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。     

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。     

膀胱全切原位尿流改道术治疗膀胱非尿路上皮癌的疗效评价

目的：评价膀胱全切原位尿流改道术治疗膀胱非尿路上皮癌的疗效.方法：对17例膀胱非尿路上皮癌患者行根治性膀胱全切,盆腔淋巴结清扫;然后取一段肠管缝制成新膀胱,分别与输尿管和尿道残端吻合,实现原位尿流改道.结果：手术均获成功,手术时间172～380 min,平均310 min.16例获得随访,平均随访67个月（1～16年）.6例因肿瘤复发或转移于5年内死亡,2例死于非肿瘤因素,1例仍在随访,7例存活已达5年.结论：根治性膀胱全切原位尿流改道术治疗膀胱非尿路上皮癌,具有较好的治疗效果,能明显改善患者生活质量.     

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。     

截断式输尿管末端切除治疗输尿管口周围肿瘤

目的 探讨经尿道切除输尿管口周围膀胱肿瘤的有效方法。方法回顾性分析2021年1月至2021年10月期间中国人民解放军总医院泌尿外科医学部收治的15例接受截断式输尿管末端切除术患者的临床资料。所有肿瘤边缘距离输尿管口均在0.5 cm以内。所有患者均行β刀截断式输尿管末端切除术,术后定期随访。统计并分析手术时间、出血量、闭孔神经反射发生率、膀胱肿瘤复发、肾积水情况等。结果 15例患者均顺利完成手术,手术时间10～32 min,平均(21.1±6.2)min,均未发生闭孔神经反射及围手术期出血。患者术后均留置6F输尿管支架管,术后1个月应用膀胱镜拔出。术后病理均为非肌层浸润性尿路上皮癌,其中低级别12例、高级别3例,肿瘤基底部及切缘均为阴性。患者均接受6～15个月的随访,平均(10.7±3.3)个月,未见上尿路积水和输尿管、肾盂肿瘤及膀胱肿瘤复发。结论 截断式输尿管末端切除术治疗输尿管口周围膀胱肿瘤具有手术解剖清晰、切除范围精准、并发症少的特点,在彻底切除肿瘤的基础上能够保留输尿管膀胱壁内段的形态和功能,是治疗输尿管口周围膀胱肿瘤安全、有效的新术式。     

改良根治性全膀胱切除原位新膀胱术(附9例报告)

目的探讨改良根治性全膀胱切除原位新膀胱术的临床疗效。方法采用改良全膀胱切除回肠新膀胱术治疗浸润性膀胱癌9例,均为男性,年龄40～64岁,平均55岁。尿路上皮癌8例,按WHO分级标准,Ⅱ级5例,Ⅲ级3例;腺鳞癌1例。肿瘤多发6例,均为尿路上皮癌,肿瘤最大径1.5～11.0cm。TNM临床分期:T2N0M07例,T3N0M01例,T4N1M01例。结果手术时间210～330min,平均260min。术中出血量200～800ml。输血5例,输血量400～600ml。病理分期:T2aN0M05例,T2bN0M01例,T4aN0M02例,T4N2M01例。9例患者术后均获得随访,随访时间10～64个月。7例无瘤生存,肾功能良好;2例术后2年死亡(1例腺鳞癌者死于全身转移,1例死于意外事故)。所有病例白天控尿均良好,夜间控尿良好5例,剩余尿量0～50ml。1例术后出现上尿路扩张积液、肾功能不全,为两侧输尿管末端粘连所致,经内镜下粘连松解后积液消退,肾功能恢复正常。2例年龄<50岁者,术后6个月有阴茎勃起,服用西地那非片可完成性活动。结论改良根治性全膀胱切除原位新膀胱术是治疗浸润性膀胱癌的理想方法之一。     

TUR术治疗原位新膀胱术后再发尿道癌

目的 探讨膀胱癌全膀胱切除原位新膀胱术后再发尿道癌的治疗方法.方法 膀胱癌行全膀胱切除原位新膀胱术患者89例,术后发生尿道癌5例(5.6%),再发尿道癌平均时间18(9～32)个月.5例患者病理分期为T1～T2.因复发性膀胱癌行全膀胱切除术4例,因膀胱多发癌行全膀胱切除术1例.采用乙状结肠原位新膀胱术3例,回肠原位新膀胱术2例.5例患者术后因排尿不畅(3例)、肉眼血尿(1例)、血性分泌物(1例)再次就诊.尿道镜检查发现尿道肿物位于前列腺部尿道2例、阴茎部尿道3例.肿物呈菜花状向尿道腔内生长,可见基底部,肿物直径1～3 cm.尿道镜活检报告均为尿道尿路上皮癌,病理分期为T1～T2.5例均行TUR术,术后病理报告为尿道非浸润性尿路上皮癌Ⅰ～Ⅱ级.术后辅以羟基喜树碱尿道灌注,每周1次,共6周.结果 5例TUR术后平均随访37(24～52)个月,控尿满意,血尿和血性分泌物均消失,尿细胞学检查均为阴性,尿道镜检查无阳性发现.肿瘤未见复发、转移.结论 膀胱癌膀胱全切术后再发尿道尿路上皮癌可以选择保全尿道的TUR术和尿道灌注治疗,疗效较满意且生活质量良好.     

