原位尿流改道的现状及我院15年经验回顾

膀胱癌根治术目前仍然是治疗浸润性膀胱癌最有效的方法，在根治肿瘤的同时，如何重建储尿、排尿功能更接近生理状态的下尿路和保护肾功能是泌尿学者一直探索的问题。近50年来，利用肠道进行尿流改道主要有非可控皮肤尿流改道、可控皮肤尿流改道和原位尿流改道3种，而在过去近20年中，原位尿流改道在全世界许多医学中心的应用已达到膀胱全切患者术后尿流改道的（60％～70％）。     

腹腔镜下膀胱全切尿流改道术式的临床选择及疗效分析

目的分析腹腔镜下膀胱全切尿路改道术式的选择及疗效。方法86例腹腔镜下膀胱切除术患者,分为：A组,41例,Studer原位膀胱术;B组,45例,Kock回肠膀胱术。比较手术时间、出血量、输血量及住院时间;比较随访半年的控尿率及并发症。结果与B组相比,A组手术时间、出血量及输血量较少（P〈0．05）,而住院时间差异无统计学意义（P〉0．05）;A组控尿率较高（P〈0．05）,但并发症差异无统计学意义（P〉0．05）。结论腹腔镜下膀胱全切Studer原位膀胱术临床疗效好,而Kock回肠膀胱术生活质量高。     

女性尿道综合征尿流动力学检查的意义

目的探讨尿流动力学检查在女性尿道综合征诊治中的作用。方法采用美国Laborie尿流动力学检查仪对23例女性尿道综合征患者进行尿流动力学检查,并根据检查结果进行分型及相关治疗。结果不稳定性膀胱7例（30．43％）,远端尿道缩窄14例（60．87％）,逼尿肌无力4例（17．39％）,膀胱颈梗阻2例（8．70％）,低顺应性膀胱2例（8．07％）,逼尿肌尿道括约肌协同失调1例（4．35％）,其中不稳定性膀胱并发远端尿道缩窄5例（21．74％）,不稳定性膀胱并发逼尿肌无力2例（8．70％）。23例患者治愈15例（65．22％）,好转7例（30．43％）,无效1例（4．35％）,总有效率为95．65％。结论女性尿道综合征可由多种类型的膀胱尿道功能异常引起,如果要明确诊断,对症治疗,应常规作尿流动力学检查。     

根治性膀胱全切术后尿流改道术式的选择分析

目的分析因膀胱肿瘤行根治性膀胱全切后的尿流改道手术方式的选择标准及临床效果。方法选择2001年6月～2008年1月我院因膀胱肿瘤行根治性膀胱全切术后并尿流改道的病例共69例．其中回肠膀胱术37例,回肠新膀胱术32例。就两种尿流改道的术式的手术适应证和并发症进行分析。结果69例手术患者均无围手术期死亡。回肠膀胱术者出现酸中毒、电解质紊乱、肠梗阻近期并发症7例;回肠新膀胱出现近期并发症共6例。回肠新膀胱其中3例需压腹排尿或间断导尿,2例女性出现夜间尿失禁．其余术后能自行排尿。术后复查膀胱镜均未见尿道肿瘤复发。结论接受原位新膀胱患者的生活质量要优于接受非可控性尿流改道的患者,但应根据患者的具体情况来选择合适的尿流改道方式,以减少术后并发症的发生。     

