腹腔镜根治性膀胱切除+原位回肠新膀胱术治疗浸润性膀胱癌的临床疗效分析

目的:探讨腹腔镜根治性膀胱切除+原位回肠新膀胱术治疗浸润性膀胱癌的临床疗效.方法:回顾性分析2010年2月至2015年11月于蚌埠医学院第一附属医院行腹腔镜根治性膀胱切除+原位回肠新膀胱术的32例浸润性膀胱癌患者的临床资料,对手术方法(腹腔镜根治性膀胱切除+原位回肠新膀胱术)、围手术期资料、新膀胱功能、术后并发症以及肿瘤控制情况等进行分析.结果:成功随访32例,随访时间12 ～ 53个月,平均随访27个月,均为男性;所有患者手术均由同一术者顺利完成,手术时间310 ～530 min,平均370 min;术中出血300～ 850 ml,平均485 ml;术后3～5天肠道开始恢复功能;淋巴结清扫数目8～31个,平均16个;手术切缘均无阳性结果;术后12个月与6个月相比较,最大尿流率(15.2±1.3vs11.4±1.2 ml,P＜0.01)、最大膀胱容量(372.8±52.2 vs 247.9±60.3 ml,P＜0.01)、残余尿量(23.8 ±9.6 vs 39.6±11.7 ml,P＜0.01)、最大膀胱充盈压(33.7 ±5.7 vs 25.1±6.8 cmH2O,P＜O.01)、最大膀胱排尿压(63.7±15.9 vs62.9±17.6 cmH2O,P＞0.05)、膀胱顺应性(26.2±12.6 vs 25.7±13.3 cmH2O,P＞0.05)以及昼/夜控尿率(91％/81％ vs 84％/72％).术后近期并发症发生率为18.8％(6/32),远期并发症发生率为25.0％(8/32);随访期间,肿瘤局部复发率和远处转移率分别为6.3％ (2/32)和12.5％(4/32).结论:腹腔镜根治性膀胱切除+原位回肠新膀胱术是安全可行的,具有术后控尿效果好、满意的新膀胱功能和肿瘤控制效果等优点,是治疗浸润性膀胱癌的优先选择.     

经尿道辅助单孔腹腔镜下根治性膀胱切除联合原位回肠新膀胱术的疗效及安全性

目的:探讨单孔腹腔镜下根治性膀胱切除术联合原位回肠新膀胱术的疗效及安全性。方法:选取2017年01月至2019年12月于本中心收治的17例膀胱癌患者,其中7例患者在经尿道途径的辅助下行单孔腹腔镜根治性膀胱切除术联合原位回肠新膀胱术;另外10例为对照组,行多孔腹腔镜下根治性膀胱切除术联合原位回肠新膀胱术,并对两组患者围手术期资料、手术并发症以及术后随访情况进行分析。结果:两组共17例膀胱癌患者均顺利完成手术,无中转开放手术。两组患者的年龄、体质量指数（body mass index,BMI)等差异均无统计学意义（P＞0.05）。单孔组与对照组平均手术时间分别为（341.4±52.1）min和（333.0±59.5）min,术中平均出血量分别为（206.4±104.6）mL和（190.5±82.3）mL,盆腔淋巴结清扫平均个数分别为17（7~22）个和18（12~23）个,术后平均住院天数分别为（25.1±5.4）d和（26.8±6.0）d,差异均无统计学意义（P＞0.05）。而单孔组在术后VAS疼痛评分和切口满意度评分上则优于对照组（P＜0.05）。其中单孔组患者术后随访12个月时患者的最大尿流量、最大膀胱容量、最大膀胱充盈量均明显比6个月时高,而随访12个月时患者的残余尿量较6个月时低,差异均具有统计学意义（P＜0.05）。结论:经尿道辅助单孔腹腔镜下根治性膀胱切除术联合原位回肠新膀胱术是安全可行的,且术后的新膀胱功能较为良好。     

A prospective randomised controlled trial of laparoscopic vs open radical cystectomy for bladder cancer: perioperative and oncologic outcomes with 5-year follow-upT Lin et al

Background:

Laparoscopic radical cystectomy (LRC) is increasingly being used for muscle-invasive bladder cancer. However, high levels of clinical evidence comparing laparoscopic vs open radical cystectomy (ORC) are lacking.