膀胱白斑的临床诊疗探讨（附96例报告）

目的探讨膀胱白斑临床特点及诊断与治疗方法。方法经膀胱镜检查及活检确诊膀胱白斑96例，均采用经尿道电切术治疗，其中14例电切后辅以膀胱药物灌注治疗。结果术后拔除导尿管后患者尿路刺激、下腹不适症状明显改善，随访3个月～2年，未见复发及恶变者。结论经尿道电切术及膀胱内药物灌注是治疗膀胱白斑和预防其恶变的有效方法。     

后腹腔镜联合膀胱电切镜治疗上尿路移行细胞癌

目的 介绍后腹腔镜行肾输尿管全长及膀胱袖状电切治疗上尿路移行细胞癌的经验.方法 经后腹腔镜施行肾输尿管全长及膀胱袖状切除术32例.其中输尿管肿瘤20例,肾盂肿瘤12例.肿瘤位于右侧17例,左侧15例.2例输尿管肿瘤合并膀胱肿瘤.经尿道电切镜距输尿管口约0.5 cm环形切透膀胱全层,对输尿管末端电灼彻底封闭输尿管开口.输尿管末端电切结束退出电切镜后留置尿管.采用腰部3个穿刺套管针入路,行根治性肾切除,输尿管尽量向下游离,下腹部行5～9 cm切口,取出.肾标本,然后行下端输尿管及膀胱袖状切除.结果 31例手术顺利,1例术前有经皮肾镜术史,术中发生十二指肠瘘,手术中转开放修补十二指肠,术后恢复顺利.手术时间2.0～6.5 h,平均3.5 h.出血量25～1 500 ml,平均163 ml.术后随访2～36个月.29例患者无瘤存活;1例患者术后2个月发生膀胱、盆腔转移,目前带瘤存活;1例患者术后2年发生膀胱肿瘤,电切后无瘤存活;1例患者术后第3个月死于心脏疾病.结论 经后腹腔镜手术治疗肾盂和输尿管肿瘤,切口明显小于开放手术,术后恢复快.用电切镜环状切除输尿管末端可完整切除输尿管.     

选择性括约肌切断术治疗脊髓损伤性膀胱尿道功能障碍

行经尿道选择性括约肌切断术２０例，采用膀胱尿道造影尿流动力学同步检查，定位诊断和选择切断。术前间歇导尿控制尿路感染，术后辅以正确手法排尿。２０例术后随访１２～２５个月。剩余尿量降至３０ｍｌ以下，尿路感染控制，中段尿培养阳性率降至１７．６％；ＢＵＮ正常；１１例肾盂输尿管扩张，积水改善；７例有膀胱输尿管返流者中，４例基本恢复，３例明显减轻；最大尿道闭合压平均下降６．３１ｋＰａ；功能性尿道长度平均缩短１．８９ｃｍ；１１例尿失禁得到控制，６例无明显变化，３例加重。     

Upper urinary tract dilation due to conglutination of intraluminal distal ureters after orthotopic neobladder with split-cuff nipple ureteral reimplants: Early results of 8 cases

ObjectiveWe reviewed our experience with dilation of the upper urinary tract caused by the conglutination of distal ureters after orthotopic neobladder reconstruction using the split-cuff nipple ureteral reimplant technique.Materials and methodsFrom January 2000 to April 2007, 250 consecutive patients underwent radical cystectomy and orthotopic neobladder reconstruction. Ureterointestinal anastomosis was performed using the split-cuff nipple technique in 291 renoureteral units. The patients from a single center were followed up for a mean period of 8 months (range 1–22) after surgery. We incised the conglutination band using a transurethral endoscope. Patient characteristics, endoscopic technique, measurement of serum creatinine levels, and results of ultrasonography, cystoscopy, and excretory urography were collected.ResultsHydronephrosis was found in 8 patients (14 renoureteral units) due to the conglutination of the distal ureters to each other (n = 6) or to the neobladder wall (n = 2). After the incision procedure, seven patients had obvious improvement in renal function and hydronephrosis, and their symptoms disappeared. In 1 patient, hydronephrosis developed again because of ureteroenteric stenosis after 7 months and was resolved by open surgical revision. The hydronephrosis had improved greatly in this patient by 5 months after revision.ConclusionConglutination of the distal ureters is a cause of hydronephrosis after orthotopic neobladder reconstruction using the reimplant technique with the split-cuff nipple. Cystoscopy is mandatory in following up patients who have hydronephrosis with the split-cuff nipple ureteral reimplant technique, not only to confirm the diagnosis but to treat the complication by incising the conglutination band. Continued follow-up is required to evaluate the long-term results of this treatment.     

