输尿管末端粘连:原位新膀胱术后上尿路积水原因之一

目的:总结原位新膀胱术后输尿管末端粘连致上尿路积水的诊断和处理经验。方法:2000年1月~2007年4月共施行全膀胱切除加原位新膀胱术250例,发现8例原位新膀胱术后患者上尿路积水是由输尿管末端互相粘连或与新膀胱壁粘连引起,在内镜下经尿道切断粘连带予以处理。结果:术后中位随访8个月(1~22个月),7例肾功能和积水程度明显改善,1例稳定,并在密切随访观察中。1例在积水缓解后7个月再次复发,发现输尿管肠吻合口狭窄,行开放手术作输尿管新膀胱再植,随访5个月,积水程度明显改善。结论:输尿管末端粘连是使用输尿管直接种植法的原位新膀胱术后上尿路积水的原因之一。膀胱镜检查既可明确诊断又能同时作粘连带切断而达到治疗的目的,因此,对原位新膀胱术后上尿路积水患者应常规作膀胱镜检查。     

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。     

膀胱全切原位回肠新膀胱术后输尿管肠吻合口良性狭窄的处理

目的：探讨膀胱全切原位回肠新膀胱术后输尿管肠吻合口良性狭窄的处理方法。方法：我科自2003年1月～2012年6月采用膀胱全切原位回肠新膀胱术治疗395例膀胱癌患者。术后发生输尿管肠吻合口良性狭窄10例,采用输尿管镜扩张、内镜下逆行／经皮穿刺顺行球囊扩张、内镜下狭窄段内切开、开放输尿管膀胱再植术,并留置双J管3～6个月。结果：本组10例中,1例（1处）因导丝不能通过狭窄段而改行开放手术,术后随访36个月,肾积水明显改善。其余9例（11处）采用腔内技术处理,其中3例（4处）采用输尿管镜扩张,2例（3处）采用内镜下狭窄段内切开,4例（4处）采用内镜下逆行／经皮穿刺顺行球囊扩张。术后随访9～72个月（中位25个月）。5例（7处）肾积水明显改善,2例（2处）肾积水长期随访无加重,2例（2处,狭窄段长分别为1．2cm、1．5cm）再发狭窄,遂采用开放手术,分别随访16及24个月,肾积水改善。结论：腔内技术操作简单,创伤小,可作为输尿管肠吻合口良性狭窄的首选治疗方案。开放手术仍然是治疗输尿管肠吻合口狭窄的金标准。对于狭窄段〉1cm的患者,应首先考虑开放手术。     

根治性膀胱切除术后回肠与乙状结肠2种原位新膀胱术的临床疗效观察

目的:探究根治性膀胱切除术后回肠与乙状结肠2种原位新膀胱术的临床疗效及术后并发症发生率的差异。方法:选取2010年4月~2015年2月我院收治的膀胱癌患者86例作为研究对象。所有患者均行根治性膀胱切除术+原位新膀胱术,按手术方式不同,接受回肠原位新膀胱术的51例患者分为A组,接受乙状结肠原位新膀胱术的35例患者为B组。记录两组患者的手术时间、术中出血量以及术后住院时间。所有患者术后定期随访,均随访满18个月,观察记录两组患者术后并发症发生情况、术后3周控尿能力及术后6个月的尿流动力学检查结果。结果:A组患者手术时间、术中出血量以及术后住院时间均明显多于B组患者,差异有统计学意义(P<0.05);两组患者术后总并发症发生率差异无统计学意义,术后并发症Clavien-Dindo分级比较差异无统计学意义;A组患者术后3周夜间可控尿率明显高于B组,差异有统计学意义(P<0.05);两组患者术后6个月的膀胱剩余尿和最大尿流率差异无统计学意义;A组术后6个月的膀胱最大储尿量明显高于B组,而膀胱充盈压和排尿压均明显低于B组,差异有统计学意义(P<0.05);两组患者术后18个月肿瘤复发率及生活质量评分比较差异无统计学意义。结论:相比回肠原位新膀胱术,乙状结肠原位新膀胱术具有手术操作较简单、术中出血量少、术后恢复快等优势,而回肠原位新膀胱术术后夜间控尿率较满意,膀胱储尿量大,顺应性好。2种原位新膀胱术均能取得满意疗效,术后并发症发生率及Clavien-Dindo分级差异无统计学意义,随访18个月肿瘤复发率及生活质量评分差异无统计学意义,临床上可根据患者个体情况和医生擅长术式决定治疗方案。     

