原位回肠和乙状结肠尿流改道术临床疗效比较

目的比较原位回肠和乙状结肠尿流改道术的临床疗效。方法回顾性分析1995 -2005年行膀胱癌术后原位回肠尿流改道术96例,乙状结肠尿流改道术68例的患者资料。比较分析2组患者术中术后一般情况、控尿能力、尿动力学结果以及术后储尿囊相关并发症。结果164例患者失访12例(7．3%)。平均随访时间回肠组46(2～86)个月,乙状结肠组42(4～78)个月。2种术式术中失血量、术后控尿效果接近(P＞0．05),但2组手术时间(6．0±0．8 h vs 5．2±0．6 h),术后下床时间(7．8±0．8 d vs 6．4±1．0 d),新膀胱容量(550．0±122．5 ml vs 420．0±80．6 ml)等方面差异有统计学意义(P＜0．05)。原位回肠尿流改道组术后早期及晚期储尿囊相关并发症发生率分别为16．7%、29．2%,均高于乙状结肠组。原位回肠尿流改道组术后储尿囊再发肿瘤3例,乙状结肠组未见发生。结论两种术式术后疗效均良好。原位乙状结肠尿流改道术耗时短、恢复快、术后并发症发生率低,值得优先采用。     

腹腔镜下膀胱全切除、原位回肠新膀胱的尿流动力学分析

目的 探讨腹腔镜膀胱全切除、原位回肠新膀胱的临床效果。方法 对8例行腹腔镜膀胱全切除、原位回肠新膀胱患者进行排尿情况的记录和尿动力学检查。结果 8例患者均可自主控制排尿（1例夜间轻微尿失禁）,在新膀胱充盈过程中均可出现胀痛感觉,膀胱平均容量377．5ml,压力17．9cmH2O,最大尿流率18．1ml／s,最大尿道闭合压68．5cnH2O,功能性尿道长度3．7cm。结论 腹腔镜根治性全膀胱切除、原位回肠新膀胱术较传统的开放手术创伤更小,但贮尿囊一样具有容积较大、内压较低和可控性较好的优点,排尿良好,值得临床推广。     

机器人辅助全腹腔镜下"紫砂壶型"原位回肠新膀胱的临床疗效分析

目的探讨机器人辅助全腹腔镜下"紫砂壶型"原位回肠新膀胱患者的尿控和肿瘤学预后。 方法以2017年5月至2019年6月连续进行的10例机器人辅助根治性膀胱切除+回肠原位新膀胱术患者为研究对象，男9例，女1例，年龄（63±11）岁，极高危非肌层浸润膀胱癌5例，肌层浸润性膀胱癌5例；术后随访时间为12～37个月。记录手术视频、术后90 d内并发症、随访期间患者的尿控恢复、分肾功能、上尿路影像学结构改变以及肿瘤学预后。 结果10例患者均顺利完成全腹腔镜下机器人辅助根治性膀胱切除回肠原位新膀胱手术，手术时间（584±56）min，出血量（655±275）ml，术后进食时间1～3 d；1例患者术后6个月行切口疝修复术，其余无Ⅲ级以上并发症。5例（50%）患者术后6～12个月尿流动力学检查提示最大尿流率及平均尿流率分别为（6.3±4.5）ml/s、1.80（0.30）ml/s，术后新膀胱充盈尿量及残余尿量分别为（525±273）ml、161（227）ml，患者日间完全控尿9例（90%），夜间完全控尿8例（80%）。随访期间，发现4侧肾盂轻度扩张，监测分肾功能正常。1例患者术后18个月出现肺转移，其余患者未发现局部复发及转移。 结论"紫砂壶型"回肠原位新膀胱是在Studer型、VIP型回肠新膀胱基础上的储尿囊成型技术改进，术后新膀胱功能良好，能有效保护上尿路形态，恢复排尿功能。     