回肠膀胱术与原位回肠新膀胱尿流改道术术后患者的健康相关生活质量研究

目的：研究和探讨回肠膀胱术与原位回肠新膀胱尿流改道术在根治性膀胱全切术加尿流改道中的临床疗效,对两种方法在患者健康相关生活质量中的影响加以分析。方法选择2012年6月~2014年12月于本院行根治性膀胱全切术加尿流改道的患者98例作为研究对象,根据不同尿流改道方式分为两组各49例,分别给予原位回肠新膀胱术和回肠膀胱术,对比分析两组患者临床疗效,同时对患者进行至少3个月的随访,针对不同方法对健康相关生活质量的影响进行对比。结果两组在手术时间、术中出血量和住院时间方面差异均无统计学意义（P>0.05）;回肠膀胱组早期并发症发生率为44.9%,原位回肠新膀胱组早期并发症发生率为49.0%,组间差异无统计学意义（P>0.05）。失访18例,其中肿瘤复发转移死亡8例,非肿瘤原因死亡6例,其他原因失访4例。在随访期间发放FACT-BL调查问卷76份,回收有效问卷62份,有效回收率为79.5%,其中回肠膀胱组32份,原位回肠新膀胱组30份。原位回肠新膀胱组患者在躯体状况、家庭社会状况和膀胱癌模块等方面评分优于回肠膀胱组,差异有统计学意义（P<0.05）;FACT-BL总分差异亦有统计学意义（P<0.05）。结论针对膀胱癌进行根治性全切术加用回肠膀胱术与原位回肠新膀胱尿流改道术均能够有效解决临床问题,原位回肠新膀胱尿流改道术在提高患者生活质量方面具有一定的优势,应该根据患者个体化情况,综合患者个人意愿选择合适的方法。     

同伴支持康复模式对前列腺癌术后尿失禁患者控尿功能、膀胱功能及尿动力学指标的影响研究

目的：研究同伴支持康复模式的实施方法及在前列腺癌术后尿失禁患者护理中的应用价值。方法：将我院收治的120例前列腺癌术后尿失禁患者随机分为C组60例和C+T组60例,C组实施常规尿失禁康复模式,C+T组在C组的基础上联合开展同伴支持康复模式。对比两组患者控尿功能的改善效果及膀胱功能指标[膀胱最大储尿量（VMCC）、膀胱顺应性（BC）]、尿动力学指标[最大尿道闭合压（PMUC）、最大尿道压（PMU）、功能尿道长度（FUL）]。结果：C+T组患者控尿功能改善率为93.33%,高于C组的78.33%(P <0.05)。护理后,C+T组患者VMCC、BC均高于C组（P <0.05）,PMUC、PMU、FUL均高于C组（P <0.05）。结论：通过予以前列腺癌术后尿失禁患者同伴支持康复可有效提高患者的控尿功能和膀胱功能,提高尿动力学的改善效果。     

乙状结肠新膀胱术

膀胱全切术后的尿流改道一直是泌尿外科学者探讨的课题。而正位可控肠代膀胱术中 ,以回肠新膀胱和乙状结肠新膀胱术是较接近生理的尿流改道术式 ,特别以乙状结肠原位代膀胱术较为理想。 2 0 0 0年以来我科完成 8例膀胱癌、膀胱全切乙状结肠原位代膀胱术 ,取得了较为满意的疗效。资料与方法　本组 7例为男性 ,1例为女性。年龄 42～ 74岁 ,平均 62岁。术前经B超、KUB +IVU、CT及尿道膀胱镜检查 ,确诊为移行细胞癌Ⅱ -Ⅲ级 5例 ,鳞癌 2例 ,腺癌 1例 ,均为T3 期患者 ,无膀胱颈和尿道侵犯。 8例均行根治性全膀胱切除、乙状结肠原位代膀胱术。…     

盆丛神经的解剖学特点及其临床意义

目的前列腺癌根治术和后尿道断裂所致术后排尿及性功能障碍是常见并发症之一,其病理学基础是损伤形成的血肿以及术中对盆丛神经的解剖认识不足而损伤所致。本文对盆丛神经解剖学特点的研究有利于对预后及术中保护盆丛神经,提高患者生活质量,提供理论学基础。方法采用男性盆腔尸体标本10例进行解剖标记分析,对盆丛的解剖学特点、走向及组织分布进行解剖标记。结果盆丛由腹下神经、骶交感干的分支和盆内脏神经构成,呈直角型,4⁵ cm长,其中点位于精囊的尖端,在矢状面位于直肠的两侧被进入和往返直肠、膀胱、精囊和前列腺的血管穿过。其末端分支形成阴茎海绵体神经(勃起神经),走行与前列腺被膜的5点和7点到达尿道膜部而分成浅支和深支。结论术中如能对盆丛及其次级丛神经加以保护,从而可防止或减少术后排尿及性功能障碍等并发症的发生。     

