改良原位回肠代膀胱术(附25例报告)

目的：探讨改良膀胱全切原位回肠代膀胱术的疗效。方法：对24例膀胱癌及1例腺性膀胱炎患者采用改良膀胱全切原位回肠代谢膀胱术。膀胱全切采用顺行逆行相结合的方法。截取末段回肠,排列成W形,褥式缝合制作贮尿袋。输尿管以乳头法种植。结果：25例手术时间平均4h,输血量平均550ml,术后24例随访2－84个月,平均24个月,23例白天可控排尿,14例夜间自控排尿。仅2例术后发生输尿管积水,1例术前左肾积水者术后无变化。2例肾功能异常。23例行膀胱排尿造影均未发现输尿管返流。术后出现低血钾者2例,余22例血电解质均在正常范围。无肠膀胱或尿道肿瘤复发者。结论：改良膀胱全切原位回肠代膀胱手术术时间短,操作简单,出血少,并发症少,术后无膀胱输尿管返流,电解质紊乱发生率低。     

原位肠代膀胱术远期疗效评价(附266例报告)

目的 总结评价原位肠代膀胱术的远期临床效果。方法 对1991-2003年266例因膀胱癌行膀胱全切手术患者资料进行分析。Hautmann回肠原位代膀胱术206例，Reddy原位结肠代膀胱术60例。131例患者在原标准术式基础上作了手术技术改进。总结手术改进前后患者控尿率和并发症发生率等。结果 获完整随访患者225例。回肠代膀胱术改进前后男性平均随访时间62（44-146）个月和38（4-67）个月；结肠原位代膀胱手术改进前后患者平均随访时间为62（51-131）个月和34（5-67）个月。手术改进可提高男性术后夜间可控率（P〈0．05），女性改善不明显（P〉0．05），总的近期和远期并发症发生率为13．8％和19．6％。男性肿瘤尿道复发9例（4％），女性无复发。结论 原位尿流改道术的远期临床疗效满意，并发症发生率低。手术技术改进可提高男性患者的夜间控尿率。     

女性原位回肠代膀胱术的临床应用

目的:总结女性膀胱全切患者行原位回肠代膀胱术的临床疗效。方法:回顾性分析1998年1月～2006年2月36例女性膀胱全切,原位回肠代膀胱患者的临床资料。36例患者,年龄48～65岁,平均56岁。其中移行细胞癌34例,腺癌2例。原发肿瘤22例,复发性肿瘤14例。多发性非肌层侵犯肿瘤(Ta～T1)12例,浸润性膀胱肿瘤(T2～T3)24例。结果:36例手术平均时间270min(210～330min),输血量平均400ml(0～1000ml)。术后随访6～72个月,平均26个月。术后6个月昼夜控尿率分别为94%(34/36)和92%(33/36)。2例排尿可控过度,需间歇导尿。术后6个月IVU检查无输尿管狭窄和反流。血电解质和肾功能正常,无尿道残端肿瘤复发。结论:原位回肠代膀胱术治疗女性膀胱癌患者临床疗效满意,可作为广泛开展的术式。     

原位可控回结肠代膀胱术疗效总结

目的 回顾分析膀胱全切术后原位回结肠代膀胱术的疗效及并发症.方法 对52例膀胱癌患者行膀胱全切,原位回结肠代膀胱术,术后对患者排尿情况、肾功能、术后近期及远期并发症等进行随访.结果 45例患者获随访,随访时间3～146个月,平均42个月.术后6个月白天可控排尿38例,夜间可控排尿35例.3例(6.7%)术后6～15个月死于肿瘤盆腔复发或转移.2例(4.4%)于术后18、22个月尿道肿瘤复发,其中1例半年后死亡.5例(11.1%)术后3年内死于非肿瘤原因.术后近期和远期并发症发生率分别为17.8%(8例)和24.4%(11例).术后12个月2例患者出现肾功能轻度异常,血尿素氮为7.2、11.8 mmol/L,血肌酐为137、168 μmol/L.结论 原位可控回结肠代膀胱术无明显代谢紊乱及肾功能损害,具有良好的排控能力,手术并发症大多可临床治愈,是一种较为理想的尿流改道术式.     