女性全膀胱切除原位回肠新膀胱术20例报告

目的探讨女性全膀胱切除原位回肠新膀胱术的技术改进及临床应用价值。方法 2004年1月至2009年1月,对20例女性膀胱肿瘤患者行全膀胱切除原位回肠新膀胱术,其间进行了系列改良探索,包括保留子宫、卵巢及附件的膀胱全切;保留完整尿道、阴道及自主神经的膀胱全切;腹膜外顺行切除膀胱;手助拔针邻边全层连续褥式缝合制作＂W＂回肠新膀胱;用直线切割吻合器恢复肠道连续性;用自制引导探子引导新膀胱与尿道吻合等。随访观察肿瘤控制、并发症及排尿控尿功能。结果手术时间平均330min,术中平均出血560ml。术后2～4周拔除尿管,患者排尿通畅。18例获得随访,平均随访时间38个月,术后12个月内恢复昼夜尿控分别为94.4%和88.9%,新膀胱容量平均330ml,蹲式手辅腹压排尿下,最大尿流率平均24.6ml/s,残余尿量0～25ml。无肿瘤复发及种植转移。结论经初步观察,女性膀胱肿瘤患者行膀胱全切,可尝试保留子宫、卵巢、附件和完整的尿道、阴道;全膀胱切除原位回肠新膀胱术较适于女性患者;所行系列改良可降低手术难度,减少并发症,在肿瘤根治的同时利于控尿恢复。     

腹腔镜全膀胱切除原位新膀胱重建术的护理

全膀胱切除一原位新膀胱术是近年较为理想的膀胱替代术,腹腔镜技术操作具有其独特的方法和优点。本组33例患者手术均获得成功。术后正确的护理措施及出院健康指导是患者治疗中不可缺少的重要环节。本文详细介绍腹腔镜全膀胱切除原位新膀胱术护理方法。     

原位低压乙状结肠新膀胱术15例报告

浸润性膀胱癌行根治性膀胱全切后需要建立一个低内压、大容量、高顺应性、高调节性的新膀胱,与通道式尿流改道术式相比,原位新膀胱术术后生活质量更高而广为接受。2002年3月至2004年1月,我们对15例膀胱癌患者采用了根治性膀胱全切原位低压乙状结肠新膀胱术,效果良好,现报告如下。临床资料1.一般资料:本组15例,均为男性。年龄45~74岁,平均59岁。病程2个月~4.5年。术前经B超、CT、I VU、膀胱镜检查及活检诊断为膀胱癌。所有患者无上尿路肿瘤,尿道、前列腺均无肿瘤浸润。术后病理切片提示:膀胱移行上皮细胞癌12例,鳞癌2例,腺癌1例;G29例,G3…     

机器人辅助腹腔镜膀胱癌根治联合原位回肠新膀胱术后不同输尿管再植方式对术后肾功能的影响

目的:观察机器人辅助腹腔镜膀胱癌根治联合原位回肠新膀胱术后不同输尿管再植方式对术后肾功能的影响。方法:回顾性分析2014年9月～2017年12月行机器人辅助腹腔镜膀胱癌根治联合原位回肠新膀胱术的患者资料。分析不同输尿管再植方式对术后肾功能的影响以及术后肾功能的独立危险因素。结果:共纳入50例患者,其中黏膜直接吻合31例(黏膜组),乳头法19例(乳头组)。术前已发生慢性肾功能损伤患者7例,2例于术后恢复。输尿管黏膜与膀胱黏膜直接吻合的患者术后3个月肾小球滤过率(eGFR)明显优于乳头法(P=0.007),且2种方式的术后3个月eGFR均比术前有明显升高(黏膜组:P0.001,乳头组:P=0.047)。两组的术后1年eGFR也存在明显差异(P=0.011)。术前未发生慢性肾损伤的43例患者术后3个月共发生了5例慢性肾损伤。其中术后损伤的患者相比未损伤的患者,在术前eGFR水平、术后3d内eGFR水平方面明显降低(术前eGFR:P=0.001;术后3d内eGFR:P0.001)。二者均为术后发生慢性肾损伤的独立危险因素。结论:不同的输尿管再植方式对膀胱癌根治联合原位回肠新膀胱术患者的术后肾功能的保护作用有显著差异。术前及术后3d内的eGFR水平是术后长期慢性肾功能损伤的重要影响因素。     