女性去带乙状结肠原位新膀胱术6例报告

膀胱移行细胞癌分为浅表性肿瘤(T0-1)和浸润性肿瘤(T2-4)。治疗方式的选择上浅表性肿瘤为经尿道膀胱肿瘤切除术(TURBt)加系统性灌注,浸润性肿瘤则行根治切除加一定形式的尿流改道。女性全膀胱切除术后易发生尿失禁,所以对于女性全膀胱切除术后应采取的尿流改道方式仍存在争议。2002年5月~2003年6月,我院对活检证实的6例女性浸润性膀胱肿瘤进行了全膀胱切除,去带乙状结肠原位新膀胱术。随访24个月以上,效果满意,报告如下。1材料与方法1·1临床资料本文6例,年龄58~73岁。术前膀胱活检,病理证实为T2-3GII-III移行细胞癌。尿道无肿瘤生长…     

经会阴超则后尿道尿流速与尿流率诊断膀胱出口梗阻

目的 经会阴部彩色多谱勒超声测后尿道尿流速与同步测尿流率协同诊断膀胱出口梗阻（ＢＯＯ）。方法 对１组１１例有膀胱出口梗阻ＢＯＯ病人进行尿流速与尿流率同步测定；对另１组１１例无膀胱出口梗阻病人进行尿流速与尿流率同步测定进行对照。结果 两组病人测定发现经尿道压力一流率测定不真实。结论 经会阴部彩测后尿道尿流率同步测定对ＢＯＯ是一种较好的、非侵入性的诊断方法。     

早期盆底肌锻炼对产后压力性尿失禁的影响

目的 探讨妊娠分娩前、后全程行盆底肌功能锻炼对女性产后压力性尿失禁的影响.方法 选取孕产妇204例,68例自孕28周开始盆底肌功能锻炼至产后3个月(全程组),68例于产后行盆底肌功能锻炼至3个月(产后组),68例按常规妊娠分娩处理,(对照组).观察阴道分娩前、分娩后3个月盆底肌张力和产后3、6、12个月尿垫试验阳性率.结果 孕28周,各组盆底肌张力对比无统计学差异(P＞0.05 );阴道分娩前,全程组产妇Ⅱ级＜肌张力≤Ⅲ级与Ⅰ级＜肌张力≤Ⅱ级的比率均高于产后组与对照组(P＜0.05),肌张力≤Ⅰ级的明显低于产后组与对照组(P＜ 0.005 );阴道分娩后3个月,全程组产妇Ⅱ级＜肌张力≤Ⅲ级的比率明显高于产后组与对照组(P＜ 0.005),Ⅰ级＜肌张力≤Ⅱ级与肌张力≤Ⅰ级的比率均低于产后组与对照组(P＜ 0.05和尸＜0.005).全程组产后3、6、12个月的尿垫试验阳性率均低于产后组与对照组(全程组:14.7％、7.3％、1.4％,产后组:23.5％、16.1％、7.4％,对照组:39.7％、30.9％、20.6％,P均＜0.005).结论 早期全程行盆底肌功能锻炼能增强盆底肌收缩力,有助于盆底肌功能恢复,预防产后压力性尿失禁.     

