回肠原位新膀胱术在70岁以上男性肌层浸润性膀胱尿路上皮癌患者中的应用

背景与目的:原位新膀胱术是肌层浸润性膀胱尿路上皮癌患者行根治性膀胱切除术后生活质量较好的尿路重建术式.但是新膀胱术式较复杂、手术时间较长,70岁以上男性患者的手术承受力和控尿能力的恢复程度值得研究.本研究旨在探讨70岁以上男性肌层浸润性膀胱尿路上皮癌患者应用回肠原位新膀胱术的安全性和控尿能力的有效性.方法:自2006年1月1日-2010年2月20日间,本研究对23例70岁以上男性肌层浸润性膀胱尿路上皮癌患者实施根治性膀胱切除术,术中采取了保护神经血管束、不剪开盆底筋膜、不切断耻骨前列腺韧带、不缝扎阴茎背深静脉丛的方法,以Hautmann技术建立回肠原位新膀胱.结果:23例患者均安全度过手术期,其中3例患者术后出现暂时认知功能障碍,1例患者于术后24 d出现胃肠功能紊乱.23例患者术后16～21 d白天完全自主控尿;术后30、60、90、180和360 d睡眠后完全控尿例数分别为0、4、5、11及16例;均无排尿困难,23例患者均对控尿程度满意.结论:70岁以上男性肌层浸润性膀胱尿路上皮癌患者应用回肠原位新膀胱术安全,控尿效果满意,可作为根治性膀胱切除术后首选的尿路重建术式.     

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…     

腹腔镜根治性膀胱切除+原位回肠新膀胱术治疗浸润性膀胱癌的临床疗效分析

目的:探讨腹腔镜根治性膀胱切除+原位回肠新膀胱术治疗浸润性膀胱癌的临床疗效.方法:回顾性分析2010年2月至2015年11月于蚌埠医学院第一附属医院行腹腔镜根治性膀胱切除+原位回肠新膀胱术的32例浸润性膀胱癌患者的临床资料,对手术方法(腹腔镜根治性膀胱切除+原位回肠新膀胱术)、围手术期资料、新膀胱功能、术后并发症以及肿瘤控制情况等进行分析.结果:成功随访32例,随访时间12 ～ 53个月,平均随访27个月,均为男性;所有患者手术均由同一术者顺利完成,手术时间310 ～530 min,平均370 min;术中出血300～ 850 ml,平均485 ml;术后3～5天肠道开始恢复功能;淋巴结清扫数目8～31个,平均16个;手术切缘均无阳性结果;术后12个月与6个月相比较,最大尿流率(15.2±1.3vs11.4±1.2 ml,P＜0.01)、最大膀胱容量(372.8±52.2 vs 247.9±60.3 ml,P＜0.01)、残余尿量(23.8 ±9.6 vs 39.6±11.7 ml,P＜0.01)、最大膀胱充盈压(33.7 ±5.7 vs 25.1±6.8 cmH2O,P＜O.01)、最大膀胱排尿压(63.7±15.9 vs62.9±17.6 cmH2O,P＞0.05)、膀胱顺应性(26.2±12.6 vs 25.7±13.3 cmH2O,P＞0.05)以及昼/夜控尿率(91％/81％ vs 84％/72％).术后近期并发症发生率为18.8％(6/32),远期并发症发生率为25.0％(8/32);随访期间,肿瘤局部复发率和远处转移率分别为6.3％ (2/32)和12.5％(4/32).结论:腹腔镜根治性膀胱切除+原位回肠新膀胱术是安全可行的,具有术后控尿效果好、满意的新膀胱功能和肿瘤控制效果等优点,是治疗浸润性膀胱癌的优先选择.     

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.     

膀胱全切后改良肠道原位新膀胱下尿路功能性重建(附15例疗效分析)

背景与目的：膀胱全切后患者的生活质量受尿流改道方式影响,可控性或非可控性尿流改道后患者不能自主排尿、生活质量差;而肠道原位新膀胱术后患者可自主排尿,生活质量改善,但有排空不良和控尿不全等问题。本文报告改良肠道原位新膀胱术在膀胱全切后下尿路功能性重建中的经验。方法：对15例局部浸润性膀胱癌患者在根治性膀胱切除后利用改良肠道原位新膀胱术（回肠新膀胱3例,乙状结肠新膀胱12例）做下尿路功能性重建。术后随访3-30个月（其中9例随访超过16个月）,对这些患者术后新膀胱功能、控尿和排尿功能、性功能、上尿路形态和功能、血电解质和生活质量进行评价。结果：全部患者自主排尿,无需导尿。13例患者昼夜完全控尿;1例患者白天控尿良好,夜间有少量漏尿;另1例女性患者有中度张力性尿失禁。膀胱容量240-640ml,残余尿量0-250ml。全部患者总肾功能正常,14例血电解质正常;慢性代谢性酸中毒和输尿管扩张各1例。9例男性患者保留性功能。13例患者恢复工作。全部患者对新膀胱功能满意。结论：改良肠道原位新膀胱术后下尿路的控尿和排尿功能良好,是目前根治性膀胱切除后理想的下尿路重建方法。     