改良膀胱全切除原位回肠新膀胱术后效果探析

目的探讨改良膀胱全切除原位回肠新膀胱手术的临床效果。方法对18例浸润性膀胱癌患者行改良膀胱全切除原位回肠新膀胱手术治疗,记录手术时间、术中输血量、术后并发症、术后排尿情况、肿瘤控制情况和生存质量等。结果 18例患者均顺利完成手术,平均手术时间250 min。术中输血量平均470 mL。术后3例出现早期并发症,其中电解质紊乱2例,尿瘘1例。18例患者均获随访,平均时间20个月,1例发生单侧输尿管反流,1例死于脑梗死,1例死于肿瘤转移,1例死于肾功能衰竭。术后患者的生活质量比较满意。结论改良膀胱全切除原位回肠新膀胱手术术式简单、术后并发症少和代膀胱功能好,是浸润性膀胱癌较为理想的治疗术式。     

肠膀胱重建术后尿路结石的微创治疗(附4例报告)

目的：探讨肠膀胱重建术后尿路结石的微创治疗效果。方法：报告4例膀胱癌膀胱全切肠代膀胱术术后并发尿路结石患者的临床资料。结果：1例行经皮肾穿刺肾盂输尿管造影定位下体外冲击波碎石术，结石粉碎并排至结肠膀胱；1例行经皮肾镜碎石术；另2例行经尿道输尿管镜下钬激光碎石术，结石粉碎并取出。结论：肠膀胱重建术后尿结石的发生与尿路感染和手术操作等因素有关，对可控膀胱术后上尿路结石可实施经皮肾镜取石术或尿路造影定位下ESWL治疗，原位回肠代膀胱术后尿路结石可实施腔内碎石治疗。     

全去带乙状结肠原位可控膀胱术的临床应用——附15例报告

目的探讨全去带乙状结肠原位可控膀胱术的临床效果。方法对接受膀胱肿瘤根治手术的患者行膀胱全切、全去带乙状结肠原位可控膀胱术。结果15例术后随访2-25个月，平均12．3个月。全组无严重并发症，均无瘤生存；术后4周自主可控排尿，白天完全自控排尿15例，夜间完全自控排尿13例，2例偶有道尿；贮尿囊容量280-3.50ml，平均310ml;最大尿流率13-25ml／s，平均17ml／s；无输尿管反流及狭窄，无贮尿囊后尿道吻合口狭窄，肾功能正常。结论全去带乙状结肠原位可控膀胱术是目前一种方便、安全、可靠、并发症少的理想术式。     

改良Kock回肠代膀胱术51例报告

目的总结改良Kock回肠代膀胱术的优缺点，为临床推广应用提供客观依据。方法浸润性膀胱癌患者51例（T2N0M0 37例，T3N0M0 14例，病理分级Ⅱ-Ⅲ级），根治性膀胱全切术后，行改良Kock回肠膀胱术，包括缩短输入段凹肠，重建储尿囊，代膀胱低位与尿道吻合，恢复原有排尿通道。结果51例手术时间5．5～8．5h，平均6．5h。术中出血量300—1200ml，平均650ml，术中输血31例。围手术期发生应激性溃疡6例；术后发生输尿管支架管拔除安道漏尿1例，经再次引流后痊愈；其余44例均未出现严重并发症。术后6—8个月北于肿瘤广泛转移4例，余47例随访8—32个月存活，患者无腰腹胀痛、发热及血尿，B超及泌尿系造影显示储尿囊形态规则，2例患者存在输尿管返流，但无肾功能损害。术后6个月内患者白天均可完全控尿，夜间尿失禁6例。结论改良Kock回肠代膀胱术可显著提高患者生活质量，术后并发症少，符合生理性排尿，是一种较为理想的根治性膀胱全切术后尿流改道的方法。     

腹腔镜下全膀胱切除加原位回肠代膀胱术的临床疗效(附12例报告)

目的：探讨腹腔镜下全膀胱切除加原位回肠代膀胱术的手术方法和临床效果。方法：对12例浸润性膀胱移行细胞癌Ⅱ～Ⅲ级患者行腹腔镜下全膀胱切除加原位回肠代膀胱术,观察手术时间、术中出血量、术后肠道功能恢复情况及术后并发症等于术效果。结果：手术时间7～10h,术中失血600～1500ml,术后约72h恢复肠道功能。术后2周拔除输尿管导管,术后3周拔尿管后腹压排尿正常,术后3个月IVU复查未见肾积水,未出现并发症。结论：该术式具有微创、出血少、恢复快等特点,将成为治疗浸润性膀胱癌的较好方法之一。     

原位回肠代膀胱术的疗效观察（附25例报告）

目的：观察7年来行原位回肠代膀胱术的治疗效果。方法：对25例男性膀胱癌患者行膀胱全切回肠代膀胱术。结果：25例患者中有24例获得随访,随访时间2－84个月,平均84个月。手术时间平均240min,输血量平均550ml,手术并发症少,23例患者白天可控制排尿,其中14例夜间自控排尿。3例有肾脏或输尿管积水,2例肾功能异常。膀胱排尿造影均未发现输尿管反流。血生化检查除2例发现低血钾外,其余血电解质均在正常范围。未发现肠膀胱或尿道肿瘤复发。结论：原位回肠代膀胱术是值得选择的尿流改道方式。     