根治性膀胱全切加乙状结肠原位新膀胱术治疗膀胱移行细胞癌

根治性膀胱切除加原位膀胱替代术是治疗浸润性膀胱移行细胞癌的标准方式。理想的原位膀胱是术后患者接近正常排尿,有正常的控尿机制和排尿感觉,有足够的容积,内部压力不能太高,以防止尿失禁和对上尿路形成反压力。     

改良膀胱全切除原位回肠新膀胱术后疗效观察

目的报告改良膀胱全切除原位回肠新膀胱术治疗肌层浸润性膀胱癌的疗效。方法对我院2007年1月至2011月12月施行改良膀胱全切除原位回肠新膀胱术的24例患者的临床资料进行回顾性分析,包括手术时间、手术出血量、输血情况、手术并发症、新膀胱功能、肿瘤控制情况、生存情况、勃起功能以及生活质量情况。结果本组24例手术均顺利,手术时间240～380min,术中出血量200～1200ml,输血11例,术中直肠损伤1例。术后8例出现早期并发症,其中5例电解质紊乱,1例肠梗阻,2例尿瘘;另有2例真性尿失禁。20例获随访,1例死于肺部感染,1例死于脑梗死,1例死于梗阻性肾功能不全,1例死于肿瘤复发、转移,1例因肿瘤复发、转移而目前在接受放化疗中,15例无瘤生存。术后性功能均有不同程度下降。生活质量大致满意。结论对于肌层浸润性膀胱癌患者,实施改良膀胱全切除原位回肠新膀胱术效果良好,提高手术技巧是术后改善生活质量的重要因素之一。     

生活质量评分表在肠代膀胱功能评估中的应用研究

目的 探讨生活质量(QOL)评分表评估全膀胱切除肠代膀胱术后功能的可行性.方法 对22例肠代膀胱术后患者进行问卷调查,重点了解日间及夜间排尿间隔、排尿时间、尿失禁发生程度,填写QOL评分表;患者均行常规尿动力学检测.分析QOL评分与排尿间隔、尿失禁程度及常见尿动力学参数间的相关性.结果 22例患者QOL评分0～5分,平均2分;日间完全控尿19例,轻度尿失禁2例、中度尿失禁1例;夜间尿失禁12例,轻度4例、中度3例、重度5例;日间排尿间隔45～210 rain,平均136 rain.最大尿流率2.7～22.1ml/s,平均12.9 ml/s;最大尿道闭合压33～114 cm Ha0(1 em H20-0.098 kPa),平均69.3 cm H2O,剩余尿量5～300 ml,平均91.8 ml.QOL评分与尿失禁程度呈正相关(日间:r=0.510,P=0.015;夜间:r=0.911,P<0.001),与日间排尿间隔呈负相关(r=0.749,P<0.001);QOL评分的影响因素包括最大尿道闭合压、剩余尿量及最大尿流率.结论 QOL评分可以作为评估肠代膀胱功能的量化指标,能较准确地反映患者实际控尿能力及生活质量的主观感受,且与常见尿动力学参数具有显著相关性.     

肠代膀胱术中输尿管吻合方法的改进

目的：探讨肠代膀胱输尿管吻合的理想方法。方法：对60例肠代膀胱术后118侧作肠代膀胱输尿管吻合的患者进行随访．对不同吻合方法的效果作对比分析。采用黏膜下隧道法吻合6例11侧，黏膜沟法吻合10例19侧，改良黏膜沟法吻合42例84侧．改良乳头种植法吻合2例4侧。结果：吻合一侧所需时间．黏膜下隧道法和黏膜沟法为25min，改良黏膜沟法8min，改良乳头种植法5min。无吻合口漏及输尿管反流并发症，吻合口狭窄均见于黏膜下隧道法。结论：改良黏膜沟法和直接种植法是肠代膀胱输尿管吻合的理想方法。     