阑尾输出道盲升结肠可控膀胱术(附9例报告)

目的　改进膀胱癌患者膀胱全切后贮尿囊及排尿情况。方法　根治性全膀胱切除加阑尾输出道盲升结肠带切断或去管简单重建贮尿囊可控膀胱术。结果　术后随访 2～ 19个月 ,两种术式建立的贮尿囊顺应性均良好 ,平均容积为 3 0 2ml ,内压为 8cmH2 O ,阑尾输出道最大压力为 71cmH2 O ,平均 62cmH2 O ,尿控良好 ,自行导尿容易。结论　阑尾输出道盲升结肠可控膀胱术 ,操作相对简单 ,是一种较理想的尿路改道方法 ,具有较好的临床应用价值。     

217例膀胱移行细胞癌外科治疗的临床分析

背景与目的：膀胱移行细胞癌（transitional cell carcinoma,TCC）是泌尿系统常见肿瘤,手术切除是其主要治疗手段。本研究旨在探讨TCC的外科治疗方法及其临床效果。方法：对217例采用不同术式治疗的TCC术后无瘤生存、复发和死亡患者的临床资料进行回顾性分析和总结。结果：随访时间平均30个月．全组患者无瘤生存195例,复发56例次;死亡14例,其中非肿瘤死亡1例,肿瘤死亡13例。T1期或Ⅰ级肿瘤患者无死亡。全组患者2年总生存率为89．6％。患者生存率及无瘤生存率与肿瘤分期、分级呈负相关。T1期和T4期肿瘤患者预后与术式无关。对T2期和T3期肿瘤,根治性膀胱切除者的预后比保留膀胱者的预后好,两者比较具有显著性差异,P〈0．01。结论：对分期早、高分化的TCC患者采用保留膀胱的治疗措施是安全的;分期晚、低分化的浸润性TCC患者应及时行根治性膀胱切除。     

72例膀胱移行细胞癌中Fas和FaslL的表达

目的：探讨细胞凋亡基因Ｆａｓ和ＦａｓＬ在膀胱癌保作用及与肿瘤生物学行为和预后之间关系。方法：应用免疫组化方法检测１６例正常膀胱粘膜和７２例膀胱移行细胞癌标本中Ｆａｓ和ＦａｓＬ表达。结果：膀胱癌中Ｆａｓ和ＦａｓＬ表达均显著低于正常膀胱粘 中表达；Ｆａｓ表达与肿瘤分级、分期和复发之间均密切相关，但ＦａｓＬ表达与三者之间均无相关性。结论：Ｆａｓ和ＦａｓＬ系统异常可能是膀胱癌发生发展过程中免疫逃避的重要因     

腹腔镜根治性膀胱切除+回肠原位新膀胱术疗效分析

目的:回顾分析腹腔镜下全膀胱切除+回肠原位新膀胱术的临床疗效与经验.方法:随访了2006年1月-2012年2月采用腹腔镜下根治性膀胱切除术+回肠原位新膀胱术治疗的87例患者,手术方法为腹腔镜下膀胱全切术+开放新膀胱构建及吻合,并对随访3年的临床数据进行总结分析.结果:大多数患者恢复良好,所有的新膀胱漏尿并发症均被有效处理;仅有1例患者因肠瘘行肠造口,3个月后行肠回纳;术后3年整体生存率为88.5％(77/87),无瘤生存率为92.2％ (71/77);整体控尿功能及肾功能保护方面取得良好效果.结论:腹腔镜下根治性膀胱全切+回肠原位新膀胱术,具有良好的控尿功能和较好的保肾功能,可以明显提高患者生活质量.     

膀胱小细胞癌3 例报告

 原发性膀胱小细胞癌临床罕见，至今国内外文献只报道200余例，本院1980～2004年共收治3例，现结合文献报告如下。     

Survival after cystectomy for invasive bladder cancer

Aim

To determine the difference in survival after cystectomy between patients presenting with primary muscle infiltrating bladder cancer and patients with progression to muscle infiltration after treatment for initial non-muscle-invasive bladder cancer (NMIBC).