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。     

原位新膀胱术后新膀胱尿道吻合口狭窄的诊断和治疗

目的探讨根治性膀胱切除原位新膀胱术后新膀胱尿道吻合口狭窄的诊断和治疗效果。方法回顾性分析416例男性膀胱尿路上皮癌行根治性膀胱切除原位新膀胱术患者的临床资料,分析新膀胱尿道吻合口狭窄的发生率及其诊断和治疗。结果本组共15例（3.6%）发生新膀胱尿道吻合口狭窄,Ⅰ级狭窄（17F~22F）5例,Ⅱ级狭窄（〈17F）8例,Ⅲ级狭窄（针尖）2例。9例表现为排尿困难,3例表现为尿潴留,2例表现为泌尿系感染,1例表现为初发的充盈性尿失禁。7例初始行尿道探子或尿道镜扩张,其中2例无效改行经尿道狭窄钬激光或冷刀切开术,均恢复排尿通畅；3例初始即行经尿道狭窄钬激光或冷刀切开术,均恢复正常排尿；5例初始行单次或多次经尿道瘢痕切除术,4例能排空新膀胱,1例无效行新膀胱腹壁造瘘术。所有患者治疗后均定期随访,平均随访56个月,14例完全排空新膀胱,无患者出现新发的尿失禁。结论原位新膀胱术后新膀胱尿道吻合口狭窄发生率较低,主要表现为排尿困难,尿道扩张和腔内治疗是有效的微创治疗手段,大部分患者能获得满意的疗效。     

Orthotopic ileal neobladder reconstruction in patients with recurring bladder cancer after renal transplantation – a report of two cases and a review of the literature

Abstract:  Renal transplant recipients have a high risk of developing multiple and invasive urothelial tumors because of long-term immunosuppression and infections with oncogenic viruses in China. However, treatment of renal transplant recipients who developed invasive bladder tumor is challenging. We aimed to evaluate the efficacy and safety of orthotopic ileal neobladder reconstruction following radical cystectomy in renal transplant recipients. Orthotopic ileal neobladder reconstruction and preservation of the transplanted kidney were performed in two patients after one and 36 months of transplantation, respectively. One recipient was lacking a bladder because of prior cystectomy before the transplantation, and the other developed multiple and invasive bladder cancer after the transplantation. During the 14-month and seven-yr follow-up postoperation, no serious complications occurred except slight hydronephrosis in one patient. No rejection and graft dysfunction occurred in both patients with reduced dosage of immunosuppressants, and serum creatinine as a marker of renal function remained stable. Urinary continence was satisfactory during the day and night with voluntary voiding. Our experience showed that radical cystectomy and orthotopic ileal neobladder reconstruction in transplant patients with stable renal function is a safe and effective way to provide better quality of life, satisfactory urinary diversion and preservation of renal function simultaneously.     

Results of the ureteral reimplantation with serous-lined extramural tunnel in orthotopic ileal W-neobladder

Background: Our experience in uretero‐ileal anastomosis using the serous‐lined extramural tunnel in orthotopic ileal W‐neobladder is presented. Methods: Between June 1998 and November 2001, 42 patients (40 men and two women) underwent radical cystectomy and orthotopic ileal neobladder for invasive bladder cancer. The ureters were reimplanted into serous‐lined extramural tunnels as described by Abol‐Enein and Ghoneim. However, we made minor modifications during the ureteral reimplantation in cases that necessitated distal ureteral excision and with grossly dilated ureters. Evaluation included clinical and radiographic studies to determine functional and oncological outcomes. Results: There was no operative mortality. The mean follow‐up period was 28 months (range 12–52). Early complications occurred in four patients (9.5%). An endarterectomy for acute popliteal arterial embolism, the excision of the pouchointestinal fistula and a temporary colostomy were performed in two of these four patients. The other two patients were treated conservatively. Late complications occurred in eight patients (19%). Reflux was observed in three renal units (3.7%), ureterointestinal strictures in another three renal units (3.7%) and urethroileal stenosis in two patients (4.8%). In all cases, stabilization or improvement of renal function was achieved. No metabolic complications were observed. Conclusions: Ileal W‐neobladder with a serous‐lined extramural tunnel is a safe, reliable form of lower urinary tract reconstruction. The method can be carried out with equal ease in grossly dilated ureters and in cases that necessitate distal ureteral excision.     