尿流动力学与盆底三维超声对女性压力性尿失禁临床诊断价值的对比研究

目的探讨尿流动力学与三维超声在女性压力性尿失禁（SUI）临床诊断价值方面的差异,提高该疾病的诊治水平。方法对5l例临床诊断压力性尿失禁的经产妇分别进行尿流动力学及盆底三维超声检查,分析尿流动力学指标（最大尿道压、最大尿道闭合压、功能性尿道长度、AIPP）、三维超声检查指标（盆膈裂孔的前后径、左右径、面积及耻骨内脏肌的厚度T1、T2,夹角0）与女性压力性尿失禁严重程度的关系;同时对尿流动力学和三维超声检查临床诊断价值进行对比。结果多项logistic分析发现尿流动力学各指标均为影响SUI程度的相关指标,功能性尿道长度为主要影响因素（似然比为0．001）。而在三维超声指标中,在Valsalva动作时,面积A、骨内脏肌的厚度T1与SUI程度相关,T1为主要影响指标（似然比为0．001）。ROC曲线明确尿流动力学诊断价值为0．88,较静息和Valsalva下三维超声的诊断价值高（0．88VS0．58）。结论尿流动力学检查在女性压力性尿失禁的诊断中具有重要的价值,特别是功能性尿道长度的测量能有效地进行严重程度的预判。三维超声技术为压力性尿失禁的评价开辟了新的途径,仍需标准化的检查途径,获得更高的可信度及可重复性。,     

Anatomy and histology of the lower urinary tract

The function of the lower urinary tract is basically storage of urine in the bladder and the at-will periodic evacuation of the stored urine. Urinary incontinence is one of the most common lower urinary tract disorders in adults, but especially in the elderly female. The urethra, its sphincters, and the pelvic floor are key structures in the achievement of continence, but their basic anatomy is little known and, to some extent, still incompletely understood. Because questions with respect to continence arise from human morbidity, but are often investigated in rodent animal models, we present findings in human and rodent anatomy and histology. Differences between males and females in the role that the pelvic floor plays in the maintenance of continence are described. Furthermore, we briefly describe the embryologic origin of ureters, bladder, and urethra, because the developmental origin of structures such as the vesicoureteral junction, the bladder trigone, and the penile urethra are often invoked to explain (clinical) observations. As the human pelvic floor has acquired features in evolution that are typical for a species with bipedal movement, we also compare the pelvic floor of humans with that of rodents to better understand the rodent (or any other quadruped, for that matter) as an experimental model species. The general conclusion is that the "Bauplan" is well conserved, even though its common features are sometimes difficult to discern.     

Therapeutic receptor targets for lower urinary tract dysfunction

The functions of the lower urinary tract, to store and periodically release urine, are dependent on the activity of smooth and striated muscles in the bladder, urethra, and external urethral sphincter. During urine storage, the outlet is closed, and the bladder smooth muscle is quiescent. When bladder volume reaches the micturition threshold, activation of a micturition center in the dorsolateral pons (the pontine micturition center) induces a bladder contraction and a reciprocal relaxation of the urethra, leading to bladder emptying. During voiding, sacral parasympathetic (pelvic) nerves provide an excitatory input (cholinergic and purinergic) to the bladder and inhibitory input (nitrergic) to the urethra. These peripheral systems are integrated by excitatory and inhibitory regulation at the levels of the spinal cord and the brain. Injury or diseases of the nervous system, as well as drugs and disorders of the peripheral organs, can produce lower urinary tract dysfunction. In the overactive bladder (OAB) condition, therapeutic targets for facilitation of urine storage can be found at the levels of the urothelium, detrusor muscles, autonomic and afferent pathways, spinal cord, and brain. There is increasing evidence showing that the urothelium has specialized sensory and signaling properties including: (1) expression of nicotinic, muscarinic, tachykinin, adrenergic, bradykinin, and transient receptor potential (TRP) receptors, (2) close physical association with afferent nerves, and (3) ability to release chemical molecules such as adenosine triphosphate (ATP), acetylcholine, and nitric oxide. Increased expression and/or sensitivity of these urothelial-sensory molecules that lead to afferent sensitization have been documented as possible pathogenesis of OAB. Targeting afferent pathways and/or bladder smooth muscles by modulating activity of ligand receptors (e.g., neurokinin, ATP, or beta(3)-adrenergic receptors) and ion channels (e.g., TRPV1 or K) could be effective to suppress OAB. In the stress urinary incontinence condition, pharmacotherapies targeting the neurally mediated urethral continence reflex during stress conditions such as sneezing or coughing could be effective for increasing the outlet resistance. Therapeutic targets include adrenergic and serotonergic receptors in the spinal cord as well as adrenergic receptors at the urethral sphincter, which can enhance urethral reflex activity during stress conditions and increase baseline urethral pressure, respectively.     