根治性膀胱切除＋回肠原位新膀胱术后尿漏防治

目的探讨回肠正位新膀胱术后尿漏的原因及防治措施。方法回顾性分析102例行根治性全膀胱切除术＋回肠正位新膀胱术膀胱癌患者的临床资料。结果 102例患者中有9例发生尿漏,占8.8%。其中,新膀胱尿道吻合口漏5例,经局部引流等综合治疗后痊愈;输尿管代膀胱吻合口完全离断、输尿管腹腔漏2例,于术后即刻行输尿管与对侧输尿管端侧吻合痊愈;输尿管回肠漏1例,于术后1个月行输尿管代膀胱再次吻合后痊愈;代膀胱乙状结肠漏1例,术后2个月行结肠造漏、尿液充分引流治愈。结论回肠正位新膀胱术后尿漏的发生与吻合口近远端的血运不良、吻合口张力大、吻合器使用不当及合并有重度贫血、低蛋白血症等有关。膀胱尿道吻合口漏经牵引、引流、支持治疗可治愈,而出现腹腔内的漏尿,肠道内的漏尿需及时选用相应手术方法干预。     

Long-term results of orthotopic neobladder reconstruction after radical cystectomy

OBJECTIVE: To assess, in a retrospective study, the long-term results of neobladder reconstruction after radical cystectomy, as this is the standard of care for muscle-invasive bladder cancer. PATIENTS AND METHODS: Data were retrieved for all patients with muscle-invasive transitional cell carcinoma of the bladder treated by radical cystectomy and orthotopic neobladder substitution between 1988 and 1998. All perioperative and long-term complications were recorded. The voiding pattern, frequency of micturition and continence were assessed, and a complete urodynamic profile recorded. RESULTS: In all, 102 patients underwent radical cystectomy with orthotopic neobladder reconstruction in the study period; their mean (range) follow-up was 73 (36-144) months. Neobladder substitution was with an ileocaecal segment in 35 patients, sigmoid colon in 34 and ileum in 33. Early complications occurred in 32 patients (31%) although open surgical intervention was required in only nine (9%). The death rate after surgery was 3.9%. Late complications occurred in 31 patients (30%) and were primarily caused by uretero-enteric and vesico-urethral strictures (9% each). Most patients had daytime (89%) and night-time (78%) continence. The mean maximum pouch capacity (mL) and pouch pressure at capacity (cmH2O) were 562.5 and 23 (ileocaecal), 542 and 17.8 (sigmoid) and 504 and 19.1 (ileal), respectively; the mean postvoid residual was 29, 44 and 23 mL, respectively. Nine patients with ileocaecal neobladders, and 20 and seven with sigmoid and ileal neobladders, required clean intermittent catheterization. Twenty-four patients had recurrence of disease, of whom 20 died. CONCLUSIONS: Orthotopic neobladder reconstruction requires complex surgery but has an acceptable early and late complication rate in properly selected patients. It provides satisfactory continence without compromising cure rates.     

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。     

Urodynamic analysis of voiding dysfunction in orthotopic ileal neobladder

We examined the urodynamics, particularly voiding dysfunction, in patients with a neobladder. Free uroflowmetry, pressure-flow study, and voiding cystourethrography were performed in 22 patients (mean age 65 years) at a mean of 21 months after ileal neobladder substitution. The results of free uroflowmetry were used to divide patients into two groups: the good voiders and the poor. Daytime continence was achieved in all patients, while 10 (45%) had nighttime continence. To void 250 ml urine the good voiders strained 2 ± 1.5 times, and the poor voiders 6 ± 5 times. The neobladder neck was at the most caudal portion of the reservoir in good voiders, and there was wide funneling. In the group with poor emptying ability, the outlet was not located at the most dependent position. The principal factors for ensuring good voiding function in neobladder patients are the ability to perform effective straining and the location of the neobladder neck.     

Functional and oncological outcomes after orthotopic neobladder reconstruction in women

OBJECTIVE

To review our experience with orthotopic neobladder reconstruction (ONR) in women, highlighting functional and oncological outcomes, as ONR has been used increasingly for urinary diversion in women after radical cystectomy (RC), largely due to a better understanding of the natural history of urothelial cell carcinoma (UCC) and of the anatomy underlying the female continence mechanism, but defining the safety and long‐term efficacy of ONR remain important to expanding its use.

PATIENTS AND METHODS

We identified 59 women who had RC with ONR between 1995 and 2006 at the Mayo Clinic. Their records were reviewed for clinicopathological demographics, and functional and oncological outcomes.

