改良Sigma直肠膀胱术

目的评价改良Sigma直肠膀胱术式可控性尿流改道的临床疗效。方法在2002年1月～2004年6月对5例膀胱癌患者采用改良Sigma直肠膀胱术式。折叠乙状结肠约25cm后全层切开，再缝合成低压袋，顶端固定在骶岬处，两输尿管末端合并，从低压袋上方引入，与切除了一小片段的肠黏膜匙形吻合再植。结果全组所有患者尿控率100％，无尿失禁、未发生明显酸碱平衡紊乱，肾功能损害及上尿路感染、上尿路结石、吻合口狭窄等并发症。结论改良Sigma直肠膀胱术并发症低、尿控效果好，术后生活质量较高，是一种快速、安全并简单易行的尿流改道方法。     

改良Sigma直肠膀胱术109例报告

目的 观察改良Sigma直肠膀胱术可控性尿流改道的临床疗效.方法 对109例膀胱癌患者行改良Sigma直肠膀胱术.折叠乙状结肠约25 cm后全层切开,缝合成低压袋,顶端固定在骶岬处,两输尿管并腔后从低压袋上方引入,作外翻乳头插入式吻合. 结果术后患者尿控率100%,无尿失禁,未发生明显酸碱平衡紊乱.双肾积水1例,行穿刺造瘘;1例吻合口狭窄,扩张后好转;1例右侧返流性肾盂肾炎、肾功能减退,行乙状结肠皮肤造口后改善.结论 Sigma直肠膀胱术并发症低、尿控效果好,是一种生理干扰小、安全并简单易行的尿流改道方法.     

膀胱全切改良 Sigma 直肠膀胱术 10 例临床疗效分析

目的 探讨膀胱全切改良Sigma 直肠膀胱术的临床疗效.方法 2006年1月～2008年1月对10 例男性膀胱癌患者行膀胱全切后均行改良Sigma 直肠膀胱术,折叠乙状结肠约25cm 后全层切开,缝合成低压袋,两输尿管并腔后从低压袋上方引入,外翻乳头插入式吻合.结果 改良 Sigma 直肠膀胱手术时间60min.术后全部获得随访,随访5～24个月,平均16 个月,全部病例尿控良好.无明显酸碱平衡紊乱.1例单侧轻度肾积水.结论 改良 Sigma 直肠膀胱术手术时间短、操作简单、并发症少、尿控效果好且更符合生理要求,可明显提高患者生活质量.     

改良的肾盂癌肾输尿管全切术

目的：探讨经尿道输尿管口环切在肾输尿管全切术中的临床应用价值。方法：经尿道输尿管口环切后，作腰部斜切口行肾输尿管全切治疗肾盂移行细胞癌10例，并与传统的双切口肾输尿管全切术进行比较。结果：10例术后无一例出现尿漏，感染，出血等并发症，平均手术耗时2．5h，术后平均住院8d，与双切口术式相比差异有极显著性意义（P＜0．01），术后随访3－20个月，膀胱镜和CT检查未发现肿瘤复发，结论：本改良术式创伤小，并发症少，操作简单，疗效确切，较传统的双切口肾输尿管全切术有明显优点，值得推广应用。     

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。     

膀胱全切改良MainzⅡ尿液转流术综合疗效评价

目的：综合评价膀胱全切改良MainzⅡ尿液转流术的临床效果。方法：对31例膀胱根治性切除患者行改良MainzⅡ尿液转流术,即乙状结肠及直肠“N”形折叠缝合去管囊化形成低压肠袋,分别于术后3个月、6个月、1年、2年、3年、4年、5年监测肾功能、血电解质和输尿管、肾盂反流及上尿路并发症,同时作肿瘤患者生活质量评价（QOL）。结果：全组手术顺利,手术时间180～240min,平均210min,失血量200-1400ml,平均370ml。随访6～60个月,1例术后10天出现肠漏（尿粪漏）,经留置盆腔引流管（经尿道置人）,加强肛管引流而愈;3例膀胱肿瘤复发,术后8～24个月因肿瘤复发转移死亡;余28例恢复良好。术后综合评估结果：①上尿路并发症（〉3个月）：3例上尿路感染7次,经抗感染治愈;3例一侧、1例两侧肾盂轻度扩张,经观察未加重,1例一侧肾盂中度扩张,正在观察中;输尿管、肾盂反流：4例贮尿囊造影无输尿管、肾盂反流。②生化检查：死亡的3例患者在晚期多项生化指标有不同程度异常;上尿路感染的3例在急性期尿素氮、血肌酐、尿酸有轻中度升高,其余25例肾功能、血钾、血钠、血氯、血浆二氧化碳结合力均正常,无高氯血症、代谢性酸中毒。③控尿率：3个月后昼夜静息及日常活动时的尿液均可控,控尿率为100％。④夜尿次数：3个月后,晚11时到次日晨7时夜尿1～3次,尿粪可分开排泄,尿量320～550ml,平均410ml。⑤QOL评分：本组38～52分,平均45分,生活质量较好。结论：改良MainzⅡ尿液转流术较易操作,并发症少,生活质量较高,接近正常生理,有仿生学意义,是医患双方均易于接受的术式。     