改良根治性膀胱全切原位回肠新膀胱术治疗男性膀胱癌的临床研究

目的探讨改良根治性膀胱全切原位回肠新膀胱术治疗膀胱癌的临床应用价值。方法 45例膀胱癌患者随机分为对照组（20例）与改良组（25例）,其中对照组行经典根治性膀胱全切原位回肠新膀胱术,改良组行改良根治性膀胱全切原位回肠新膀胱术,术中注意对膜部尿道括约肌、神经血管束加以保留。结果①改良组手术时间短于对照组,为（265.1±27.8）min vs.（302.4±46.5）min,出血量少于对照组,为（403.9±156.2）ml vs.（485.3±121.6）ml,P〈0.05。②改良组术后发生并发症12例（48%）,明显低于对照组的18例（90%）,P〈0.01。③两组间最大膀胱容量和充盈期膀胱内压无明显差异（P〉0.05）,但改良组残余尿量少于对照组,为（22.9±7.6）ml vs.（45.3±12.4）ml,最大尿流率高于对照组,分别为（18.3±3.5）ml/s vs.（14.9±3.2）ml/s（P〈0.01或P〈0.05）。④改良组患者勃起功能保留率明显高于对照组（82.4%vs.46.7%）,P〈0.05。⑤改良组与对照组间2年生存率（87.5%vs.78.6%）、5年生存率（66.7%vs.71.4%）和平均生存时间（52.6±8.2）个月vs.（56.9±7.8）个月比较差异无统计学意义（P〉0.05）。结论改良根治性膀胱全切原位回肠新膀胱术不仅可达到肿瘤根治目的,而且可明显改善患者储尿、排尿、控尿功能,有效保护患者阴茎勃起功能。     

三种正位新膀胱术后膀胱功能的临床观察

目的评价3种正位新膀胱术式患者术后膀胱功能。方法胃代膀胱术后患者38例、回肠代膀胱术后31例、乙状结肠代膀胱术后33例,术后1～3个月随访患者排尿状况、上尿路B超、肾图或IVU检查、尿动力学检查,统计学分析比较各组疗效。结果胃代膀胱术后排尿通畅性较好,最大尿流率（17．2±6．2）ml/s,尿路感染发生率5％,膀胱容量（230±56）ml、尿失禁26％、遗尿21％；回肠代膀胱术和乙状结肠代膀胱术后膀胱容量分别为（320±70）ml、（300±60）ml,尿失禁分别为6％、9％,遗尿分别为6％、9％；上尿路梗阻和返流发生率均较低,与胃代膀胱术比较差异有统计学意义（P＜0．05）。结论3种代膀胱术术后膀胱贮尿功能良好,以回肠代膀胱术和乙状结肠代膀胱术后功能更好,胃代膀胱术由于其胃壁的生理特点在新膀胱抗感染和排尿功能方面满意。     

改良膀胱全切新回肠膀胱术治疗男性浸润性膀胱癌

目的 探讨根治性全膀胱切除术中保留远端的前列腺包膜及精囊对原位新膀胱功能及勃起功能的影响。方法 对24例男性浸润性膀胱癌患者施行改良根治性全膀胱切除及原位回肠膀胱术：保留远端的前列腺外科包膜及精囊，新回肠膀胱与残留前列腺包膜连续缝合；对术后新膀胱的储尿、排尿、控尿功能及患者的勃起功能进行随访和比较。结果 术后病理分期：T2aN0M0 5例，T2bN0M0 9例，T3aN0M0 7例，T3bN1M0 3例。术后随访3—24个月，平均12．7月。无瘤生存22例；带瘤生存2例。新膀胱容量（385±68）mL，最大充盈压（24±16）cmH2O。排尿良好，最大尿流率（18±5）mL／s，剩余尿（35±16）mL；完全控尿22例，夜间尿失禁2例；21例术前勃起功能正常者术后2例发生勃起功能障碍。结论 在改良根治性膀胱全切术中保留远端的前列腺外科包膜及精囊，可明显改善患者术后的储尿、排尿、控尿功能和勃起功能，同时可有效防止新膀胱一尿道吻合口狭窄的发生。     