Methods:

A prospective randomised controlled clinical trial comparing LRC vs ORC in patients undergoing radical cystectomy for bladder cancer. Thirty-five patients were eligible for final analysis in each group.

Results:

The median follow-up was 26 months (range, 4–59 months) for laparoscopic vs 32 months (range, 6–60 months) for ORC. Significant differences were noted in operative time, estimated blood loss (EBL), blood transfusion rate, analgesic requirement, and time to resumption of oral intake. No significant differences were noted in the length of hospital stay, complication rate, lymph node yield (14.1±6.3 for LRC and 15.2±5.9 for ORC), positive surgical margin rate, postoperative pathology, or recurrence rate (7 for LRC and 8 for ORC). The 5-year recurrence-free survival with laparoscopic vs ORC was 78.5% vs 70.9%, respectively (P=0.773). The overall survival with laparoscopic vs ORC was 73.8% vs 67.4%, respectively (P=0.511).

Conclusion:

Our study demonstrated that LRC is superior to ORC in perioperative outcomes, including EBL, blood transfusion rate, and analgesic requirement. We found no major difference in oncologic outcomes. The number of patients is too small to allow for a final conclusion.     

腹腔镜根治性膀胱切除+回肠原位新膀胱术疗效分析

目的:回顾分析腹腔镜下全膀胱切除+回肠原位新膀胱术的临床疗效与经验.方法:随访了2006年1月-2012年2月采用腹腔镜下根治性膀胱切除术+回肠原位新膀胱术治疗的87例患者,手术方法为腹腔镜下膀胱全切术+开放新膀胱构建及吻合,并对随访3年的临床数据进行总结分析.结果:大多数患者恢复良好,所有的新膀胱漏尿并发症均被有效处理;仅有1例患者因肠瘘行肠造口,3个月后行肠回纳;术后3年整体生存率为88.5％(77/87),无瘤生存率为92.2％ (71/77);整体控尿功能及肾功能保护方面取得良好效果.结论:腹腔镜下根治性膀胱全切+回肠原位新膀胱术,具有良好的控尿功能和较好的保肾功能,可以明显提高患者生活质量.     

咀嚼口香糖对根治性膀胱全切+回肠膀胱术后患者胃肠功能恢复的影响

目的:探讨咀嚼口香糖对回肠膀胱术后患者胃肠功能恢复的影响.方法:2014年2月至2015年2月我科对146例恶性膀胱肿瘤患者均实施了根治性膀胱全切+回肠膀胱术,将146例患者随机分为实验组和对照组,每组各73例.对照组采用常规的床上活动的护理方法来促进胃肠功能恢复,实验组在采用床上活动的护理常规的基础上,在患者手术完毕回到病房后6小时后开始咀嚼口香糖,每天早、中、晚3次,每次2片,每次时间15分钟,直到肛门排气.观察两组患者术后首次排气时间以及术后发生腹胀的情况.结果:两组患者术后排气时间差异比较有统计学意义(Z=-4.633,P＜0.001),实验组患者术后排气时间短于对照组.结论:咀嚼口香糖有助于根治性全膀胱切除+回肠膀胱术后患者胃肠功能的恢复.咀嚼口香糖是一种价廉、方便的促进肠道蠕动、恢复肠道功能的方法,可作为术后辅助回肠膀胱术患者康复的护理措施.     

