腹腔镜下膀胱全切除原位回肠代膀胱术的围术期处理

2005年5月～2007年11月,我科对12例膀胱癌患者行腹腔镜下膀胱全切除原位回肠代膀胱术,效果满意,现将同术期处理体会报告如下。     

膀胱全切原位回肠新膀胱与回肠膀胱术对患者生活质量影响的Meta分析

目的 通过系统评价比较原位回肠新膀胱(IONB)与回肠膀胱术(IC)对患者术后生活质量的影响。方法 检索中国生物医学文献数据库、中国知网、万方和维普中文科技期刊数据库、PubMed、Medline、Embase、The Cochrane Library从2005年1月至2018年4月,采用国际公认生命质量量表对IONB与IC患者进行术后生命质量比较的研究。结果 共纳入12篇对照研究,共1207例患者,涉及5种量表：特异性量表（FACT-BL、EORTC QLQ-C30、EORTC QLQBLM30、BCI）,通用性量表（SF-36）。Meta分析结果显示：IONB患者的总体生活质量优于IC,差异有统计学意义（SMD=0.27,95%CI：0.13～0.41,P=0.0002）。进一步比较膀胱癌特异性量表维度评分,FACT-BL量表：IONB躯体功能（P=0.0007）及功能状况（P=0.04）方面优于IC,情感状况、社会/家庭状况以及膀胱癌特异性模块方面的差异均无统计学意义;EORTC QLQBLM30量表：IONB与IC在未来期望,身体形象,腹胀三者的差异均无统计学意义;BCI量表：在泌尿功能的差异有统计学意义（P=0.0005）,IC优于IONB,二者在泌尿烦恼的差异无统计学意义。癌症特异性量表维度评分,EORTC QLQ-C30 量表：认知功能方面IONB优于IC（P=0.03）,在躯体功能、角色功能、情感功能、社会功能、总体生活质量四者的差异均无统计学意义。通用性量表SF-36：生理功能的差异有统计学意义（P=0.003）,IONB优于IC,但一般健康状况、躯体角色、情感角色、肌体疼痛、心理健康、精力状态、社会功能的差异均无统计学意义,IONB并不优于IC。结论 根据非随机对照证据,膀胱癌根治性全切行IONB较IC术后对患者生活质量的影响有一定优势。     

腹腔镜下膀胱全切除原位回肠代膀胱术病人的围手术期护理

目的:探讨腹腔镜下膀胱全切回肠代膀胱术围手术期的护理要点.方法:对2例膀胱肿瘤的患者行膀胱全切回肠代膀胱术,术前做好心理护理、术前准备、术后密切观察病情及生命体征变化,做好术后并发症的观察和护理,予以对症护理及出院指导.结果:2例膀胱全切回肠代膀胱术无一例并发症发生,患者病情稳定,均取得满意的治疗效果.结论:膀胱全切回肠代膀胱术是一种较理想的膀胱替代术式,充分术前准备,精心的术后护理以及恢复期代膀胱功能的训练,是确保手术成功的关键.     

原位回肠新膀胱的研究进展

与其他尿流改道方式相比,由于原位回肠新膀胱有越来越多的优势,更多的病例选择了原位回肠新膀胱手术方法。为了解在膀胱全切后施行原位回肠新膀胱手术后患者的效果和经验,我们回顾了当前的相关文献。长期的随访表明原位回肠新膀胱的术后效果优于其他尿液转流方式,同时,新膀胱具有与生理膀胱相类似的容量和功能。尽管该手术有一定的并发症和手术操作的复杂性,但仍然是一种安全和容易实施的手术。随着更多的技术上的改进,腹腔镜下膀胱全切和原位回肠新膀胱术有可能取代传统的手术方式。     

改良腹腔镜下全膀胱切除原位M形回肠代膀胱术

2004年9月及2005年3月分别对2例膀胱癌患者施行改良术：先在腹腔镜下切除膀胱、前列腺，再利用下腹壁小切口行原位M形回肠代膀胱术。本术式改良之处在于：采用气囊导尿管牵拉对合代膀胱开口与尿道断端；代膀胱底部开口周围行荷包缝合以加固其强度；安置代膀胱造瘘管。2例患者术后恢复良好，无严重并发症，术后恢复自主控尿。本改良术式具有操作相对简单，利于术后恢复及训练控尿能力等优点。     