Carney Ⅱ式原位回肠膀胱术的远期疗效分析

目的 评价CarneyⅡ式原位回肠膀胱术后患者的远期疗效.方法 膀胱移行细胞癌行根治性膀胱切除CarneyⅡ式原位回肠膀胱术患者33例.采用美国癌症患者生命质量量表(FACT)和国际前列腺症状评分(IPSS)衡量患者术后生活质量,采用膀胱容量、最大尿流率、残余尿量,充盈期膀胱压力等尿动力学结果评估回肠膀胱功能.结果 33例患者中,术后10个月因肿瘤尿道复发死亡1例,失访2例.30例患者随访12～60个月.术后尿动力学检查回肠膀胱容量(380±65)ml、最大尿流率(12.6±2.3)ml/s、残余尿量(25±11)ml,充盈期膀胱压力明显低于尿道闭合压[(20.4±8.7)cm H2O(1 cm H2O=0.098 kPa))与(57.2±10.5)cm H2O,P<0.05].并发肾功能不全1例、尿瘘2例.术后1年28例患者白天控尿均满意,夜间控尿满意26例.FACT评分为(110.5±16.0)分,IPSS评分(14.5±4.2)分.结论 CarnyⅡ式原位回肠膀胱术式是一种效果良好、并发症较低的尿流改道术,有较好的临床应用价值.     

乙状结肠原位新膀胱术的临床疗效观察

目的评估乙状结肠原位新膀胱术的临床疗效。方法回顾性研究113例乙状结肠原位新膀胱术患者的临床资料,包括临床、生化、影像和尿流动力学等资料,患者术后随访3～84个月。结果平均手术时间（4.2&#177;0.9）h,失血量（252&#177;124）ml,26例（23%）患者出现尿潴留,储尿囊容量达（482&#177;54）ml,日间可控和夜间可控率分别达到90.5%和78.6%,残余尿量约50ml。结论根治性膀胱全切后行乙状结肠原位新膀胱术,疗效满意。     

正位回结肠和回肠膀胱替代术尿控差异的对照研究

目的：通过根治性膀胱全切术后回结肠和回肠正位膀胱替代术的临床观察,重点评价两种术式的尿控及其对上尿路的影响及机制。方法：从2002～2006年期间行标准的根治性膀胱全切术后行正位膀胱替代术中选取获得随访的膀胱癌患者31例,其中17例采用回结肠新膀胱重建术（Le Bag术）,14例采用回肠新膀胱重建术（Studer术）。术后3个月内（近期）和3个月后（远期）观察相关并发症和尿控情况,并行尿动力学检查和静脉肾盂造影或B超检查。结果：回结肠新膀胱组手术后并发症率为11．8％（2／17）;回肠新膀胱组并发症率为14．3％（2／14）。虽然回结肠新膀胱组3个月后白天完全获得尿控76．4％（13／17）．低于回肠新膀胱组92．8％（13／14）,但统计学差异不显著;而夜间社会性尿控回肠新膀胱组7I．4％（10／14）,显著高于回结肠新膀胱组35．3％（6／17）。尿动力学结果表明两组间的尿流率、功能尿道长度、最大尿道压和新膀胱压力无明显差异,但回结肠新膀胱组容量高于回肠新膀胱组,而顺应性则低于回肠新膀胱组。此外。回结肠新膀胱组的上尿路扩张发生率为11．8％（2／17）,略高于回肠新膀胱组0（0／14）。结论：虽然回结肠新膀胱在近期能获得较大容量,但由于回结肠新膀胱顺应性较回肠新膀胱低,因而在获得满意的尿控和对上尿路的保护上,回肠新膀胱更具优势。     

根治性膀胱切除回肠去带乙状结肠原位膀胱术(附31例报告)

目的探讨双U形回肠原位膀胱和去带乙状结肠原位脐胱术的疗效。方法31例膀胱癌，全部行根治性膀胱切除术，其中10例行双U形回肠原位膀胱术，21例行盘带乙状结肠腺值膀胱术。结果31例手术时间4．5-7h，平均5．6h，31例随访1—36个月，平均19．5个月，两组病人均控尿良好，3例高氯血症，4例轻度腹泻（均为回肠组）。膀胱造影未见输尿管反流，IVU示左肾盂轻度积水3例，新膀胱容量220-400mL，平均315mL，新膀胱充盈时最大压力2．5-4．9kPa（回肠组）、2．1-5．8kPa（乙状结肠组）。结论双U形回肠和去带乙状结肠均为理想的贮尿囊，操作简单，并发症少，疗效可靠，而去带乙状结肠原值膀胱更接近生理膀胱，很少引起代谢紊乱和腹泻。     

