肠代膀胱术中回肠反套入抗输尿管返流方法的临床研究

目的 评价肠代膀胱术中回肠反套入的抗输尿管返流作用。方法 患者5例，男4例，女1例。年龄48～67岁，平均61岁。均为浸润性移行细胞癌，行膀胱全切、回肠正位膀胱术。距回盲部屈氏韧带15cm处切取回肠30cm，近端回肠反套入4cm，回肠段远端肠管对系膜缘纵形剖开，U形缝合；套入肠管与对应肠片均切除1cm宽之黏膜，相应浆肌层可吸收线固定4针，对应黏膜缘缝合，防止套入肠管滑脱；双侧输尿管远端剖开6cm，侧侧吻合后经套入肠管引入，吻合口与套入肠管口间断缝合；U形肠管对折成储尿囊，与尿道吻合。术后定期行血生化、双肾B超、排泄性膀胱造影和尿动力学检查。结果 5例患者随访10～33个月。排尿次数白天3～5次，夜间0～3次；日间控尿100％，夜间控尿80％；尿动力学检查：最大尿流率9．5～31．5ml／s，膀胱容量350～710ml，平均433ml；剩余尿50～305ml；最大膀胱排尿压23～52cmH2O；膀胱出口无梗阻。B超检查双肾无积水。膀胱造影未见输尿管返流。结论 回肠正位膀胱术中回肠反套入方法有良好的抗输尿管返流作用。     

输尿管回肠吻合术在可控性尿流改道中的应用

目的 评价输尿管回肠吻合术在可控性尿流改道术后抗返流及防止上尿路感染中的效果。方法 根治性膀胱切除术后行去带盲升结肠可控膀胱术和新膀胱术的患者10例，采用带回盲瓣的回肠段作为可控性膀胱的输入襻，双侧输尿管黏膜下隧道法与回肠吻合，随访观察患者术后输尿管返流及上尿路感染情况等。结果 10例手术顺利，术后随访6～36个月，均未发生输尿管返流或上尿路感染，1例发生单侧肾积水，为吻合口狭窄所致。结论 黏膜下隧道法输尿管回肠吻合术预防去带盲升结肠可控性尿流改道术后输尿管返流及上尿路感染效果良好。     

抗返流技术的回肠代输尿管治疗长段输尿管狭窄

2002年3月至2003年11月我们采用带血管蒂的游离回肠替代输尿管，同时采用回肠壁外与腰大肌间隧道抗返流技术治疗腹膜后纤维化所致长段输尿管严重梗阻患者3例，疗效较好。现报告如下。     

输尿管回肠膀胱端端吻合在全膀胱切除术中的应用

目的:探讨全膀胱切除、Bricker术(回肠膀胱术)中输尿管-回肠端端吻合术的优势及临床应用价值。方法:回顾性分析13例全膀胱切除、Bricker术中行输尿管-回肠端端吻合术患者的临床资料:男10例,女3例。术前均行膀胱镜检查并活检确诊为浸润性膀胱癌,病变均位于膀胱颈及以上。结果:所有患者均顺利完成手术,手术时间205~260min,平均230min。输尿管-回肠吻合时间8~10min。术后2周拔除单J管,无漏尿发生。随访1~5年,B超或造影显示无肾积水和输尿管扩张。结论:全膀胱切除、回肠膀胱术中采用输尿管-回肠端端吻合术,操作简单、省时,术后并发症少,方法较为理想,具有良好的临床应用价值。     

回肠纵行折叠抗返流方法的实验研究和临床应用

以狗在体回肠制作了不同长度回肠纵行折叠和回肠套叠５ｃｍ乳头瓣抗返流措施的动物模型，用顺流压、返流压综合评价抗返流效果。结果回肠纵行折叠６ｃｍ的顺流压为２．３８±１．３３ｋＰａ，返流压为４．０５±２．１２ｋＰａ，是尿流改道术中最佳抗返流长度；回肠套叠５ｃｍ乳头瓣的顺流压为３．９２±１．００ｋＰａ，返流压大于９．１８ｋＰａ，其抗逆流作用强但顺流压较高。随访临床应用回肠纵行折叠抗返流的４０例患者，术后血ＢＵＶ，Ｃｒ和血电解质均在正常范围，ＩＶＵ除一例双肾积水外，尿液流入膀胱通畅，膀胱造影无返流。     

膀胱输尿管返流的发病机制及诊治进展

膀胱输尿管返流与反复尿路感染、下尿道功能障碍及返流性肾病密切相关。是导致慢性肾功能不全的主要原因之一。探讨其发病机制，寻找简单可靠的诊断手段和合理有效的治疗措施已日益受到学者们的重视。本文对近年来在膀胱输尿管返流的发病机制、诊断及治疗方面的进展作一综述。     

膀胱输尿管返流的发病机制及诊治进展

膀胱输尿管返流与反复尿路感染、下尿道功能障碍及返流性肾病密切相关。是导致慢性肾功能不全的主要原因之一。探讨其发病机制,寻找简单可靠的诊断手段和合理有效的治疗措施已日益受到学者们的重视。本文对近年来在膀胱输尿管返流的发病机制、诊断及治疗方面的进展作一综述。     