RESULTS

The median (range) age at surgery of the women was 62 (20–82) years, and the median follow‐up was 29.2 (1–141) months. Fifty‐three women had RC for malignant disease, including UCC in 47. Five women (8.5%) required resection of the anterior vaginal wall during surgery, while 39 (66%) had concurrent hysterectomy. One patient had a positive surgical margin, at the left distal ureter, on final pathology. Thirteen (22%) patients had perioperative complications, including two (3%) who required reoperation. In addition, three patients (5%) developed a neobladder‐vaginal fistula after RC with ONR, requiring surgical repair. At the last follow‐up, daytime urinary continence (defined as needing no pads) was reported by 44/49 (90%) patients, while 28/49 (57%) had achieved continence at night. Seventeen (31%) patients required intermittent self‐catheterization to facilitate emptying of the neobladder. Fifteen (28%) women had recurrence of disease, at a median of 8 (2–36) months after ONR, including seven (13%) who developed a pelvic recurrence. Twelve (20%) patients died during the follow‐up, with four (8%) dying from UCC at a median of 14 (11–65) months after surgery.

CONCLUSION

ONR provides a safe and effective option for urinary diversion in women, with oncological and functional outcomes similar to those for men. Thus, the technique remains a preferred option for urinary diversion in appropriately selected women treated with RC.     

回肠原位新膀胱术后10年以上患者随访

目的 总结回肠原位新膀胱手术的远期效果. 方法 1991至1998年共施行回肠原位新膀胱手术79例.男73例,女6例.平均年龄55(41～75)岁.术后随访时行肾功能、电解质、血常规等测定,B超测定残余尿,作IVU或MRU检查;测量术后5、10～14和15年患者肾盂最大横径和膀胱最大垂直和水平径线,不同时段结果间作两两比较;观察肿瘤局部或远处是否复发以及手术并发症等. 结果获随访64例.男58例,女6例.平均随访167(121～216)个月.死于非肿瘤原因7例,肿瘤盆腔复发7例,尿道复发2例,死于肿瘤远处转移3例,输尿管再发肿瘤1例,新膀胱再发肿瘤1例.存活时间＞10年者48例,术后5、10～14和15年患者SCr、BUN、K+、Na+、Cl-、Ca2+和血红蛋白测定均在正常值范围,且不同时段间比较差异无统计学意义(P＞0.05);5、10～14和15年平均肾盂最大横径分别为14.0、14.1和13.7 mm(P＞0.05);平均膀胱最大垂直径线分别为110.4,111.5和127.0 mm,水平径线分别为90.4、95.3、97.0 mm(P＞0.05).残余尿＞50 ml者5例,随访期间残余尿量均未见明显增加.发生新膀胱结石8例,经腔内碎石治愈;尿道狭窄2例,经内切开治愈;腹股沟疝14例,再手术治愈12例.无与手术或肿瘤有关并发症者17例. 结论回肠原位新膀胱术后上尿路和新膀胱功能能够保持长期稳定,肿瘤治愈率满意,但术后需要终身随访.     

Quality of life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion

The impact of bladder removal and urinary diversion for patients' everyday life is largely unknown. The aims of this study were to compare subjective morbidity of ileal neobladder to the urethra versus ileal conduit urinary diversion and to elucidate its influence on quality of life. A total of 102 patients who underwent cystectomy due to a bladder malignancy were included in the study. In 69 patients (67.6%) an orthotopic neobladder and in 33 patients (32.4%) an ileal conduit was performed as urinary diversion. The compliance was 99% and mean follow-up was 37 months. All patients completed two retrospective quality of life questionnaires, namely the QLQ-C30 and a questionnaire developed at our institution to ask for urinary diversion specific items. The questioning and assessment was performed by non-urologists. The results obtained from the validated (QLQ-C30) and our own specially compiled questionnaire clearly demonstrate that patients with an orthotopic neobladder are more able to adapt to the new situation than patients with an ileal conduit. In addition, neobladder to the urethra improves the quality of life because it improves self-confidence, causes better rehabilitation as well as the restoration of leisure, professional, travelling, and social activities, and reduced risk of inadvertent loss of urine. For example, 92.8% of neobladder patients did not feel handicapped at all, and 87% did not feel sick or ill, in contrast to 51.5% and 66.7% of ileal conduit patients, respectively. Of the neobladder patients, 74.6% felt absolutely safe with the urinary diversion in contrast to 33.3% in the ileal conduit group. Only 1.5% of neobladder patients had wet clothes caused by urine leakage during the day, versus 48.5% of ileal conduit patients. Moreover, 97% of our neobladder patients would recommend the same urinary diversion to a friend suffering from the same disease, but only 36% of ileal conduit patients would do so. These results demonstrate that the quality of life is preserved to a higher degree after orthotopic neobladder than after ileal conduit urinary diversion.