Quality of life following urinary diversion: Orthotopic ileal neobladder versus ileal conduit. A multicentre study among long-term,female bladder cancer survivors

IntroductionWomen undergoing radical cystectomy (RC) followed by urinary diversion (UD) for bladder cancer experience a substantial reduction in health-related quality of life (HRQOL). At present, studies comparing long-term QOL outcomes for different UD methods, needed to inform evidence-based choices of bladder reconstruction for female patients, are sparse. Our objective was to compare two common UD methods in terms of their HRQOL outcomes in women.Materials and methodsWe retrospectively analysed HRQOL in 73 consecutive female bladder cancer patients having undergone orthotopic ileal neobladder (IONB, N = 24) or ileal conduit (IC, N = 49) following RC between 2007 and 2013 in six Italian academic urological centres. Patients had no evidence of tumour recurrence and were actively followed up. Validated Italian versions of the European Organisation for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and bladder-cancer-specific (QLQ-BLM30) questionnaires were used to evaluate HRQOL.ResultsPatients in the IONB group were significantly younger than those in the IC group (median age: 67 and 73 years, respectively, p = 0.02). Barring that, the two groups did not present statistically significant differences in median length of follow-up (43 vs 54 months), pathological stage, grading of the neoplasm, or adjuvant chemo - or radiotherapy. No significant differences in QOL were found between the groups, with the exception of financial difficulties, affecting IONB patients significantly more than IC patients (mean score on a scale of 0–100: 33.3 ± 29.5 vs 18.4 ± 19.3, respectively; p = 0.05).ConclusionFinancial difficulties was the only HRQOL item to differ between the two UD groups.     

Treatment of muscle‐invasive bladder cancer: A systematic review

There is uncertainty regarding the use of bladder‐sparing alternatives to standard radical cystectomy, optimal lymph node dissection techniques, and optimal chemotherapeutic regimens. This study was conducted to systematically review the benefits and harms of bladder‐sparing therapies, lymph node dissection, and systemic chemotherapy for patients with clinically localized muscle‐invasive bladder cancer. Systematic literature searches of MEDLINE (from 1990 through October 2014), the Cochrane databases, reference lists, and the ClinicalTrials.gov Web site were performed. A total of 41 articles were selected for review. Bladder‐sparing therapies were found to be associated with worse survival compared with radical cystectomy, although the studies had serious methodological shortcomings, findings were inconsistent, and only a few studies evaluated currently recommended techniques. More extensive lymph node dissection might be more effective than less extensive dissection at improving survival and decreasing local disease recurrence, but there were methodological shortcomings and some inconsistency. Six randomized trials found cisplatin‐based combination neoadjuvant chemotherapy to be associated with a decreased mortality risk versus cystectomy alone. Four randomized trials found adjuvant chemotherapy to be associated with decreased mortality versus cystectomy alone, but none of these trials reported a statistically significant effect. There was insufficient evidence to determine optimal chemotherapeutic regimens. Cancer 2016;122:842–51 . © 2016 American Cancer Society.     

Health related quality of life after radical cystectomy: Comparison of ileal conduit to continent orthotopic neobladder

Aims

To compare health related quality of life (HRQOL) between patients with two different types of urinary diversion, ileal conduit and orthotopic neobladder, and between them and an age-matched population of healthy subjects.

Materials and methods

Eighty eight patients treated with radical cystectomy for bladder cancer at our institutions between 2002 and 2007 were contacted for this survey. All of them had a follow-up of more than 12 months after surgery and were recurrence free. The SF-36 questionnaire was provided to each patient during a follow-up visit at outpatient clinics. Overall, 79 patients (90%) returned the questionnaire and were included in this analysis. They were divided into two groups: group 1 comprised 44 patients with an ileal conduit diversion, and group 2 included 35 patients with a neobladder. As a control, normative values of an age-matched healthy Italian population were considered.