改良膀胱全切、原位回肠代膀胱术的疗效观察

目的:探讨膀胱根治术后行尿流改道的方法。方法:对17例男性膀胱癌患者行膀胱全切、原位回肠代膀胱术,采用改良的手术方法。结果:手术时间平均230min;输血量平均480ml;全部病例可完全控尿,需夜间定时排尿;膀胱最大贮尿量平均330ml,剩余尿均小于80ml。17例全部随访,时间7～48个月,平均19个月。术后仅发生单侧输尿管反流1例,肾功能衰竭死亡1例,肿瘤转移死亡1例。无电解质紊乱发生,未发现尿道肿瘤复发。结论:改良膀胱全切、原位回肠代膀胱术是膀胱根治术后尿流改道的较为理想术式。     

A three-centre experience of orthotopic neobladder reconstruction after radical cystectomy: initial results

OBJECTIVE: To assess, in a retrospective three-centre series, the initial experience and results of patients undergoing radical cystectomy and orthotopic neobladder reconstruction. PATIENTS AND METHODS: The medical records were retrospectively reviewed for 104 suitable consecutive patients undergoing radical cystectomy and orthotopic neobladder reconstruction between June 1994 and April 2003. The initial histology, operating times, transfusion rates, complications, mortality rates, continence rates, potency rates, and cancer control rates were recorded. RESULTS: The median (range) follow-up was 48 (6-113) months; 90 patients had a reconstruction with a 'Studer' neobladder, 12 with a 'Hautmann W pouch' and two with a 'T pouch' ileal neobladder. There were 24 early complications, and in eight patients re-operation was required; there was one death after surgery. There were 14 late complications and 10 patients required re-operation. The daytime continence rate was 99% and the nocturnal continence rate 78%. Five patients required intermittent self-catheterization. Twenty-two patients died from local and/or distant recurrences, and four from other causes. CONCLUSIONS: Orthotopic neobladder reconstruction provides excellent continence rates, and both acceptable complication and mortality rates. Suitable patients undergoing radical cystectomy should be offered orthotopic neobladder reconstruction.     

Supra-ampullar cystectomy with preservation of sexual function and ileal orthotopic reservoir for bladder tumor: twenty years of experience

OBJECTIVE: We describe the original surgical technique of supra-ampullar cystectomy associated with ileal neobladder, and present our results in terms of preservation of sexual potency, urinary continence and cancer control along twenty years of experience. MATERIALS AND METHODS: Twenty-eight consecutive patients with bladder tumor-27 transitional cell carcinomas (TCC) and 1 leiomyosarcoma-underwent supra-ampullar cystectomy with ileal orthotopic neobladder (2 Camey I and 26 Camey II) between May 1984 and June 1999. The median age of the patients was 51.0 years (range 23-65). Preoperatively 24 patients had superficial high-risk TCC. Involvement of prostatic urethra was excluded by means of preoperative endoscopic biopsies. The bladder, part of the prostate with the prostatic urethra and regional lymph nodes were removed, while the vas deferens with deferential ampullae, seminal vesicles, ejaculatory ducts and the peripheral portion of the prostate were maintained. Median followup was 90.5 months (range 10-228). RESULTS: Out of 28 patients 6 died of bladder cancer (all with metastases, 2 also with local recurrence); 4 out of the 22 patients who were free of disease at followup died of other causes. Potency was preserved in 26 patients (92.8%), reporting satisfactory sexual intercourses; 15 patients (53.5%) also maintained antegrade ejaculation allowing procreation in 3 cases. In one patient the orthotopic neobladder according to Camey I was converted into an ileal conduit because of the excessive capacity of the reservoir, high post-void residual and recurrent pyelonephritis. Of the remaining 27 patients 16 showed both daytime and nighttime urinary continence (average interval between micturitions = 3 hours), 6 were continent during the day and 5 performed self-intermittent catheterization. CONCLUSION: Supra-ampullar cystectomy with detubularized ileal orthotopic neobladder allows to preserve sexual function in nearly all the cases and to maintain urinary continence in most patients, without compromising oncological outcome. The indication must be restricted to highly selected cases, without potential risk of local recurrences and concomitant prostatic carcinoma.     

