腹腔镜膀胱全切术治疗极高龄肌层浸润性膀胱癌临床效果观察

目的探讨腹腔镜膀胱全切术治疗80岁以上极高龄肌层浸润性膀胱癌患者的临床疗效与安全性。方法选取2014年7月至2016年7月收治的80岁以上浸润性膀胱癌患者32例,所有患者均行腹腔镜膀胱全切术。观察并记录手术时间、术中失血量、术后住院时间及并发症发生情况等。结果 32例患者手术均获成功,无死亡,其中,4例中转开腹;平均手术时间为(181.0±40.3)min;平均术中出血量为(325.0±88.9)ml;平均术后住院时间为(10.0±2.8)d;术后发生肺部感染2例、下肢静脉血栓2例、应激性溃疡1例、切口感染1例。结论腹腔镜膀胱全切术治疗80岁以上极高龄肌层浸润性膀胱癌患者安全有效,可在临床推广应用。     

根治性经尿道膀胱肿瘤治疗肌层浸润性膀胱癌的疗效观察

目的：探讨化疗联合根治性经尿道膀胱肿瘤电切术（TURBt）治疗肌层浸润性膀胱癌的疗效及安全性。方法：选取从2009年11月～2012年11月辅助检查确诊的肌层浸润性膀胱癌患者70例,为患者应用化疗联合根治性经尿道膀胱肿瘤电切术治疗。肿瘤的最大直径大小平均为2．7±0．2om（1～5cm）。临床上分期分为：T2a期35例,T2b期35例,病理上分期为：G2：50例,G3：20例。为患者签订知情同意书后。首先为患者行根治性经尿道膀胱肿瘤电切术,术后为患者联合应用多西他赛75mg／m。＋奥沙利铂130mg/m^2静脉化疗,羟喜树碱20mg＋生理盐水20ml膀胱灌注治疗。为患者进行定期的随诊观察,检测治疗的效果。结果：术中平均出血量为37±10．2（10～170）ml,平均手术时间为：59±20．1（20～80）min。所有患者术中及术后均未见严重的手术并发症。病理诊断确诊所有患者均未移行性细胞癌。有20例患者出现化疗的副作用,其中11例患者出现骨髓抑制引起白细胞降低,9例患者出现头痛低热及轻微恶心,经对症治疗后均行好转。对所有患者进行随访平均为39个月（12～50个月）。其中12个月时有5例患者复发,24个月时有9例患者复发。在所有随诊患者中共20例患者死亡,无瘤存活患者为50例。结论：化疗联合根治性膀胱肿瘤电切术是一种安全且疗效显著地治疗肌层浸润性膀胱癌手术方法。     

经腹腔镜根治性全膀胱切除回肠原位代膀胱术18例

目的探讨腹腔镜技术在根治性全膀胱切除回肠原位代膀胱术中的应用价值。方法本组18例均为膀胱尿路上皮癌,TNM分期为T2a N0M011例、T3a N0M05例、T3b N0M02例,麻醉选择气管插管全身麻醉,采用5点穿刺法置入腹腔镜,手术方式为根治性全膀胱切除回肠原位代膀胱术。结果全组18例均手术顺利,无一例中转行开放手术。手术时间为5⁷.5(6.4±0.8)h;出血1507.5(6.4±0.8)h;出血150⁴00(292.2±79.0)ml;术后肠道功能恢复时间为2400(292.2±79.0)ml;术后肠道功能恢复时间为2⁴ d,2例出现漏尿,均在14 d内消失。术后随访时间为64 d,2例出现漏尿,均在14 d内消失。术后随访时间为6¹2(9.4±1.8)个月,所有病例控尿情况均较理想,超声检查均未发现输尿管扩张、肾积水,3例代膀胱残余尿>100 ml,均未发现复发及转移。结论根治性全膀胱切除回肠原位代膀胱术是治疗浸润性膀胱癌的一种有效的微创手术方法。     

腹腔镜下膀胱全切术(附7例报告)

目的 探讨腹腔镜下膀胱全切除术的手术方法和临床效果。方法 浸润性膀胱癌患者7例,年龄53-74岁,平均61岁,均为男性,无远处转移,采用5个套管针,腹腔镜下行膀胱全切术,前列腺切除,下腹正中作7cm切口,取出切除的膀胱前列腺,常规行回肠膀胱术。结果 手术时间平均9．2h,出血量平均为264ml,所有病例均未输血,术后血红蛋白正常。术后2～10个月随访,肾功能正常,IVU检查未见输尿管吻合口狭窄或反流。结论 腹腔镜下膀胱全切术创伤小,出血少,恢复快,是全膀胱切除术一种具有临床应用前景的治疗方法。     