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。     

带蒂大网膜移植修补肾移植术后复杂性尿瘘

目的探讨带蒂大网膜移植修补肾移植术后复杂性尿瘘的应用价值。方法肾移植术后尿瘘行多次手术失败的患者21例，年龄23-55岁，平均32岁。尿瘘瘘口部位：肾盂2例，输尿管2例，输尿管膀胱吻合口11例，输尿管末端坏死6例。肾盂瘘切除瘘口后局部修补再用带蒂大网膜移植覆盖，输尿管瘘、输尿管膀胱吻合瘘或输尿管长段坏死者在行移植肾输尿管与自体输尿管对端吻合或与膀胱再植后用带蒂大网膜包绕于吻合口。结果21例患者手术一次成功20例（95％），失败1例（5％）。手术时间75-120min，平均95min。术中失血100-550ml。平均310ml。失败原因为伤口感染导致大网膜坏死而切除移植肾。随访1-7年，尿瘘无复发，吻合口无狭窄、肾积水及尿路感染，肾功能正常。结论利用大网膜的生物学特性，采用带蒂大网修补肾移植术后复杂性尿瘘取材方便，组织修复快，尿瘘复发率低，一次成功率高。     

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。     

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。     

阑尾与尿道吻合的回盲肠代膀胱手术远期疗效观察(附11例报告)

目的　评价阑尾与尿道吻合的回盲肠代膀胱手术远期疗效。　方法　应用回盲肠作贮尿囊 ,阑尾代后尿道原位排尿的方法治疗膀胱肿瘤病人 5 6例。　结果　 11例病人术后获 10年以上随访。其中白天完全自控排尿 10例 ,夜间完全自控排尿 8例。伴后尿道假性瓣膜 2例 ,贮尿囊内继发结石 1例 ,后尿道狭窄 1例 ,无输尿管返流 ,无高氯性酸中毒。贮尿囊容量 2 90～ 5 2 0ml,平均 388ml,压力 2 3～ 36cmH2 O(1cmH2 O =0 .0 98kPa) ,平均 2 8cmH2 O。平均尿流率 9.6ml/s。　结论　阑尾与尿道吻合的回盲肠代膀胱术式具有贮尿囊内压低 ,容量大 ,可控性和原位排尿的优点 ,是一种较理想的尿流改道方式。     

Clinical experience in a modified Roux‐Y‐ shaped sigmoid neobladder: assessment of complications and voiding patterns in 43 patients

Study Type – Therapy (case series)Level of Evidence 4

OBJECTIVE

To evaluate the complications and urinary voiding patterns in patients with a new Roux‐Y‐shaped continent neobladder, using a modified sigmoid pouch.

PATIENTS AND METHODS

Between June 2003 and July 2008, 43 patients (26 men and 17 women, mean age 69.5 years) underwent a modified Roux‐Y‐shaped sigmoid continent neobladder reconstruction after radical cystectomy. The surgical procedures involved the construction of a Roux‐Y‐shaped sigmoid pouch, making an antifeces‐refluxing valve into the sigmoid urine reservoir and ureterosigmoidostomy using the Leadbetter method. This pouch method has not been described before. The patients’ clinical, biochemical, radiological and urodynamic variables were assessed.

RESULTS

During the mean (range) follow‐up of 24 (6–65) months, there were no deaths related to the procedure. In 16% of the patients, early complications occurred, whereas 12% had late complications. There were no cases with local recurrence and metastasis. Routine electrolyte evaluation revealed a slight metabolic acidosis in six patients (14%). Hypovitaminosis B₁₂ did not occur in any patients. All patients were continent in the daytime and night‐time continence was poor in eight patients (19%). The mean (sd , range) neobladder capacity and residual urine volume was 330 (110, 120–410) mL and 48 (26, 25–80) mL, respectively. Moreover, the maximum urinary flow rate was 9.2–25.3 mL/s.