Modified orthotopic spiral ileal bladder substitution: Surgical technique and long-term results

ObjectivesThe objectives of this study are to introduce the surgical technique of a modified spiral orthotopic ileal neobladder and to assess the long-term outcomes.Patients and methodsBetween January 1998 and January 2006, 44 male and 7 female patients with bladder cancer received radical cystectomy (RC) and pelvic lymphadenectomy. An ileal segment 40 cm to 45 cm long was isolated to create a spiral orthotopic ileal neobladder, and the ureters were implanted into the reservoir using a non-refluxing split-cuff nipple technique. Preoperative, perioperative, and postoperative data were collected. Complications were classified as early (less than 3 months after surgery) or late (more than 3 months after surgery). Continence incidence and urodynamic studies were evaluated 5 years after surgery. Duration of follow-up was an average of 95 months (range 60–156 months).ResultsThere were no perioperative deaths. The mean operative time was 315 ± 34 minutes. The mean blood loss was 783 ± 316 ml. There were 31 early complications in 21 patients (41%) and 42 late complications in 30 patients (59%). Urodynamic studies showed the maximum neobladder capacity to be 500 ± 71 ml, maximum flow rate to be 16 ± 5 ml/s and post-voiding residual (PVR) to be 50 ± 44 ml. Postoperative continence was excellent with a daytime continence rate of 90% and a nocturnal continence rate of 78% 5 years after surgery.ConclusionsThe modified spiral neobladder is easy to perform and allows for excellent long-term results with regard to complications and continence.     

Comparison of orthotopic sigmoid and ileal neobladders: continence and urodynamic parameters

OBJECTIVES: The objective this of the study was to compare continence rates and urodynamic parameters among patients who had undergone orthotopic bladder substitution with sigmoid or ileal segments. METHODS: Continent urinary reservoirs were constructed in 112 patients. Fifty patients received a sigmoid neobladder (SN) and 62 patients an ileal neobladder (IN). Thirty-four patients with an SN (mean age 64.4 years), and 20 with an IN (mean age 57.8 years) agreed to postoperative urodynamic evaluation at a median time after surgery of 18 and 37 months, respectively. Continence and urodynamic parameters were compared in both groups. RESULTS: The average reservoir capacity of the SN (296 ml) was lower than the IN (546 ml). The majority of patients voided by the Valsalva maneuver and achieved good peak flow rates [SN group 16.6 (range 7-32) ml/s, IN group 25.5 (range 5-35) ml/s]. Of the patients with an SN 26 (76%) and with an IN 15 (75%) emptied to near completion with a post-void residual (PVR) of less than 100 ml. Daytime continence was achieved in 90% of IN patients and 85% of SN patients. Only 9% of patients with an SN and 60% of patients with an IN were continent at night. CONCLUSION: A neobladder constructed from detubularized ileum or sigmoid achieves adequate capacity with a satisfactory daytime continence rate. Nighttime incontinence in patients with IN can be at least partly explained by periods of high pressure due to neobladder contractions in combination with a relaxed sphincter during sleep. The low nighttime continence rate of the SN is probably related to its small functional capacity.     

女性去带盲结肠新膀胱术(附四例报告)

目的 提高女性患者膀胱全切术后生活质量。方法 采用改良根治性膀胱切除加去带盲结肠新膀胱术治疗女性膀胱癌4例。在根治性膀胱切除术中3例采用保护阴道前壁方法，1例采用切除阴道前壁方法。结果 随访6～30个月，4例患者白天均可控制排尿，3例夜间能控制排尿，1例夜间有尿失禁。尿动力学检查显示贮尿囊容量305～438ml，最大囊内压18～45cmH2O(1cmH2O=0．098kPa)，剩余尿量0～30ml，最大尿流率15．1～22．6ml／s。贮尿囊造影及IVu检查未见输尿管返流和输尿管狭窄。血电解质和。肾功能正常。结论 女性膀胱癌患者行改良的根治性膀胱切除去带盲结肠新膀胱术可获得满意的排尿控尿效果。     

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.     