Results

No significant difference was found in scale scores between the neobladder and ileal conduit groups. Scale scores for role-physical functioning, social functioning and role-emotional functioning in both the neobladder and ileal conduit groups were significantly below the Italian population norm. Patients with a neobladder 65 years old or older (n = 18) had significantly lower scores for role-physical functioning and role-emotional functioning than those younger than 65 years (n = 17; p < 0.05).

Conclusion

Few differences between ileal conduit and orthotopic bladder substitution have been detected. Thus, the assumption that continent reconstruction provides better HRQOL than ileal conduit diversion cannot be supported. Patient education and active participation in treatment decisions seem to be the key to postoperative satisfaction.     

保留前列腺远端包膜及精囊对改善原位新膀胱功能及勃起功能的作用

背景与目的:膀胱全切是浸润性膀胱癌的主要治疗手段,膀胱全切后尿流改道方法很多,其中原位新膀胱下尿路重建在近年得到广泛应用.本研究旨在探讨改良根治性全膀胱切除术中保留前列腺远端包膜及精囊对改善原位新膀胱功能及勃起功能的作用.方法:选择2000年1月至2006年12月应用改良根治性膀胱全切及新回肠膀胱术治疗膀胱癌患者27例,同期应用经典术式治疗9例.观察两组患者术后并发症、新膀胱(术后6个月)的储尿、排尿、控尿功能及患者的勃起功能并进行比较.结果:术后随访3～84个月.术后6个月改良和经典组新膀胱容量[(385±68)mL vs.(388±71)mL]、最大充盈压[(24±16)cmH2O vs.(25±15)cmH2O],两组比较差异无统计学意义(P＞0.05).但在最大尿流率[(18±5)mL/s vs.(14±7)mL/s]、剩余尿[(35±16)mL vs.(97±35)mL]、完全控尿率[(24/27)vs.(3/9)]、夜间尿失禁[(3/27)vs.(6/9)]、新膀胱-尿道吻合口狭窄[(4/27)vs.(3/9)],以及患者正常勃起功能术后得以保留[(19/23)vs.(3/7)]方面,两组比较差异有统计学意义(P＜0.05).结论:在改良根治性膀胱全切术中保留远端的前列腺包膜及精囊,可明显改善患者术后的储尿、排尿、控尿功能,保护阴茎的勃起功能,同时可有效防止新膀胱-尿道吻合口狭窄的发生.     

Treatment of muscle-invasive bladder cancer

In the USA, the incidence of bladder cancer is three-times higher in men than in women and it is the fourth most common cancer in men after prostate, lung and colorectal cancer. Muscle-invasive urothelial urinary bladder cancer has a very high mortality rate. This is regardless of intensive therapeutic efforts such as radical surgery in combination with oncological treatment options. The development of treatments with better outcomes regarding disease-specific survival and treatment-inflicted morbidity is likely to occur over the next few years. The significance of meta-analyses on the effect of neoadjuvant chemotherapy, the development of sentinel node dissection and the impact of the introduction of robot-assisted surgery on the possibility of performing minimally invasive surgery in advanced bladder cancer patients is discussed.     

原位低压回肠代膀胱术的技术改进及临床应用

目的：探讨低压回肠代膀胱术的技术改进及远期疗效。方法：对１６ 例全膀胱切除的膀胱癌病人,施行回肠袋近端肠管人工套迭加隧道式输尿管肠吻合术,同时用２ ％ 碘酊处理回肠袋粘膜以减少肠粘膜的分泌与吸收。结果：手术时间平均５ 小时５０ 分钟。术后随访１１ ～７２ 个月,全部病人白天均能自控排尿,无输尿管返流,无代谢性酸中毒,无手术死亡及再次手术。结论：本术式具有成功率高,并发症少,病人术后生活质量高等优点     

Improving bladder cancer patient care: a pharmacoeconomic perspective

Bladder cancer is the most expensive cancer per capita to treat in the US healthcare system. Substantial costs associated with the diagnosis, management and surveillance of bladder cancer account for the bulk of the expense; yet, for that cost, patients may not receive high-quality care. Herein the authors review the sources of expenditure associated with bladder cancer care, review population-level analyses of the quality of bladder cancer care in the USA, and discuss opportunities for quality improvement that may yield greater value for men and women newly diagnosed with bladder cancer.     