腹腔镜与开放根治性膀胱全切-回肠原位新膀胱术的疗效对比

目的 比较开放及腹腔镜根治性膀胱全切-回肠原位新膀胱术的临床疗效。方法 回顾性分析我院自2010年9月至2014年3月行开放(ORC)及腹腔镜(LRC)根治性膀胱全切-回肠原位新膀胱术患者的资料,其中ORC组13例,LRC组21例。对两组患者的术前基本资料、围术期数据、术后并发症情况、术后控尿情况及肿瘤学随访数据进行对比分析。结果 LRC组较ORC组具有术中出血量少(P=0.013)、术后恢复进食时间短(P=0.001)、住院时间短(P=0.005)的特点。两组在术后并发症发生率方面无明显差异(P=0.725)。所有患者术后切缘均为阴性,两组患者在淋巴结清扫个数(P=0.393)以及淋巴结阳性率(P=0.562)方面无统计学差。中位随访时间28.5个月(8~47个月)。在术后1年内,LRC组与ORC组在日间控尿率(88.2%vs.84.6%,P=0.773)及夜间控尿率(70.6%vs.76.9%,P=0.697)无明显差异。在随访过程中,4例患者发生肿瘤复发或转移,其中盆腔复发2例,脑转移1例,肺转移1例。3例患者死亡。LRC组与ORC组在肿瘤特异性生存率及无复发生存率上无统计学差异(P均>0.05)。结论 与开放手术相比,腹腔镜根治性膀胱全切-回肠原位新膀胱术具有术中出血少、术后恢复快的特点,其术后控尿功能及肿瘤学结果与开放手术疗效相当,因此应作为首选手术方案。     

改良全膀胱切除-原位回肠新膀胱术治疗膀胱癌的临床疗效(附12例报告)

目的：评价改良全膀胱切除方法和原位回肠新膀胱术的临床疗效。方法：对12例膀胱癌患者行改良全膀胱切除术．顺行分离膀胱顶部、侧壁上半部、底部,切断输尿管后改逆行分离。示指紧贴前列腺包膜将前列腺与直肠分开后,向上向外将膀胱颈部侧韧带和精囊尾的纤维束钩于示指掌握之中,切断并结扎。女性患者保留内生殖器及尿道内口。尿流改道采用原位回肠新膀胱术,并就手术并发症、术后控尿排尿情况、新膀胱容量、影像学和生化检查进行随访,随访时间8～62个月,平均35个月。结果：切除膀胱时间平均80min,术中平均出血450ml。原位回肠新膀胱控尿、排尿良好,术后静脉尿路造影、B超检查未见上尿路扩张,膀胱造影未发现输尿管反流,血生化检查正常,未发现新膀胱或尿道肿瘤复发。结论：改良膀胱切除术-原位回肠新膀胱术是治疗浸润性膀胱癌的理想方法。     

经阴道联合腹腔镜下根治性女性全膀胱切除原位回肠新膀胱术

目的 探讨经阴道联合腹腔镜下根治性女性全膀胱切除及原位回肠新膀胱的手术方法.方法浸润性膀胱癌患者6例,平均年龄61(55～73)岁.5孔法先行腹腔镜下手术:游离输尿管后分侧清扫盆腔淋巴结;举宫器配合下,用血管闭合器LigaSure切断子宫相关韧带及膀胱两侧血管蒂;电凝钩分离子宫直肠陷窝及膀胱前间隙;LigaSure切断阴蒂背血管复合体;超声刀切开膀胱颈尿道后游离膀胱颈后壁至阴道前穹窿部.阴道手术:直视下剪开阴道前后穹窿,于阴道取出标本,缝合阴道.回肠新膀胱术:下腹正中4～5 cnl切口,将回肠拉出切口外,游离30～40 cm回肠,剖开后w形折叠缝合形成贮尿囊;插入法植入输尿管后将贮尿囊还纳腹腔.缝合切口后重新开启气腹,腔镜下行新膀胱尿道吻合. 结果 手术时间平均6.2(4～8)h;出血量平均665(400～1200)ml.术后1～3个月患者均恢复较满意的控尿功能,IVU显示双肾功能良好,无膀胱输尿管反流及梗阻.新膀胱最大容量平均427(300～600)ml.无新膀胱阴道瘘等需要手术处理的严重并发症.术后平均随访16(9～30)个月,6例均存活.1例术后8个月发现肝转移. 结论 经阴道联合腹腔镜下根治性女性全膀胱切除回肠新膀胱术治疗女性浸润性膀胱癌可行、有效,应用举宫器及经阴道直视下手术可一定程度上降低腹腔镜下全膀胱切除术的手术难度、缩短手术时间.由于阴道切口整齐、缝合确切,新膀胱阴道瘘等并发症的发生机会减少.     