腹腔镜下全膀胱切除原位回肠新膀胱重建术(附5例报告)

目的:介绍腹腔镜下全膀胱切除原位回肠新膀胱重建术的经验。方法:采用腹腔镜下全膀胱切除原位回肠新膀胱重建术治疗浸润性膀胱癌患者5例。方法是经腹壁小切口取出切除物,行回肠去管成形新膀胱,然后在腹腔镜下将新膀胱与尿道连续吻合。结果:5例患者手术成功,手术时间4.5~7.2h。腹腔镜手术中以超声刀及双极电凝行膀胱侧韧带、前列腺血管蒂及前列腺尖部切断止血,未使用钛夹、术中出血量180~550ml,平均输血400ml。术后4~5天恢复饮食,3周拔除输尿管支架管,4周拔除尿管。患者白天可完全控制排尿,2例夜间偶有尿失禁。1例术后尿漏,经引流治愈。结论:腹腔镜下全膀胱切除术具有创伤小、出血少、恢复快等优点;而回肠新膀胱和尿道连续吻合具有操作方便、省时、缝合紧密、可防止尿漏等优点。     

A three-centre experience of orthotopic neobladder reconstruction after radical cystectomy: initial results

OBJECTIVE: To assess, in a retrospective three-centre series, the initial experience and results of patients undergoing radical cystectomy and orthotopic neobladder reconstruction. PATIENTS AND METHODS: The medical records were retrospectively reviewed for 104 suitable consecutive patients undergoing radical cystectomy and orthotopic neobladder reconstruction between June 1994 and April 2003. The initial histology, operating times, transfusion rates, complications, mortality rates, continence rates, potency rates, and cancer control rates were recorded. RESULTS: The median (range) follow-up was 48 (6-113) months; 90 patients had a reconstruction with a 'Studer' neobladder, 12 with a 'Hautmann W pouch' and two with a 'T pouch' ileal neobladder. There were 24 early complications, and in eight patients re-operation was required; there was one death after surgery. There were 14 late complications and 10 patients required re-operation. The daytime continence rate was 99% and the nocturnal continence rate 78%. Five patients required intermittent self-catheterization. Twenty-two patients died from local and/or distant recurrences, and four from other causes. CONCLUSIONS: Orthotopic neobladder reconstruction provides excellent continence rates, and both acceptable complication and mortality rates. Suitable patients undergoing radical cystectomy should be offered orthotopic neobladder reconstruction.     

腹腔镜膀胱癌根治—原位回肠新膀胱术(附5例报告)

目的探讨腹腔镜膀胱癌根治—原位回肠新膀胱术的临床疗效。方法 2008年11月至2011年4月,采用5点穿刺经腹入路,先行腹腔镜下膀胱癌根治,继而体外构建回肠新膀胱,最后腹腔镜下行新膀胱尿道吻合,实施腹腔镜膀胱癌根治—原位回肠新膀胱术5例。皆为男性,平均年龄67岁。结果手术时间420～600min,平均480min,术中失血量350～800ml,平均400ml。术后淋巴结及手术切缘均阴性。随访3～24个月,除1例有轻度夜间尿失禁外,其余患者均昼夜控尿良好。代膀胱充盈良好,容量200～350ml,平均270ml。平均最大尿流率12ml/s。1例出现勃起功能障碍。结论腹腔镜膀胱癌根治—原位回肠新膀胱术创伤小、出血少、并发症少且疗效满意。     

原位肠代膀胱术远期疗效评价(附266例报告)

目的 总结评价原位肠代膀胱术的远期临床效果。方法 对1991-2003年266例因膀胱癌行膀胱全切手术患者资料进行分析。Hautmann回肠原位代膀胱术206例，Reddy原位结肠代膀胱术60例。131例患者在原标准术式基础上作了手术技术改进。总结手术改进前后患者控尿率和并发症发生率等。结果 获完整随访患者225例。回肠代膀胱术改进前后男性平均随访时间62（44-146）个月和38（4-67）个月；结肠原位代膀胱手术改进前后患者平均随访时间为62（51-131）个月和34（5-67）个月。手术改进可提高男性术后夜间可控率（P〈0．05），女性改善不明显（P〉0．05），总的近期和远期并发症发生率为13．8％和19．6％。男性肿瘤尿道复发9例（4％），女性无复发。结论 原位尿流改道术的远期临床疗效满意，并发症发生率低。手术技术改进可提高男性患者的夜间控尿率。