The importance of an extended lymphadenectomy in the management of high-grade invasive bladder cancer

The role of a regional lymphadenectomy in the surgical management of high-grade invasive bladder cancer has evolved over the last several decades. A growing body of evidence suggests that an extended lymph node dissection may provide, not only improved prognostic information, but also a clinically significant therapeutic benefit for both lymph node-positive and -negative patients undergoing radical cystectomy. The extent of the primary bladder tumor, number of lymph nodes removed and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy. In addition, the concept of lymph node density may further improve stratification of lymph node-positive patients. The historical development and contemporary rationale for an extended pelvic lymphadenectomy in patients undergoing radical cystectomy are reviewed.     

Current status of neoadjuvant and adjuvant chemotherapy for muscle-invasive bladder cancer

Muscle-invasive transitional cell carcinoma occurs in approximately 30% of patients and is associated with a high risk of distant metastasis. Radical local therapy in the form of cystectomy or radiotherapy is curative in a portion of patients. Systemic therapy to treat occult micrometastasis at the time of local control is necessary to improve outcomes. Neoadjuvant chemotherapy is associated with a 5–6% improvement in overall survival at 5 years, and adjuvant chemotherapy may achieve similar results, although this remains unproven. Operative complications are not increased with neoadjuvant therapy. Perioperative treatment strategies remain underutilized, and many patients are not offered treatment to reduce the risk of relapse. Neoadjuvant strategies are a potent tool for research and should be employed to test new agents for the treatment of transitional cell carcinoma.     

Assessment of long-term quality of life using the FACT-BL questionnaire in patients with an ileal conduit, continent reservoir, or orthotopic neobladder

OBJECTIVE: To assess and compare quality of life (QOL) of patients followed for a long time who underwent an ileal conduit (IC), continent reservoir (CR) or ileal neobladder (NB) using FACT-BL, a bladder-cancer-specific questionnaire. METHODS: One hundred and forty-seven patients underwent radical cystectomy and urinary diversion for bladder cancer from 1987 to 2002 at our institution. Of them, 79 (54%) patients were asked to participate in this study. Forty-nine patients (20 IC, 14 CR and 15 NB) returned the answered questionnaire for a survey response rate of 62%. Mean follow-up was 83.0 months. RESULTS: Four categories (physical, social/familial, emotional and functional well-being) in FACT-G were equally favorable in these groups. Patients with IC had less trouble controlling urine but had a worse image on altered body appearance compared with NB patients. Interest in sex was extremely low in all patients and capability of maintaining an erection was also low in 39 male patients. The mean total value of FACT-BL in IC, CR and NB patients was 106.3+/-16.4, 104.0+/-14.2, and 110.9+/-18.0, respectively, showing no significant difference. Ten (77%) of 13 IC, seven (78%) of nine CR and six (86%) of seven NB patients answered that they would choose the same type of diversion if they had the choice again. CONCLUSIONS: The type of urinary diversion does not appear to be associated with a different QOL by general cancer-related assessment. Urinary function and body image are affected and related to the method used to reconstruct the urinary system.     