回肠膀胱术围手术期护理

利用肠道行膀胱替代是根治性膀胱全切术的重要环节。目前,各种可控和不可控的肠道代膀胱术种类繁多,Bricker回肠膀胱术相对来说是一种比较简单和安全的尿路改道手术。自1999年至2004年应用该术式对7例因膀胱癌行膀胱全切的病人行回肠膀胱术,随访效果满意。1资料与方法1.1一般资料7例,男6例,女1例。年龄52~73岁,平均56岁。病程3个月~3年。均有间歇性无痛性全程肉眼血尿。所有患者均行经腹B超,IVU,CT及膀胱镜检查加活检,发现多发性乳头状瘤2例,多发性原位癌1例,浸润性肿瘤4例,伴单侧输尿管扩张、肾中度积水2例。病理检查均为移性细胞癌。W…     

PK-TURBT联合羟喜树碱治疗非肌层浸润性膀胱癌

目的探讨经尿道等离子双极膀胱肿瘤电切术(PK-TURBT)联合羟基喜树碱膀胱灌注治疗非肌层浸润性膀胱癌的临床疗效。方法 66例非肌层浸润性膀胱癌患者在硬腰麻醉或腰硬联合麻醉下行PK-TURBT,术后定期给予羟基喜树碱膀胱灌注治疗,每3个月复查泌尿系超声和膀胱镜1次。结果 66例均顺利完成手术,手术时间平均40 min。5例发生闭孔神经反射,无膀胱穿孔及电切综合征发生。术后随访6～32个月,7例复发,再次行PK-TURBT,术后病情稳定,随访至今未复发。结论 PK-TURBT联合羟基喜树碱术后膀胱灌注化疗治疗非肌层浸润性膀胱癌疗效确切,安全性好。     

膀胱全切乙状结肠去带原位新膀胱术的护理

目的探讨腹腔镜膀胱全切乙状结肠去带原位新膀胱术的护理要点。方法对7例浸润性膀胱癌患者行腹腔镜膀胱全切乙状结肠去带原位新膀胱术,观察患者的术前准备、术后护理及新膀胱功能训练的效果。结果所有手术均取得成功,术中无并发症发生,随访3～18个月,所有患者白天可完全控制排尿,2例夜间偶有尿失禁。结论术前充分的肠道准备、术后保持各引流管通畅及早期缩肛训练新膀胱是保证手术疗效、减少并发症的护理关键。     

早期肠内营养在机器人辅助全膀胱切除术围术期应用研究

目的探讨机器人辅助全膀胱切除术围术期应用早期肠内营养的临床效果与安全性。方法选取行机器人辅助全膀胱切除术治疗肌层浸润性膀胱癌的患者32例,随机分为肠内营养组(EN组,15例)与肠外营养组(PN组,17例)。观察术后排气时间、总住院时间及并发症发生情况。结果 EN组术后排气时间为(51.8±21.3)h,短于PN组的(72.1±17.2)h;EN组总住院时间为(13.2±2.9)d,短于PN组的(17.9±4.1)d,差异均有统计学意义(P<0.05)。EN组手术并发症尿瘘、切口愈合不良的发生率分别为0、6.7%(1/15),低于PN组的23.5%(4/17)、29.4%(5/17),差异有统计学意义(P<0.05);EN组术后胃肠道相关并发症恶心呕吐、腹胀腹痛、腹泻的发生率分别为20.0%(3/15)、40.0%(6/15)、20.0%(3/15),高于PN组的11.8%(2/17)、23.5%(4/17)、5.9%(1/17),但差异无统计学意义(P>0.05);两组均无严重并发症(如严重肠梗阻、回肠吻合口瘘)发生,均不需二次手术。结论机器人辅助全膀胱切除术围术期应用早期肠内营养安全有效,不会增加并发症的发生率。     

改良全膀胱切除原位回肠代膀胱术11例

2002年10月-2005年5月，我们对膀胱癌11例行改良根治性膀胱切除、原位W形回肠代膀胱术，疗效满意。 1 临床资料 1．1 一般情况 11例均为男性，年龄42～70岁，平均63岁。经B超、CT和膀胱镜检查，诊断为复发性多发浅表肿瘤（Ta～T1）6例，浸润性肿瘤5例。病理报告移行细胞癌9例，鳞状细胞癌2例。术前前列腺特异性抗原（PSA）均未升高，尿动力学检查示尿道括约肌功能正常。     