Patients and Methods

We retrospectively analyzed the files of 188 patients who underwent cystectomy for transitional cell carcinoma between 1987 and 2005. Two groups were defined: patients presenting with muscle-invasive tumours and those progressing to muscle invasion after initial treatment. This second group was further divided into low-intermediate and high risk according to the EAU grouping for NMIBC.

Results

The 5-year disease specific survival (95% confidence intervals) for all patients was 50%(42–59%); 49%(40–60%) in the primary muscle infiltrating group and 52%(37–74%) in the progressive group (p = ns). The 5-year disease specific survival in the progressive group according to EAU risk groups was 75%(58–97%) for the initially diagnosed low-intermediate risk tumours and 35%(17–71%) for the initially diagnosed high-risk tumours (p = 0.015). The percentage of patients with non-locally confined tumours (pT3/4-N0//any pT-N+) was 31%//45% and 24%//46% in the primary muscle infiltrating and progressive group, respectively.

Conclusions

Despite close observation of patients treated for non-muscle-invasive bladder cancer, the survival of patients who progress to muscle invasion is not better than survival of patients presenting with primary muscle infiltrating cancer. Patients with high-risk non-invasive tumours (EAU risk-categories) who progress to muscle-invasive disease have a worse prognosis compared to patients with low or intermediate risk tumours.     

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.     

Recurrence risk factors in patients with transitional cell carcinoma of bladder

Objective： To study recurrence factors and set up a model to evaluate the prognosis of patients with bladder cancer. Methods： An analysis on recurrence-related factors was made by Cox＇s proportional hazards model analysis and logistic multiple linear regression model analysis in 212 patients with transitional cell carcinoma treated surgically from 1995-2001. These factors included clinical and pathologic figures. Results： The most important factor is metastasis to the regional lymph nodes, the Hazards ratio is 6.6 （P=0.0004）, followed by multiple tumors （Hr=2.255, P〈0.0001）, tumor in trigone and bladder neck （Hr=2.053, P〈0.0001）, stage （Hr=2.057, P〈0.0001）, grade （Hr=1.569, P=0.0081）, intravesical chemotherapeutic instillations （Hr-0.559, P=0.0011） and hematuria （Hr=0.762, P=0.0076）. A predicting equation was established, and the predicting values were calculated according to the individual features of patients. The predicting and actual values were compared, and the sensitivity, specificity and overall concordance were 83.5%, 67.6% and 80.1% respectively. Conelusion：The evaluation of prognosis could be made quite accurately based on these factors.     

野生型PTEN基因高表达对膀胱移行细胞癌EJ细胞的抑癌作用

目的 探讨外源性野生型人酪氨酸磷酸酶（PTEN）基因的高表达对膀胱移行细胞癌EJ细胞的抑癌作用。方法 利用携带人PTEN基因的野生型、磷酸酶域突变型质粒体外分别转染人膀胱移行细胞癌EJ细胞。Western blot检测目的基因PTEN的表达,观察细胞形态变化及超微结构变化;MTIO法检测细胞增殖率及转染细胞对吡柔比星（THP）和丝裂霉素（MMC）的敏感性;Western blot法检测bcl-2蛋白的表达。以空载质粒作为对照。结果 质粒转染后,EJ细胞的PTEN蛋白表达上升75．0％。转染野生型质粒后,EJ细胞异型性低,出现典型凋亡小体,细胞增殖率下降40．1％,bcl-2蛋白表达被下调,并提高了对THP和MMC的敏感性。而转染突变型质粒的EJ细胞则无此作用。结论 野生型PTEN基因在体外对膀胱移行细胞癌EJ细胞增殖有明显抑制作用,诱导细胞凋亡,磷酸酶域突变型PTEN基因无此作用。野生型PTEN的抑癌作用可能与其对bcl-2蛋白表达的下调有关。     

保留部分前列腺的全膀胱切除术治疗浸润性膀胱癌

背景与目的：经典的根治性膀胱切除术将膀胱和前列腺全部切除,术后阳痿和尿失禁发生率高。在肿瘤没有累及前列腺的情况下,根治术中保留部分前列腺可改善术后性功能和控尿功能,但对预后是否有影响尚不清楚。本文报告10例保留部分前列腺的改良全膀胱切除术的经验,阐述改良术式对术后性功能、控尿功能和肿瘤控制的影响。方法：对10例男性浸润性膀胱癌患者,先经尿道电切除部分前列腺,全膀胱切除时保留部分前列腺包囊。下尿路重建采用肠道新膀胱术,新膀胱与残留的前列腺包囊吻合。术后随访评价肿瘤控制、尿液控制和性功能情况。结果：术后病理分期均为T2NOM0。随访3～12个月(平均9个月),9例无瘤生存,l例低分化移行细胞癌患者术后2个月出现全身骨骼及淋巴转移;全部患者自主排尿,完全控尿9例,部分控尿l例;术前有性功能的8例中,术后6例保持阴茎勃起功能。结论：保留部分前列腺的改良全膀胱切除术可以较好保留下尿路控尿功能和阴茎勃起功能,但对肿瘤控制的远期影响有待进一步观察。     