女性压力性尿失禁的发病机制及治疗进展

压力性尿失禁是一种严重影响患者生活质量的疾病,多发生于老年人,随着我国人口老龄化迅速加剧,妇科泌尿系统疾病的发病率不断上升,已经成为影响我国老年妇女生活质量的严重问题,也给政府和家庭带来诸多社会问题和经济负担,近年来针对压力性尿失禁的发病机制和治疗方法的研究,已经得到妇产科学界的重视,其具体的发病机制尚未明确,治疗方法也日趋多样化,为此该文对压力性尿失禁的发病机制和治疗进展进行综述。     

Glutamate-mediated spinal reflex potentiation involves ERK 1/2 phosphorylation in anesthetized rats

The extracellular signal-regulated kinase (ERK) cascades are suggested to contribute to excitatory plasticity in the CNS, including the spinal cord. This study investigated whether the ERK involves in the repetitive stimulation-induced spinal reflex potentiation (SRP) in the pelvic nerve-to-external urethra sphincter reflex activities. External urethra sphincter electromyogram in response to pelvic afferent nerve test stimulation (TS, 1/30 Hz) or repetitive stimulation (RS, 1 Hz) was recorded in anesthetized rats. TS evoked a baseline reflex activity, whereas RS produced SRP in associated with significant ERK 1/2 phosphorylation. RS-induced SRP and ERK 1/2 phosphorylation were both abolished by pretreatment of U0126 (MEK inhibitor). Intrathecal CNQX (AMPA receptor antagonist) attenuated, while AP5 (NMDA receptor antagonist) abolished the RS-induced SRP and ERK 1/2 phosphorylation. Pretreated U0126 abolished the SRP elicited by glutamatergic agonists including glutamate, NMDA and AMPA. Intrathecal H89 and BIS7 (PKA and PKC inhibitors, respectively) both abolished the RS- and glutamate agonist-induced SRP as well as ERK 1/2 phosphorylation. In addition, forskolin and PMA (PKA and PKC activator, respectively) induced SRP, which were both abolished by pretreated U0126. Saline distension, mimicking the storage phase of the urinary bladder, induced SRP and ERK 1/2 phosphorylation. In conclusion, activated ERK 1/2 may produce SRP in the pelvic nerve-to-external urethra sphincter reflex activity, which is essential for urine continence. In addition, blockage of spinal ERK 1/2 activation decreases the physiological function of the urethra, indicating that phosphorylation of the ERK 1/2 cascade may represent a novel target for the treatment of patients with neurological incontinence of spinal origin.     

实时三维超声观察健康成年女性尿道-阴道间隔100例分析

目的：探讨健康成年女性尿道-阴道间隔的实时三维超声表现,为女性尿道-阴道间隔的形态学观察提供有效的影像学方法。方法：对100例正常成年女性进行实时三维超声尿道-阴道间隔检查,分别经腹部及会阴部观察女性尿道-阴道间隔横断面及矢状面的超声声像图表现。结果：100例经实时三维超声均可显示尿道、阴道以及尿道-阴道间隔全程不同横断面及矢状面的声像图,经腹部可清晰显示近段尿道-阴道间隔图像,经会阴部检查可显示整段尿道,其中中段及远段尿道-阴道间隔图像较清晰。不同水平横断面及矢状面尿道-阴道间隔图像均显示由低回声-光带-低回声的＂三文治＂征逐渐融合成一低回声带,融合部起始点以中-远段连接部常见。结论：实时三维超声可显示成年女性尿道-阴道间隔在不同水平横断面及矢状面的超声表现,为女性尿道-阴道间隔疾病的诊断提供了一种新思路。     