CONCLUSION

The modified Roux‐Y‐shaped sigmoid neobladder replacement provides a new simple surgical procedure with low complication rates. The procedure offers comparatively satisfactory daytime continence with low postvoid residual urine volumes and voiding patterns. This technique is a valid alternative to continent urinary diversion.     

腹腔镜下膀胱全切除-乙状结肠新膀胱术初步报告

目的 探讨腹腔镜下膀胱全切除-乙状结肠新膀胱手术方法。方法 浸润性膀胱癌患者4例。均为男性。年龄58—74岁，平均65岁。手术采用气管内全麻、膀胱截石位、头低15℃，下腹部置入5根套管，腹压设定12mmHg（1mmHg=0．133kPa）。在髂总动脉分叉处剪开腹膜，找到输尿管向下游离至膀胱，剪开髂血管鞘，行盆腔淋巴结清扫；游离输精管及精囊，切开狄氏筋膜分离狄氏间隙；分离膀胱前间隙，切开两侧盆筋膜反折和耻骨前列腺韧带，缝扎阴茎背深静脉复合体；切断输尿管及膀胱前列腺侧血管蒂；剪断阴茎背深静脉复合体及尿道，将前列腺及膀胱一并切除。距肛门15cm处切开乙状结肠，将标本经该开口从肛门取出；隔离15cm乙状结肠，将肠道吻合器经肛门插入，乙状结肠近远端作端端吻合。在隔离乙状结肠肠管的中点作一小切口，将该口与尿道断端吻合；插入Foley导尿管，左右输尿管种植在乙状结肠肠管两端，将输尿管末端插入乙状结肠内1cm，4-0可吸收线固定4—6针。关闭乙状结肠两端开口，用剪刀小心剪开前结肠带，形成去带乙状结肠膀胱。结果 手术时间7—9h，出血量200～350ml，术后第3天肛门排气，第2周拔除导尿管。术后1—3个月恢复控尿功能，膀胱容量200—300ml，无上尿路梗阻及返流，无明显围手术期并发症。结论 腹腔镜下膀胱全切除-乙状结肠新膀胱术技术可行，手术效果良好。     

A new technique for continent urinary reservoir reconstruction

A new technique for urinary reservoir reconstruction has been applied to 14 patients following radical cystectomy. The sigmoid colon was used in 10 cases and the ileum in 4. The pouch is constructed of adjacent detubularized intestinal segments. The continence mechanism is achieved by the formation of a double-jacket intestinal tube anastomosed to the skin. All patients except 1 were continent during stressful situations and resting with easy catheterization of the pouch. Urodynamic study in 3 cases showed a low pressure sigmoid reservoir with an average of 15 cm. water, and the tube had good tone with an average of 35 cm. water and a 5.5 cm. functional length. The technique is simple, can be applied to either the sigmoid colon or ileum and results in urinary continence with easy catheterization.     

改良Sigma直肠膀胱术中输尿管单腔、并腔肠吻合的疗效分析

目的 评价改良Sigma直肠膀胱术中输尿管单并腔肠吻合的疗效.方法 对14例膀胱多发移行细胞癌、1例膀胱腺癌根治性膀胱全切术后患者行改良Sigma直肠膀胱术.折叠25 cm直肠乙状结肠缝合成U形储尿囊,其中输尿管分别单腔与储尿囊吻合5例、双输尿管末端1.5～2.0cm并腔缝合后与储尿囊吻合10例.结果 15例患者控尿良好,无明显水电解质酸碱紊乱,术后15～22 d痊愈出院.13例随访8～24个月,其中输尿管单腔肠吻合4例出现吻合口狭窄、轻～重度肾积水,并腔肠吻合9例未出现肾积水.结论 改良Sigma直肠膀胱术创伤小、并发症少,患者可通过肛门括约肌自控排尿,无需配带尿袋或间断导尿,符合生理要求,提高了患者的生活质量;输尿管并腔后吻合口径大,不易发生狭窄等严重并发症.