乳腺癌前哨淋巴结的研究现状与评价

前哨淋巴结活检为乳腺癌患者提供了精确的分期,并且减少了手术并发症,因此日益为临床所接受。但是在临床研究中,前哨淋巴结活检的方法、适应证尚有一些争议。本文就前哨淋巴结活检技术、前哨淋巴结病理学评估、前哨淋巴结活检的适应证和前哨淋巴结活检取代腋淋巴结清扫等几方面进行讨论,明确了同位素和染料示踪剂可以互补,淋巴核素显像对于内乳前哨淋巴结活检的价值,内乳前哨淋巴结活检目前仍处于临床研究阶段;术中前哨淋巴结的病理学评估方法中,细胞学印片显示了快速、廉价、节省组织材料等优点,但对微转移灶的识别仍有不足;前哨淋巴结有微转移的患者目前仍应进行腋淋巴结清扫。导管内癌、预防性乳房切除、乳房缩小成型术及隆乳手术后患乳腺癌的患者,有必要进行前哨淋巴结活检;虽然NSABPB32、Z0010、Z0011等大样本前瞻性随机临床试验结果要等待许多时间,但是乳腺癌前哨淋巴结活检已在临床上广泛开展,我们必须重视技术的规范和病例的选择。     

Urinary diversion and morbidity after radical cystectomy for bladder cancer

BACKGROUND:

The rate of continent urinary diversion after radical cystectomy for bladder cancer varies by patient and provider characteristics. Demonstration of equivalent complication rates, independent of diversion type, may decrease provider reluctance to perform continent reconstructions. The authors sought to determine whether continent reconstructions confer increased complication rates after radical cystectomy.

METHODS:

From the Nationwide Inpatient Sample, the authors used International Classification of Disease (ICD‐9) codes to identify subjects who underwent radical cystectomy for bladder cancer during 2001‐2005. They determined acute postoperative medical and surgical complications from ICD‐9 codes and compared complication rates by reconstruction type using the nearest neighbor propensity score matching method and multivariate logistic regression models.

RESULTS:

Adjusting for case‐mix differences between reconstructive groups, continent diversions conferred a lower risk of medical, surgical, and disposition‐related complications that was statistically significant for bowel (3.1% lower risk; 95% confidence interval [95% CI], ?6.8% to ?0.1%), urinary (1.2% lower risk; 95% CI, ?2.3%, to ?0.4%), and other surgical complications (3.0% lower risk; 95% CI, ?6.2% to ?0.4%), and discharge other than home (8.2% lower risk; 95% CI, ?12.1% to ?4.6%) compared with ileal conduit subjects. Older age and certain comorbid conditions, including congestive heart failure and preoperative weight loss, were associated with significantly increased odds of postoperative medical and surgical complications in all subjects.

CONCLUSIONS:

Mode of urinary diversion after radical cystectomy for bladder cancer is not associated with increased risk of immediate postoperative complications. These results may encourage broader consideration of continent urinary diversion without concern for increased complication rates. Cancer 2010. © 2010 American Cancer Society.     

膀胱癌根治性全膀胱切除术后行不同尿流改道术对患者生活质量的影响

目的:分析膀胱癌根治性全膀胱切除术后行不同尿流改道术对患者生活质量的影响。方法:选取我院2014年7月至2015年12月期间收治的142例行根治性膀胱全切除及尿道改造术患者的临床资料进行回顾性分析。按照不同改道术将患者分成A组（原位新膀胱术组）（71例,其中原位乙状结肠新膀胱术16例,原位回肠新膀胱术55例）与B组（非原位尿流改道术组）（71例,其中输尿管皮肤造口术10例,回肠通道术61例）,治疗结束后记录并比较2组患者近期临床疗效和生活质量。结果:A组手术时间、住院时间均较B组延长（P＜0.05）。B组患者并发症发生率较A组低,但两组患者并发症发生率比较差异无统计学意义（P=0.370）。两组患者术后生活质量比较均存在差异（P＜0.05）,其中在生理机能、生理职能、社会功能、精神健康及情感职能5个方面两组患者比较差异具有统计学意义（P＜0.05）,且均以A组患者得分较高,而在躯体疼痛、一般健康状况、精力的比较上两组患者差异无统计学意义（P＞0.05）。结论:在根治性膀胱全切除术中采用不同尿流改道术对治疗膀胱癌均具有一定的临床疗效和安全性,但采用原位新膀胱尿流改道的方式更利于提高患者术后生活质量,值得临床上推广使用。