低压可控性回肠代膀胱术17例报告

目的：探讨膀胱全切除术后患者理想的膀胱替代式。方法：采用Ｗ形尿囊及球形贮尿囊代膀胱作低压可控性回长膀胱术治疗因膀胱癌而行膀胱全切除术患者１７例。结果：随访０．５￣２年,经代膀胱造影、测压和ＩＶＵ检查,效果满意,仅５例术后出现没的并发症,经症处理均治愈;术后膀胱容量达２４０￣５６０ｍｌ,膀胱静压为２．４４￣４．６８ｋＰａ。结论：本文式代膀胱内压低、容量大、抗反流效果好无明显输尿管梗阻及肾盂积水,无     

低压回肠双重抗反流代膀胱术疗效观察(附4例报告)

目的：改善根治性膀胱全切除术后患者的生活质量。方法：对４例膀胱癌膀胱全切除术后行可控低压回肠双重抗反流代膀胱术,采用肠管套入乳头瓣及输尿管“Ｙ”形孔头袖套式膀胱吻合双重抗反流。结果：随访１￣３年,代膀胱内压力低、顺应性好、容量大,抗反流好,能有效地预防逆行感染,无水、电解质紊乱,无输尿管扩张、梗阻,白天自控排尿良好。结论：对可保留尿道的膀胱癌患者是一种较理想的膀胱替代手术。     

Antireflux uretero-ileal implantation via a mucosal sulcus

The authors present an original antireflux uretero-ileal implantation. This procedure is based on the insertion of the ureter in a mucosal sulcus. The ileal mucosa progressively grows over the ureter. 260 ureters have been reimplanted according to this procedure. The antireflux system is effective in 85% of cases. The incidence of stenosis seems to be low: less than 2%.     

Three years' experience with an ileal low pressure bladder substitute

At the beginning of this century it was realised that peristalsis would cause incontinence if bowel was used for augmentation or substitution of the bladder. Trans-section of the antimesenteric border and cross-folding of the intestinal segments (Goodwin's cup-patch technique) is an efficient means of solving this problem and has been successfully used in the Kock pouch. We anastomosed the ileal low pressure reservoir to the membranous urethra in 22 male patients following radical cystoprostatectomy for bladder cancer. The mean observation time was 16 months (range 3-36). The capacity of the bladder substitute increased with time, the average being 450 ml after 6 months. In the first 4 patients with a short (2-5 cm) intestinal segment between the pouch and the urethra, micturition was prolonged, residual urine varied from 50 to 300 ml and bacteriuria was found. Occasional expulsions of several ml of urine were caused by peristalsis within this short tubular segment. In the following 18 patients, the low pressure reservoir was anastomosed directly to the membranous urethra. Micturition was good, with no notable residual urine, no bacteriuria and no paroxysmal urinary incontinence. However, a safety pad is used by half of the patients because once or twice a week, mainly at night, a few ml of urine may be lost. No significant changes in serum electrolytes, bicarbonate or creatinine were noted. With the three different antireflux techniques used, no obstructive or inflammatory changes in the upper urinary tracts were found, although no long-term antibiotic prophylaxis was given.     

可控回肠膀胱术治疗膀胱移行细胞癌7例报告

采用膀胱全切除加可控回肠膀胱术治疗胱移行细胞癌７例，术后患者恢复顺利，随访１年９个月￣８年６个月，回肠膀胱自控功能良好，电解质紊乱不明显，并就回肠段的处理，乳头瓣的建立与固定等问题予以讨论，认为适时用９５％无水乙醇灌注可减少肠粘液的分泌，在距切开肠壁７￣８ｃｍ处用丝线牵引固定乳头瓣十分便利。     

Tapered ileum as ureter substitute in severe renal damage: Antireflux technique for bladder implantation

Three cases are reported in which ileum has been used to replace irreparably damaged ureters despite preexisting moderate to severe pyelocaliectasis. Two cases have had satisfactory results while one had increasing pyelocaliectasis and azotemia requiring subsequent cutaneous diversion. The rationale for using ileum to replace ureter is presented with a discussion of objectives to be achieved surgically to assure the success of the procedure.     