Fecal incontinence: a clinical approach

"Fecal incontinence" is defined as the involuntary loss of stool at any time of life after toilet training. It is a socially and psychologically devastating condition for patients and their families, and a topic which both patients and physicians are reluctant to approach. Although the true prevalence of fecal incontinence is unknown, studies have reported it to be as high as 2. 2% in the general population, with significantly higher rates among nursing home residents and hospitalized elderly. Risk factors include advancing age, female gender and multiparity. An understanding of pelvic floor anatomy and physiology is required to appreciate how diverse medical conditions can affect mechanisms involved in normal continence. The rectum serves as a storage reservoir until elimination can take place at a socially acceptable time and place. The pelvic floor muscles help to regulate the defecatory process and maintain continence. These muscles include the internal anal sphincter, the external anal sphincter and the puborectalis muscle. Each muscle contributes to normal continence, although the relative importance of each is controversial. Neurologic integrity and sensation are also key factors. Conditions associated with fecal incontinence include diarrheal states, fecal impaction, idiopathic neurologic injury, surgical and obstetric injury, pelvic trauma, collagen vascular disease, and neurologic impairment related to stroke, diabetes, or multiple sclerosis. Evaluation of the patient with fecal incontinence includes a directed history and physical examination, with particular attention paid to integrity of the perineum and rectum, and a complete neurologic evaluation. Diagnostic tools such as stool studies, anorectal manometry, defecography, electromyography, pudendal nerve conduction, and endoanal ultrasound may be employed in an outpatient setting. Fecal incontinence may be treated conservatively by employing such methods as dietary restriction, stool bulking agents, and biofeedback. Surgery may be the best option for cases refractory to medical treatment, or for those patients with rectocele or obstetrical injury. In this article, we review the presentation, epidemiology, pathophysiology, and etiology of fecal incontinence. Evaluation, including key components of directed history and physical examination, and the appropriate use of diagnostic studies and indications for treatment options are also addressed.     

TOT治疗女性压力性尿失禁疗效分析

目的回顾性分析经闭孔无张力尿道悬吊（TOT）治疗女性压力性尿失禁的安全性和有效性。方法选择2010年1月--2013年12月在该院行TOT治疗的女性压力性尿失禁患者45例，分析患者术后的安全性和有效性。结果尿失禁患者平均手术时间为21min，术后平均住院时间5．6d。术后无严重并发症的出现。术后平均随访时间为18个月，无尿失禁复发，手术治愈率达100％。结论TOT治疗女性压力性尿失禁疗效可靠，安全，创伤小，患者恢复快。     

盆底脏器脱垂患者与下尿路功能障碍关系的探讨

目的探讨盆底脏器脱垂患者与下尿路功能障碍之间的关系。方法于2009年7月-2010年11月对54例诊断为盆腔脏器脱垂的住院患者进行病史采集、妇科检查、POP—Q评分及尿动力学检查,探讨盆腔脏器脱垂与下尿路功能障碍的关系。结果54例POP患者中,出现下尿路主观症状44例,其中尿失禁症状27例（压力性24例,急迫性1例,混合性2例）,尿急和／或尿频27例,排尿功能障碍16例。尿动力学检查结果显示：压力性尿失禁28例,急迫性尿失禁2例,混合性尿失禁2例,伴膀胱顺应性降低1例,腹压排尿3例。腹部漏尿点压力（ALPP）〈60cmH2O有10例,60～90cmH2O13例,〉90cmH2O7例。与尿失禁主观症状的符合率为70％（19／27）;隐匿性尿失禁的发生率为41％（11／27）,均为重度阴道前壁脱垂的患者。结论POP患者术前在减轻脱垂程度情况下行尿动力学检查可更客观地评价下尿路功能障碍,POP患者术前应了解膀胱及尿道括约肌功能,注意排除隐匿性尿失禁。