lower rate (8%) of CCS type ≥IIIa (p = 0.03). A longer operative time was an independent risk factor of CCS ≥III (OR: 1.005; CI: 1.002–1.007 per minute; p = 0.0001).

Conclusions

In our study, RC is associated with a significant morbidity (65%) and a reduced mortality (1.7%) when compared to previous experiences. The modified CCS represents an easily applicable tool to classify the complications of RC and UD in a more objective and detailed way.     

Oncological outcome after radical cystectomy and orthotopic bladder substitution in women

Aim

The pathological outcome after radical cystectomy and orthotopic bladder substitution in women and the possibility of genital sparing are studied in a prospective way.

Methods

Between January 1995 and June 2003, 180 women with bladder cancer (mean age 50.6 years) underwent orthotopic neobladder reconstruction. Histopathologic assessment of the cystectomy specimens was performed. Involvement of the internal genitalia by primary or secondary cancer was evaluated by preoperative CT or MRI. Histopathological evaluation of these organs was made in the cystectomy specimens.

Results

Mean follow-up was 57 months. At follow-up, isolated urethral recurrence developed in two patients. Local pelvic recurrence developed in 30 patients, distant metastasis in 14 and both in nine. Uterine infiltration, which was suspected by preoperative CT, was confirmed by definitive histopathology after radical cystectomy in only two cases; otherwise there were no primary or secondary malignancies of the internal genitalia. Isolated recurrence of bladder cancer in the vaginal remnant during follow-up after cystectomy was not noted in any woman.

Conclusions

The rate of urethral recurrence and oncological failure after orthotopic bladder substitution in women is low and acceptable and thus justifies the continued performance of this type of diversion. Proper selection of cases is mandatory. In women with absence of malignant involvement of the internal genitalia on preoperative imaging, the risk of secondary malignant involvement of these organs in cystectomy specimens is very low. Therefore, preservation of the uninvolved gynecologic organs during radical cystectomy in premenopausal women with unifocal, organ-confined tumor above the bladder base, is justified.     

Outcomes of urinary diversion after surgery for locally advanced or locally recurrent rectal cancer with complete cystectomy; ileal and colon conduit

IntroductionSurgery for locally advanced rectal cancer (LARC) or locally recurrent rectal cancer (LRRC) may require total pelvic exenteration with the need for urinary diversion. The aim of this study was to describe outcomes for ileal and colon conduits after surgery for LARC and LRRC.MethodsAll consecutive patients from two tertiary referral centers who underwent total pelvic exenteration for LARC or LRRC between 2000 and 2018 with cystectomy and urinary reconstruction using an ileal or colon conduit were retrospectively analyzed. Short- (≤30 days) and long-term (>30 days) complications were described for an ileal and colon conduit.Results259 patients with LARC (n = 131) and LRRC (n = 128) were included, of whom 214 patients received an ileal conduit and 45 patients a colon conduit. Anastomotic leakage of the ileo-ileal anastomosis occurred in 9 patients (4%) after performing an ileal conduit. Ileal conduit was associated with a higher rate of postoperative ileus (21% vs 7%, p = 0.024), but a lower proportion of wound infections than a colon conduit (14% vs 31%, p = 0.006). The latter did not remain significant in multivariate analysis. No difference was observed in the rate of uretero-enteric anastomotic leakage, urological complications, mortality rates, major complications (Clavien-Dindo≥3), or hospital stay between both groups.ConclusionPerforming a colon conduit in patients undergoing total pelvic exenteration for LARC or LRRC avoids the risks of ileo-ileal anastomotic leakage and may reduce the risk of a post-operative ileus. Besides, there are no other differences in outcome for ileal and colon conduits.     

Patterns of complications following urinary tract reconstruction after multivisceral surgery in colorectal and anal cancer

Background

Multi-visceral resection, including parts of the urinary tract, is sometimes warranted to achieve cancer clear resection margins and optimize survival in patients with locally advanced colorectal and anal cancer. The aim of this study was to assess morbidity after urinary tract reconstruction dictated by colorectal and anal malignancy and to identify potential predictors of urological complications.

全逆行根治性膀胱切除治疗男性膀胱癌的临床应用及110例病例报告

背景与目的：膀胱癌根治手术难度大,围手术期并发症多,且学习曲线长。本研究介绍了全逆行根治性膀胱切除并腹腔重建这一新的系统手术方式,并探讨其临床价值。方法：2012年4月—2013年4月,共有110例男性膀胱癌患者于复旦大学附属肿瘤医院泌尿外科接受该手术治疗,中位年龄64(35~83)岁;整理术前临床资料,分析手术相关参数、并发症、病理特征、远期并发症及复发转移情况。结果：术中清扫淋巴结个数为12(8~16)个;65例保留双侧神经血管束,31例保留单侧;手术耗时4.4(2.2~6.0)h,中位腹腔脏器暴露时间为43.0(5.0~75.0)min,中位出血量140.0(50.0~600.0)mL,4例患者输血;中位盆腹腔引流时间为10.0(6.0~15.0)d,中位术后通气时间为2.5(1.0~12.0)d,中位术后住院时间为17.0(10.0~39.0)d;术后并发症CDC分级为2级即需要药物干预的19例,CDC分级为3级以上的8例;术后轻到中度肠道梗阻5例,对症支持治疗,中位时间2(1~4)周后恢复进食;无围手术期死亡病例。病理诊断结果显示,中位随访9(3~15)个月,无CDC分级3级以上并发症,无复发转移。结论：全逆行根治性膀胱切除手术入路解剖清晰,全程腹腔脏器暴露时间短,肠道与手术野相互干扰少,这一系统手术有效加快患者肠道恢复,降低术后并发症,特别是减少肠道梗阻的发生及严重程度的作用,值得进一步的研究和推广。     

An analysis of the relation between physical characteristics of prostate I-125 seed implants and lower urinary tract symptoms: Bladder hotspot dose and prostate size are significant predictors

PURPOSE: Lower urinary tract symptoms are frequently observed after I-125 seed implantation of the prostate. More knowledge about causes and predictors is necessary to be able to develop less toxic implantation techniques. The aim of this study was to identify implantation related factors that contribute to post-implant urinary morbidity. MATERIALS AND METHODS: Analysed was a group of 72 patients that filled in a symptom score questionnaire before, 3 months and 6 months after implantation as well as a group of 15 patients that suffered from acute urinary retention. Several dose-volume parameters of prostate, urethra and bladder wall were determined based on a post-implant TRUS-CT scan. RESULTS: The dose to a 1cm(3) hotspot in the bladder wall (D1cc-bl) as well as the prostate volume were independently correlated with urinary morbidity symptom scores at 3 months (p=0.006 and p=0.005, respectively) and at 6 months (p=0.001 and p=0.015, respectively) after implantation. The number of implanted seeds and the D1cc-bl were significant discriminators (p<0.001 and p=0.015, respectively) for either mild or severe early urinary morbidity. CONCLUSION: Bladder hotspot dose appears to be an important dosimetric predictor for urinary morbidity both at 3 months and at 6 months after implantation. Other predictors are prostate volume, or equivalently, the number of implanted seeds.