Conservation of bladder function in patients with invasive bladder cancer treated by definitive irradiation and selective cystectomy

Four hundred seventy patients with invasive bladder cancer treated by definitive irradiation (5000 rad or more) and selective cystectomy were followed to assess their survival status and bladder function status. (90 % were followed for at least 10 years or to death.) The survival rates for these patients were similar to those obtained in studies of preoperative irradiation with compulsory cystectomy: 5 and 10 year survival rates were 38 and 22% respectively. Sixty-five to 70% of these survivors lived with healthy, functioning bladders to at least 10 years after treatment. Seventy-five patients had a selective cystectomy, usually for recurrent disease, with an operative mortality rate of 11 %. Pre-irradiation catheterization, used to control bladder distension and to reduce the possibility of geographic miss in irradiating the tumour, had no effect on the control of local disease or on the long-term survival of patients. Therefore, definitive irradiation with selective cystectomy warrants serious consideration in treating patients with invasive bladder cancer, especially considering the quality of life and the high proportion of patients who retain functioning bladders.     

Metastasis to the ovaries from transitional cell carcinoma of the bladder and renal pelvis: a report of two cases

Ovarian metastases from a primary urinary tract carcinoma are extremely rare. This can be difficult to distinguish from transitional cell carcinomas (TCC) of ovarian origin because of histologic similarity. A 65-year-old woman who was diagnosed with renal pelvis TCC 4 months prior was referred for evaluation of a left ovarian mass. A 47-year-old woman who underwent radical cystectomy due to bladder TCC 1 year ago was referred because of a right ovarian mass. Both patients underwent a bilateral salpingo-oophorectomy. The tumor cells had morphology identical to those of the primary urinary tract tumors. Gynecologic oncologists should consider metastatic TCC of the ovary from urinary tract origin, as well as breast, and gastrointestinal tract origins.     

SMALL CELL CARCINOMA OF THE URINARY BLADDER：THREE CASES REPORT

Objective: To study the clinical features of patients with primary small cell carcinoma (SCC) of the bladder and to improve the diagnosis and treatment. Methods:Clinical data of 3 cases with primary SCC of the bladder were discussed and the pathology, diagnosis, treatment and prognosis were reviewed. Results: 3 cases of primary SCC of the bladder were presented. Of them the diagnosis was confirmed by pathological examination after operation (2 cases) and biopsy (1 case). One case with stage T4M1 died after three months‘ chemotherapy. One case with stage T2M0 underwent partial cystectomy and was treated with chemotherapy and one year later died of miocardial infarction. Another case with stage T4M0 underwent radical cystectomy and postoperative irradiation therapy. The patient was alive and had no recurrence of symptoms during two years follow-up. Conclusion: Primary SCC of the urinary bladder is highly malignant. Radical cystectomy combined with radiotherapy appears to be the efficient treatment. Chemotherapy seems to be of no significant effect.     

Gender and cystectomy for bladder cancer: A high-volume tertiary urologic care center experience

BackgroundDifferences have often been reported in the outcomes of bladder cancer (BC) patients according to gender.ObjectiveThis study aims to provide data on patients undergoing radical cystectomy (RC) in a high-volume tertiary urologic center and to assess whether gender discrepancies do exist in terms of surgical options and clinical outcomes.Materials and methodsConsecutive BC patients treated between 2016 and 2020 at a single center (Careggi University Hospital, Florence, Italy) were included in the study. The impact of gender on disease stage at diagnosis, overall survival (OS), and type of surgery was analyzed.ResultsThe study series comprised 447 patients (85 females and 362 males). At a median follow-up of 28.3 months (IQR: 33.5), OS was 52.6% and cancer-specific survival was 67.6%. Significant differences in OS emerged for age, acute myocardial infarction (AMI), Charlson Comorbidity Index (CCI), pT, and pN. OS rates were higher in patients undergoing robot-assisted surgery and in those receiving open orthotopic neobladder (ONB) (p = 0.0001). No statistically significant differences were found between male and female patients regarding surgical offer in any age group, surgical time, early postoperative complications, pathologic stage, and OS.ConclusionsAfter adjustment for pathologic tumor stage and treatment modalities, female and male patients showed similar oncologic outcomes. Further studies should be undertaken to evaluate functional results in women subjected to RC.