体外协助尿流改道的腹腔镜全膀胱根治性切除术

目的 探讨体外协助尿流改道的腹腔镜全膀胱根治性切除术的疗效.方法 2006年6月～2012年6月施行体外协助尿流改道的腹腔镜全膀胱根治性切除术28例,全膀胱切除和盆腔淋巴结清扫均在腹腔镜下完成,标本自下腹部小切口取出,体外协助尿流改道采用回肠膀胱术（Bricker手术）和原位回肠新膀胱2种术式,其中Bricker手术22例、原位回肠新膀胱术6例.结果 均一次手术成功,腹腔镜盆腔淋巴结清除及全膀胱切除手术时间150～240 min,平均180 min;体外协助尿流改道时间90～270 min,平均150 min;术中出血200 ～900 ml,平均350 ml;肠功能恢复时间3～4d.6例原位回肠新膀胱2～4周拔除导尿管,能正常排尿,无尿潴留和肾功能损害发生.26例随访6～36个月,平均15个月,1例术后23个月死于复发及远处广泛转移,2例死于其他内科疾病,其余患者一般情况良好,未见肿瘤复发及转移.结论 体外协助尿流改道的腹腔镜全膀胱根治性切除术疗效满意.     

腹腔镜下根治性膀胱切除回肠新膀胱术（附15例报告）

目的介绍腹腔镜下根治性膀胱切除回肠新膀胱术的方法及经验。方法本组15例，均为男性，年龄45～62岁，平均54岁。术前均明确诊断为浸润性膀胱癌。采用腹腔镜下行膀胱癌根治性切除，然后取长约40cm回肠于体外缝制贮尿囊及输尿管贮尿囊吻合，体内行贮尿囊尿道吻合术。结果手术时间5．5～8h，平均6．5h；出血量200～1100ml，平均550ml。术后8周静脉尿路造影以及代膀胱造影检查显示：双肾显影良好，无输尿管返流及梗阻，代膀胱充盈良好，容量约300ml。术后3个月全部患者日间控尿良好，7例患者夜间控尿良好，夜间排尿2～3次。结论腹腔镜下膀胱全切除、体外建成贮尿囊及输尿管再植、体内贮尿囊尿道吻合术创伤小、出血少、术后尿控率高、恢复快。     

Orthotopic Ileal Neobladder Reconstruction after Renal Transplant

Radical cystectomy and urinary diversion is an effective curative treatment for muscle invasive bladder cancer. The orthotopic ileal neobladder has become a favorable choice of urinary diversion as it offers superior quality of life, cosmetic outcome and the potential for normal voiding. We treated two patients with bladder cancer who previously underwent renal transplant for end-stage renal disease. Radical cystectomy and orthotopic ileal neobladder reconstruction was performed in both patients. One patient had two renal transplants and underwent transplant nephrectomy at the time of cystectomy. In the other patient, the native kidneys were still present and the ureters were anastomosed to the neobladder. There is excellent function of the neobladder. There were no increased complications seen in these patients. Our cases demonstrate that an orthotopic ileal neobladder is safe and feasible after renal transplant and should be offered to these patients.     

Wallace direct versus anti-reflux Le Duc ureteroileal anastomosis: comparative analysis in modified Studer orthotopic neobladder reconstruction

Objectives: To investigate and compare Wallace direct ureteroileal anastomosis with Le Duc anti‐reflux procedure in modified Studer orthotopic neobladder reconstruction after radical cystectomy. Methods: A total of 72 consecutive patients who underwent modified Studer orthotopic bladder reconstruction after a radical cystectomy for bladder cancer were investigated. They were examined for vesicoureteral reflux, hydronephrosis, and pyelonephritis at 6 months after surgery according to the type of ureteroileal anastomosis. Results: Vesicoureteral reflux occurred in 29 ureters (38.2%) after the Wallace procedure compared to six ureters (9.6%) with the Le Duc (P < 0.05). Hydronephrosis was detected in 12 ureters (18.8%) in the Le Duc patients compared to seven (9%) in the Wallace patients (P > 0.05). Six months after the operation, all three patients with vesicoureteral reflux‐related hydronephrosis improved using clean intermittent catheterization in the Le Duc patients; five of seven patients were cured by clean intermittent catheterization and two improved without any treatment in the Wallace patients. Seven of nine cases of ureteroileal anastomosis stenosis causing hydronephrosis were cured without any treatment but one case resulted in a non‐functional kidney despite treatment of the stenosis. Conclusions: Direct ureteroileal anastomosis using the Wallace method is effective for minimizing ureteroileal anastomosis stenosis and it represents a simple surgical procedure when combined with a modified Studer procedure.