改良低压回肠代膀胱术的疗效评价

目的 总结改良原位低压回肠代膀胱术的疗效及患者生活质量。方法 膀胱癌患者53例，平均年龄61岁，均施行根治性膀胱全切术。截取末端35—45cm回肠，“U”形缝合形成代“膀胱”，并与输尿管形成抗返流的“乳头”缝合。结果 术后所有患者血生化及电解质均正常，随访3—6个月，51例患者白天完全可控排尿，完全夜间可控制排尿25例。47例无残余尿，5例有残余尿20-35mL。结论 改良低压回肠代膀胱术，膀胱容量大、压力低、无返流、效果好、无吸收性酸中毒，患者白天均能够控制尿液，夜间需定时排尿，生活质量高，多数患者满意。     

Ileal neobladder for urinary bladder replacement following total pelvic exenteration for rectal carcinoma

OBJECTIVE: The aim of this study was to determine the feasibility of using the ileal neobladder as a substitute for the urinary bladder following total pelvic exenteration for rectal carcinoma. PATIENTS AND METHODS: Between 1992 and 1998, we performed total pelvic exenteration with ileal neobladder in 5 men with rectal carcinoma. Four patients had primary tumors, and one had recurrent disease after low anterior resection for rectal carcinoma. Histological types were adenocarcinoma in 4 and squamous cell carcinoma in 1. Invaded organs were: the urinary bladder in 1, the urinary bladder and prostate in 2, the prostate and seminal vesicle in 1, and the prostate in 1. RESULTS: There was no operative death. In 1 patient, an ileal conduit was needed because of partial necrosis of the neobladder. Minor leakage on the dorsal wall of the neobladder occurred in 2 patients, which was successfully stopped with simple closure and a gluteus maximus fasciocutaneous flap, respectively. All except one patient with the ileal conduit could void via the urethra. Complete daytime urinary continence was achieved, but nocturnal continence was maintained with voiding once or twice per night. As the urodynamic state, the mean maximum flow rate was 20.9 ml/s (range 9.0-34.1), the mean average flow rate was 7.7 ml/s (range 3.0-11.0), and the mean voided volume was 285.5 ml (range 160-432). The mean length of follow-up was 47.8 months. One patient died of local recurrence 38 months postoperatively, and 1 died of pneumonia 10 months postoperatively. Both patients could void via the urethra until death. The other three patients are currently alive without any evidence of recurrence. CONCLUSIONS: Although total pelvic exenteration is a laborious surgical procedure, an ileal neobladder could be a good alternative to the urinary bladder enabling the patients to void via the urethra with urinary continence.     

正位回结肠和回肠膀胱替代术尿控差异的对照研究

目的：通过根治性膀胱全切术后回结肠和回肠正位膀胱替代术的临床观察,重点评价两种术式的尿控及其对上尿路的影响及机制。方法：从2002～2006年期间行标准的根治性膀胱全切术后行正位膀胱替代术中选取获得随访的膀胱癌患者31例,其中17例采用回结肠新膀胱重建术（Le Bag术）,14例采用回肠新膀胱重建术（Studer术）。术后3个月内（近期）和3个月后（远期）观察相关并发症和尿控情况,并行尿动力学检查和静脉肾盂造影或B超检查。结果：回结肠新膀胱组手术后并发症率为11．8％（2／17）;回肠新膀胱组并发症率为14．3％（2／14）。虽然回结肠新膀胱组3个月后白天完全获得尿控76．4％（13／17）．低于回肠新膀胱组92．8％（13／14）,但统计学差异不显著;而夜间社会性尿控回肠新膀胱组7I．4％（10／14）,显著高于回结肠新膀胱组35．3％（6／17）。尿动力学结果表明两组间的尿流率、功能尿道长度、最大尿道压和新膀胱压力无明显差异,但回结肠新膀胱组容量高于回肠新膀胱组,而顺应性则低于回肠新膀胱组。此外。回结肠新膀胱组的上尿路扩张发生率为11．8％（2／17）,略高于回肠新膀胱组0（0／14）。结论：虽然回结肠新膀胱在近期能获得较大容量,但由于回结肠新膀胱顺应性较回肠新膀胱低,因而在获得满意的尿控和对上尿路的保护上,回肠新膀胱更具优势。     

Orthotopic ileal neobladder: the influence of reservoir volume and configuration on urinary continence and emptying properties