Abstract：

Objective To make a comparison of curative effect of 1 and 2 ureters anastomosis in modified sigma operation. Methods Modified sigma operation was used after radical cystectomy in 14 cases of bladder transitional cell carcinoma and 1 case of adenocarcinoma of the bladder.We used a folded suture of 25 cm from the sigmoid colon to make the U-shaped urinary reservoirs to anastomose with the ureters in study group.Among study group,1 ureter was anastomosed with urinary reservoir in 5 cases.In the other 10 cases,1.5-2 cm of the terminal parts of 2 ureters were sutured tI am not sure what the authors mean by "big diamogether and then anastomosed with the urinary reservoir.Results 15 cases obtained good voiding control and no obvious water-electrolyte disturbance occurred.All the patients were cured and discharged within 15 to 22 days.Thirteen cases were followed-up in 8 to 24 month time period.Anastonmtic stenosis and moderate-severe hydronephrosis occurred in 4 cases with 1 ureter anastomosis.No hydronephrosis occurred in the 9 cases with 2 ureters anastomosis.Conclusions Modified sigma operation has the advantages of less injury and fewer complications.The patients can obtain self-control urination by anal sphincter without urine bags or intermittent catheterization,so the life quality of the patients is improved.Modified sigma operation with 2 ureters anastomosis has big diameter and there was a lower incidence of serious complications such as anastomotic stenosis.     

Continent urinary diversion after radical cystectomy: 3 years' experience

The authors performed 27 continent urinary diversions among 36 urinary diversion operations between 1992 and 1995. Fifteen orthotopic diversions (14 ileal neobladders, 1 sigma neobladder) and 12 Mainz pouch II were created. During these 3 years, 4 patients died after operation. Tumour progression was observed in four patients. Three ureteral and 1 urethral stricture developed, 1 patient had complete incontinence (after Mainz pouch II operation) and another three had stress and night incontinence. In 12 patients a modified Hautmann operation was performed (modified by the authors) and the ureters were implanted in a 15 cm long tubular afferent ileum. Also they changed the convential Goodwin technique for ureter implantation in Mainz pouch II operation and instead they used the Paquin technique for ureter reimplantation in the sigma. The authors concluded according to the literature and their own results that continent urinary diversion (ileal or sigma neobladder or Mainz pouch II) could be the first choice after radical cystectomy to achieve for these patients a better quality of life.     

腹腔镜下膀胱全切除——MainzⅡ式膀胱术6例报告

目的探讨腹腔镜下膀胱全切除——MainzⅡ式膀胱术的可行性。方法 2005年4月～2009年3月对6例浸润性膀胱癌行腹腔镜下膀胱全切除。下腹部置入5个trocar。先于腹腔镜下分离切除膀胱,并做盆腔淋巴结清扫。女性患者一并切除子宫、附件。再于直肠起始端对系膜缘切开直肠约10 cm,将标本经此开口从肛门取出,女性患者自阴道残端取出。于下腹正中做一15 cm纵切口。再取乙状结肠约10 cm,对系膜缘剖开,切口与直肠切口相连接,将所取直肠和乙状结肠从连接处对折双层缝合成贮尿囊后壁,左右输尿管分别与乙状结肠和直肠吻合,黏膜下潜行2～3 cm。双侧输尿管支架管由直肠引出体外,贮尿囊内放置F26三腔Foley 1根,最后双层缝合前壁建成Mainz贮尿囊。结果 6例腹腔镜下膀胱全切成功,手术时间500～660 min,平均540 min;出血量100～150 ml,平均120 ml。肛管保留7～10 d,双侧输尿管支架管保留14 d。6例随访3～24个月,平均12个月,1例术后有尿失禁,1个月后自行消失,另5例排尿正常;6例均无复发,均无上尿路梗阻及返流。结论腹腔镜下膀胱全切除——MainzⅡ式膀胱术技术简便可行,出血少,并发症少,效果良好,值得推广。     

可控回肠袋代膀胱术40例随访报告

为探讨可控回肠袋代膀胱术的远期效果，对１９８８年１０月～１９９６年１２月收治的４０例病人进行随访分析。随访１２～９６个月。结果：白天完全自控排尿４０例（１００％），夜间完全自控排尿３４例（８５％）。偶有遗尿４例，需垫尿垫２例（５％），输尿管返流２例（５％），代谢性酸中毒２例（５％），无再手术和手术死亡病例。认为可控回肠袋代膀胱术具有手术成功率高，可控性好，远期并发症少的优点，是尿路改道的较理想术式