原位新膀胱术与回肠膀胱术临床效果比较

目的：比较膀胱肿瘤患者膀胱全切术后行原位新膀胱术与回肠膀胱术的临床治疗效果及术后早期并发症。方法：选择我院2000-2009年行根治性膀胱切除术治疗膀胱尿路上皮细胞癌65例患者的临床资料,其中行原位新膀胱术31例,回肠膀胱术34例。比较两组一般情况、围手术期情况（术中失血量、手术时间、肠功能恢复时间、住院天数）以及术后早期并发症等指标。结果：两种术式在术中失血量（1140．32±492．82ml vs 920．91±410．48ml）、手术时间（464．81±79．37min vs 413．32±99．54min）、住院天数（47．68±7．53天vs41．09±8．12天）等方面差异有统计学意义（P〈0．05）。结论：原位新膀胱术较回肠膀胱术虽手术步骤复杂,术中出血较多,但因手术安全,可自主性控制排尿,明显提高患者的生活质量而易于接受,是值得推荐的膀胱替代手术方式,在根治性膀胱切除术中值得优先采用。     

拖靠吻合法在腹腔镜根治性全膀胱切除回肠原位新膀胱术中的应用

目的 探讨拖靠吻合法在腹腔镜下根治性全膀胱切除加原位新膀胱术中新膀胱与尿道吻合中的应用。方法 2016年1月至2019年6月,我们对南昌大学第二附属医院22例浸润性膀胱癌患者行腹腔镜根治性膀胱全切加原位新膀胱术,采用拖靠吻合法行新膀胱与尿道的吻合。结果 20例男性患者均在腹腔镜下完成根治性全膀胱切除术,缝合时间为10～18 min,平均15 min。术后第4天拔除引流管,因1例术后出现尿瘘,第7天停止并拔除引流管。常规术后2周拔除导尿管,20例患者均无尿潴留情况发生,无排尿困难。9例出现尿失禁,3例1周内恢复,4例4周恢复,2例8周恢复。8周后在膀胱镜下拔除双J管,见储尿囊尿道吻合处宽敞、光滑平坦,无狭窄。12周后行尿道造影提示吻合口处宽畅、平坦,无尿瘘;超声测残余尿均<15 ml,最大尿流率平均为19.3 ml/s。术后随访3～24个月,平均16个月。所有患者12周后都恢复尿控,控尿情况均较理想;未出现尿道狭窄,吻合口无肿瘤复发。结论 尿道拖靠吻合法操作简便,可有效缩短新膀胱与尿道的吻合时间,学习曲线短,疗效确切,具有较高的临床应用价值。     

腹腔镜下根治性膀胱切除Studer回肠新膀胱术

目的 介绍腹腔镜下根治性膀胱切除Studer回肠新膀胱术的方法.方法 膀胱癌患者8例.均为男性,年龄51～69岁,平均57岁.浸润性膀胱癌7例,腺癌1例.临床分期:T27例,T21例.经腹取5个穿刺点,腹腔镜下清扫双侧闭孔、髂内及髂外淋巴结;游离膀胱腹侧,剪开双侧盆筋膜,缝扎阴茎背静脉复合体;游离输精管和精囊,剪开狄氏筋膜,分离前列腺与直肠间隙;分离前列腺尖部尿道,切断尿道,将切下的膀胱和前列腺装入标本袋.下腹正中切口6～8 cm,取出标本,于该切口外距回盲部20 cm处截取45 cm回肠.取远端40 cm段对折,纵行切开对系膜缘肠壁,交叉折叠缝制新膀胱,将双侧输尿管吻合于新膀胱近端未剖开的5 cm肠管上.新膀胱颈部与保留尿道断端间断缝合.结果 8例手术顺利,手术时间 6～8 h,平均7.2 h;出血量200～800 ml,平均420 ml;无中转开放手术者.术后病理分期pT2 6例、pT31例、pT2N2M01例,切缘均为阴性.术后发生右侧输尿管套叠1例,经输尿管镜下还纳松解.8例随访3～12个月,生活质量良好.结论 腹腔镜下根治性膀胱切除术切11小、出血少,技术可行,Stueder原位膀胱技术简单、输入袢长、术后功能好.     