OBJECTIVE: To evaluate the influence of the volume and configuration of the neobladder on urinary continence and reservoir emptying in orthotopic urinary reservoirs using intestinal segments for bladder replacement after radical cystectomy. PATIENTS AND METHODS: Fifty-nine patients who had had a radical cystectomy and urinary reconstruction with an orthotopic ileal neobladder were followed for > or = 1 year; 27 (group 1) had the ileal neobladder created with a shorter intestinal segment (40 cm) in an elongated shape ('J'), and 32 (group 2) had their reservoir made more spherical with a longer ileal loop (60-65 cm). The rates of urinary continence, enuresis, neobladder capacity and postvoid residual urine were evaluated first at 3-6 months and again 1 year after surgery in both groups. RESULTS: At 3-6 months after surgery urinary incontinence and enuresis were more common in group 1, but at 1 year had the same frequency in both groups, at respectively 11% and 44% in group 1, and 13% and 47% in group 2 (P > 0.05). The neobladder capacity and postvoid residual urine were significantly higher in group 2, at > 600 mL and > 100 mL, respectively, in 14% and 14% of the patients in group 1 and 57% and 52% of those in group 2 (P < 0.05). Urinary retention requiring intermittent catheterization did not occur in group 1 but did in 19% of group 2. CONCLUSION: The orthotopic spherical ileal neobladder with a large initial volume is apparently not associated with better continence rates and is prone to developing progressive enlargement, which can lead to neobladder atony and progressive emptying failure, increasing the chance of complete urinary retention.     

改良W形回肠代膀胱术的疗效观察(附36例报告)

目的 :探讨改良W形回肠代膀胱术的疗效。方法 :对 36例膀胱肿瘤患者行根治性膀胱切除、W形回肠代膀胱术 ,并对术式进行改进。结果 :36例手术时间平均 4 .2h。术后 31例随访 4～ 19个月 ,平均 10 .6个月 ,无严重并发症 ,均无瘤生存。患者一般于术后 3周自主可控性排尿 ,日间尿控率为 10 0 % ,术后 3、6、12个月夜间尿失禁发生率分别为 2 2 .5 %、11.1%及 6 .2 %。术后 6个月尿动力学检查膀胱容量 (36 0± 30 )ml,最大尿流率 (13.6± 2 .6 )ml/s,剩余尿量 (11.5± 5 .8)ml,充盈期膀胱压力明显低于尿道闭合压。新膀胱造影发现新膀胱呈球形 ,完全位于盆腔 ,未见输尿管反流。B超及IVU检查发现原上尿路积水 4例均明显减轻 ,其余未发现输尿管狭窄和上尿路积水征象。无高氯性酸中毒 ,肾功能正常。结论 :改良W形回肠代膀胱术手术时间短 ,操作简单 ,创伤轻 ,并发症少 ;新膀胱容量大 ,内压低 ,顺应性好 ,功能接近于正常膀胱 ,保持原位排尿 ,明显提高了患者术后生活质量 ,值得临床推广应用。     

Laparoscopic radical cystectomy and continent orthotopic ileal neobladder performed completely intracorporeally: the initial experience

PURPOSE: We introduce the operative technique of laparoscopic radical cystectomy and orthotopic ileal neobladder with a Studer limb performed completely intracorporeally. MATERIALS AND METHODS: The procedure was performed in 1 man and 1 woman. Using a 6 port transperitoneal approach, radical cystectomy in the female patient and radical cystoprostatectomy in the male patient were completed laparoscopically with the urethral sphincter preserved. Bilateral pelvic lymphadenectomy was done. A 65 cm. segment of ileum 15 cm. from the ileocecal junction was isolated, and ileo-ileal continuity was restored using Endo-GIA staplers (U.S. Surgical, Norwalk, Connecticut). The distal 45 cm. of the isolated ileal segment were detubularized, maintaining the proximal 10 cm. segment intact as an isoperistaltic Studer limb. A globular shaped ileal neobladder was constructed and anastomosed to the urethra. Bilateral stented ureteroileal anastomoses were individually performed to the Studer limb. All suturing was done exclusively using free-hand laparoscopic techniques and the entire procedure was completed intracorporeally. An additional case is described of Indiana pouch continent diversion in which the pouch was constructed extracorporeally. RESULTS: Total operative time for laparoscopic radical cystectomy and orthotopic neobladder was 8.5 and 10.5 hours, respectively, with a blood loss ranging from 200 to 400 cc. Hospital stay was 5 to 12 days and surgical margins of the bladder specimen were negative in each case. Both patients with orthotopic neobladder had complete daytime continence. Postoperative renal function was normal and excretory urography revealed unobstructed upper tracts. During followup ranging from 5 to 19 months 1 patient died of metastatic disease, while the other 2 are doing well without local or systematic progression. CONCLUSIONS: Laproscopic radical cystectomy and orthotopic ileal neobladder performed completely intracorporeally are feasible.