透明质酸在膀胱移行细胞癌、乳头状瘤组织中的表达及其意义

目的　探讨人膀胱移行细胞癌 (BTCC)、乳头状瘤组织中透明质酸的表达情况及其意义。方法　应用免疫组织化学染色方法检测 60例BTCC、2 5例膀胱乳头状瘤和 15例正常膀胱黏膜上皮组织标本中透明质酸表达情况并进行统计学分析。结果　正常对照组HA染色 :(-) 11例 ,( ) 4例 ,染色位于上皮细胞间质。膀胱乳头状瘤组染色 :(-) 3例 ,( ) 10例 ,( ) 12例 ;G1级膀胱移行细胞癌组染色 :(-) 2例 ,( ) 7例 ,( ) 11例 ;G2 级 :( ) 2例 ,( ) 13例 ,( ) 5例 ;G3级 :( ) 1例 ,( ) 8例 ,( ) 11例 ;染色均位于癌细胞胞浆和间质中。正常对照组与BTCC、膀胱乳头状瘤组 ,膀胱乳头状瘤组与BTCC组比较 ,差异均有极显著性 (P <0 .0 0 1) ;G1级组与G2 级组、G1级组与G3 级组之间差异有显著性 (P =0 .0 13 2 ,0 .0 0 3 5 ) ,G2 级组与G3 级组比较 ,差异无显著性 (P =0 .0 5 2 8) ;膀胱乳头状瘤组与G1级组之间的差异无显著性 (P =0 .64 0 7)。结论　透明质酸与BTCC的生物学特性有直接的关联 ,膀胱移行细胞癌细胞本身具有合成透明质酸的功能 ;膀胱乳头状瘤的生物学行为有恶性倾向     

Twenty years experience with an ileal orthotopic low pressure bladder substitute--lessons to be learned

PURPOSE: We present the long-term results of a large consecutive series of patients undergoing ileal orthotopic bladder substitution following radical cystectomy. MATERIALS AND METHODS: Between April 1985 and 2005 orthotopic bladder substitution with an ileal low pressure reservoir was performed in 482 patients (including 40 women) after radical and, if possible, nerve sparing cystectomy. In 447 cases the procedure was combined with an afferent ileal isoperistaltic tubular segment. The patients were followed prospectively. RESULTS: In the 482 patients 61 early (less than 30 days) diversion related complications requiring prolonged hospital stay or readmission were noted and 115 late complications required treatment. At 1 year continence was good in 92% of patients during the day and in 79% at night. At last followup 93% of patients could void spontaneously. Of 442 evaluable men 99 (22.4%) reported having erections without and 68 (15.4%) with medical assistance. Ureteroileal stenosis was observed in 12 of 447 (2.7%) patients. Urethral recurrence was detected in 25 of 482 (5%) patients. A total of 15 (5%) patients received vitamin B12 substitution. Renal parenchyma decreased only in patients with preoperative or postoperative ureteral obstruction. After 10 years patients with normal renal function had no long-term acidosis and in 20 patients the incidence of osteoporosis resembled that of the normal population. CONCLUSIONS: Ileal orthotopic bladder substitution combined with an afferent ileal tubular segment allows for good long-term functional results provided patients are restrictively selected, postoperative instructions are followed carefully, and typical complications such as outlet obstruction and hernias are treated early.     

改良低压回肠代膀胱术16例

目的 探讨低压回肠代膀胱术的技术改进及远期疗效。方法 对16例全膀胱切除的膀胱癌患者,施行回肠袋近端肠管人工套迭加隧道式输尿管肠吻合术,同时用20g·L~(-1)碘酊处理回肠袋粘膜以减少肠粘膜的分泌与吸收。结果 手术时间平均5h50min。术后随访11～72月,全部病人白天均能自控排尿,无输尿管返流,无代谢性酸中毒,无手术死亡及再次手术。结论 本术式具有成功率高,并发症少,病人术后生活质量高等优点。     

In vitro analysis of the effect of hyperbilirubinemia on rabbit ureter and bladder

Spontaneous resolution of intrauterine pelvic dilatations after birth is an expected outcome. In nonobstructive pelvic dilatations, changes in ureteral and bladder physiology may also play a part. We aimed to demonstrate the effect of increased concentrations of bilirubin on ureteral and bladder muscles in vitro. Normal and pathologic concentrations of bilirubin (3.5×10^-7–10^-5M and 10^-4–4×10^-4M, respectively) caused no change in the basal ureter tension (343.9±29.4 mg). Normal concentrations of bilirubin caused no difference in basal bladder tension (430.2±70.2 mg), but pathologic concentrations caused a decrease of 303.8±52.9 mg. Normal and pathologic amounts of bilirubin were cumulatively applied to rabbit ureteral and bladder tissues both after reaching basal tension and when contracted with KCl (80 mM and 120 mM KCl for ureter and bladder, respectively). The cumulative addition of normal bilirubin concentrations to the ureteral tissues precontracted with KCl produced 86.4±7.2% relaxation, while the addition of pathologic bilirubin concentrations produced a relaxation of 133.9±17.4%, which was significantly higher (p=0.04). Similarly, the addition of normal concentrations of bilirubin to the bladder tissues precontracted with KCl produced a maximal relaxation of 35.3±2.2%, while pathologic concentrations produced a maximal relaxation of 53.5±3.5%, which was significantly higher (0.001). Consequently, high concentrations of bilirubin caused a mild relaxation in basal ureteral and bladder tensions, while pathologically increased concentrations led to significant relaxation in both types of precontracted tissues. We suggest that high bilirubin levels may partly but not directly contribute to the spontaneous recovery of hydronephrosis because of the relaxation effect on bladder while probably causing susceptibility to urinary tract infections because of relaxation of both ureteral and bladder tissues.