Local recurrence in patients after radical cystectomy and orthotopic ileal neobladder: impact on function

Whether an orthotopic bladder substitute should be constructed in patients with locally advanced or lymph node positive bladder cancer remains a subject of debate. These patients are at risk that local recurrence may impair reservoir function in orthotopic neobladders. We retrospectively assessed reservoir function in 68 consecutive patients with locally advanced bladder cancer. Tumor stage was multifocal carcinoma in situ, multifocal pT1 disease, pT2, pT3a, pT3b, and pT4a in 3, 4, 19, 11, 25, and 6 patients respectively. Lymph nodes were positive for carcinoma in 17 patients. Out of the 68 patients, 65 could be followed for at least three months. Within a median follow-up of 26 months (range three to 87 months), recurrence developed in 16 of the 65 patients (25%). 7 patients (11%) had distant failure. 9 patients (14%) showed local and distant recurrence. In the six out of the nine patients with local recurrence located lateral, dorsal, or cranial of the neobladder, adequate neobladder function was retained until the last follow-up visit or until death. Only those three patients with local recurrence involving the pelvic floor or urethra needed a suprapubic catheter due to urinary retention caused by tumor obstruction. Excluding pelvic floor and anterior urethral disease, we recommend orthotopic bladder substitution even in locally advanced but resectable disease as far as the patient is in a good performance status.     

腹腔镜下膀胱全切除、原位回肠新膀胱的尿流动力学分析

目的 探讨腹腔镜膀胱全切除、原位回肠新膀胱的临床效果。方法 对8例行腹腔镜膀胱全切除、原位回肠新膀胱患者进行排尿情况的记录和尿动力学检查。结果 8例患者均可自主控制排尿（1例夜间轻微尿失禁）,在新膀胱充盈过程中均可出现胀痛感觉,膀胱平均容量377．5ml,压力17．9cmH2O,最大尿流率18．1ml／s,最大尿道闭合压68．5cnH2O,功能性尿道长度3．7cm。结论 腹腔镜根治性全膀胱切除、原位回肠新膀胱术较传统的开放手术创伤更小,但贮尿囊一样具有容积较大、内压较低和可控性较好的优点,排尿良好,值得临床推广。     

Supra-ampullar cystectomy and ileal neobladder

OBJECTIVE: This article describes both the open and laparoscopic operative techniques of supra-ampullar cystectomy (SAC). METHODS: Both open (photographs and drawings) and laparoscopic (attached DVD) SAC are explained step by step. RESULTS: Between May 1984 and December 2005, 31 patients with bladder tumour underwent SAC with ileal orthotopic neobladder (2 Camey I, 26 Camey II, and 3 Y). Three patients underwent laparoscopy. Preoperatively, 26 patients had superficial high-risk transitional cell carcinoma (TCC). Median follow-up was 95.0 mo (range: 5-260 mo). The 10-yr cause-specific survival rate was 76.7%. Two patients had local recurrence. Potency was preserved in 28 patients (90.3%); 15 patients (48.3%) also maintained antegrade ejaculation, allowing procreation in 3 cases. In one patient the Camey I neobladder was converted into an ileal conduit (high postvoid residual, recurrent pyelonephritis). None of the remaining patients had daytime incontinence, eight had nightime urinary incontinence, and six performed intermittent self-catheterisation. CONCLUSION: SAC with detubularised ileal orthotopic neobladder allows preservation of sexual function and maintenance of urinary continence in most patients, without compromising oncologic outcome. The key element is the very strict and careful preoperative selection of the patients.     

Laparoscopic radical cystectomy with orthotopic ileal neobladder: a report of 85 cases

PURPOSE: The preliminary results of laparoscopic radical cystectomy in 85 patients are presented in this study. The functional and oncologic outcomes of this procedure in these patients are discussed. PATIENTS AND METHODS: Between December 2002 and May 2006, we performed 85 laparoscopic radical cystectomies with orthotopic ileal neobladder for bladder cancer in 77 men and 8 women. A 5-port transperitoneal approach was applied. The standard bilateral pelvic lymphadenectomy was performed first, then radical cystectomy was completed laparoscopically. The construction of the ileal neobladder and the anastomosis of ureter-neobladder were performed extracorporeally. The neobladder was anastomosed to the urethral stump under laparoscopy. A nerve-sparing procedure was performed for eight patients. RESULTS: The median operative time was 320 min, and the median blood loss was 280 mL. Conversion to open surgery was not necessary in any of the patients. The average time to oral intake after operation was 3.9 days. There were no perioperative mortalities. The complication rate was 14.1% (12/85), including such complications as three uretero-pouch anastomotic strictures, one vesicourethral anastomotic stricture, one pouch-vaginal fistula, one colonic pouch fistula, one ileo-pouch fistula, three ileus, one pneumonia, and one pyelonephritis. The daytime continence rate was 91.2%, and the nighttime continence rate was 82.4% at 6 months postoperatively. The neobladder capacity was about 343 mL. Surgical margins were tumor free for all patients. Of the eight patients who underwent a nerve-sparing procedure, four patients had potency for intercourse. During a follow-up period of 1 to 41 months (average 21.3 months), three patients had local recurrence, one patient had trocar site seeding, and five patients had distant metastasis, of whom four died. CONCLUSIONS: Laparoscopic radical cystectomy with extracorporeal formation of a neobladder is a feasible procedure with low morbidity and acceptable neobladder function. Long-term follow-up is needed to confirm the oncologic outcomes.     

腹腔镜下腹膜外膀胱根治和原位新膀胱术的初步体会

目的 评估腹腔镜腹膜外全膀胱切除和原位新膀胱术的安全性及疗效。方法 回顾性分析安徽医科大学第二附属医院2021年3月至2022年2月行腹腔镜腹膜外全膀胱切除和原位新膀胱术的8例膀胱癌患者,收集患者的基本资料、手术相关数据及术后随访相关情况。结果 所有患者均顺利完成手术,年龄为[65(40～78)]岁,BMI为[23.85(19.59～29.07)]kg/m2,手术时间为[280.5(235.0～366.0)]min,术中出血量为[100(50～200)]ml,通气时间为[3(2～4)]d,术后住院时间为[11.5(10.0～20.0)]d,淋巴结清扫数目为[13.5(8.0～29.0)]枚。术后分别有一例患者出现切口愈合不良和漏尿。6例患者进行了术前新辅助治疗,其中2例患者术后病理为T0期。中位随访时间为11个月,其中1例出现骨转移,1例出现泌尿道感染,1例出现肾积水。结论 腹腔镜下腹膜外全膀胱切除及原位新膀胱术是安全可行的,因其极大程度地保留了腹膜的完整性及避免长时间经腹腔操作对肠道造成干扰,有利于减少肠道并发症,缩短住院时间,值得临床推广。     

正位回肠膀胱重建术(附26例报告)

目的：探讨膀胱全切术后理想的膀胱替代术式。方法：采用回场折叠成“W”形成或“U”形贮尿囊与尿道吻合，尿液经原尿道排出的正位回肠膀胱重建术治疗膀胱全切术患者26例。结果：围术期无一例死亡，随访0.5-2.5年，膀胱容量220－460ml，平均380ml；膀胱充盈压1.27-4.41kPa(平均2．94kPa)，最大尿流率12－20ml/s(平均18ml/s)，新膀胱排尿功能良好；3例出现上尿路积水，间断自我导尿后好转，血电解质显示7例患者血甭Cl^-偏高，介无酸中毒发生，血清肌酐，尿素氮均在正常范围。结论：正位回肠膀胱重建术是较理想的膀胱替代术式。