髂内动脉化疗栓塞联合双极等离子电切术治疗大体积膀胱癌的临床应用

【摘要】 目的 探讨髂内动脉化疗栓塞（TACE）联合经尿道双极等离子电切术（TURis）治疗直径≥ 3 cm高危肌层浸润性膀胱癌的临床疗效。方法 选取不能或不愿接受膀胱全切手术的直径≥3 cm肌层浸润性膀胱癌患者58例为研究对象,采用抽签法随机分为对照组（A组）28例和观察组（B组）30例,A组单纯行传统术式经尿道膀胱肿瘤双极等离子电切术（TURis）治疗,B组采用经皮穿刺股动脉插管,实施髂内动脉TACE后2～3 d行TURis治疗,比较A组和B组的经尿道电切手术时间、术中出血量、导尿管保留时间、术后住院时间及术后3个月肿瘤复发率、术后2年肿瘤复发率、术后2年肿瘤特异生存率。 结果 B组30例患者均成功行TACE 治疗,介入手术成功率100%。两组电切手术均顺利完成,无中转开放术式。58例患者均获得随访,平均随访25（10～38）个月。B组手术时间（45.8±7.5） min、导尿管留置时间（2.7±1.2） d、术后住院时间（3.5±1.4） d,分别短于A组手术时间（56.3±11.7） min、导尿管留置时间（3.8±1.5） d、术后住院时间（4.9±1.6） d;B组出血量为（55.4±8.2） mL 低于A组（67.6±13.5） mL（P＜0.05）,差异均有统计学意义。B组术后3个月肿瘤复发率13.3%低于A组35.7%（P＜0.05）,B组术后2年肿瘤复发率53.3%明显低于A组78.6%（P＜0.05）,B组术后2年肿瘤特异生存率73.3%明显高于A组46.4%（P＜0.05）,差异有统计学意义。 结论 髂内动脉TACE联合TURis治疗直径≥3 cm的高危膀胱癌安全有效,明显减少术中出血,有利于肿瘤彻底切除,提高了保留膀胱功能患者的生活质量和肿瘤特异生存率。     

Reconstructed urinary bladder following radical cystectomy for bladder cancer. Multidetector CT evaluation of normal findings and complications

PURPOSE: The aim of this paper is to report the normal and pathological multidetector computed tomography (MDCT) findings in the morphofunctional evaluation of the orthotopic ileal reservoir in patients treated with radical cystectomy for transitional cell carcinoma. MATERIALS AND METHODS: During a clinical and imaging follow-up of 43 months, 30 patients (27 men and three women) with prior cystectomy and urinary reconstruction with an orthotopic ileal neobladder [six Studer and 24 Paduan Ileal Bladder (VIP)] underwent multislice CT scan with multiplanar reconstruction (MPR), volume rendering and virtual endoscopic evaluation of the contrast-filled neobladder. The following CT data were considered: neobladder position within the pelvis, neobladder capacity, sphericity index, vesico-urethral angle, vesico-ureteral reflux, pseudo-diverticular herniation, visualisation of ileal folds and parietal thickness. The CT scan results were correlated with those of the urodynamic assessment (uroflowmetry and entero-cystometry). RESULTS: Right-sided dislocation was observed in 12/30 neobladders (six VIP and six Studer); mean capacity was around 254 ml; six VIP were spherical whereas the others were oval. The vesico-urethral angle was less than 90 degrees in five patients (normal range: 90 degrees-170 degrees). One patient had grade-3 unilateral, passive, vesico-ureteral reflux and nine patients had active or passive bilateral reflux. One patient had pseudo-diverticular herniation. The ileal folds in the afferent limb of the neobladder could be visualised in all six patients with Studer neobladders. Mean parietal thickness was 3.59 mm (SD 1.34 mm). Increased endoluminal pressure, evaluated by uroflowmetry, was associated with lateralisation of the new reservoir during straining in nine patients, with decreased neobladder capacity in six patients, vesico-ureteral reflux in five patients and pseudo-diverticular herniation in one case. Decreased urinary flow was correlated with vesico-urethral angle less than 90 degrees in four patients and with low sphericity index in five patients. No significant correlation was found between parietal thickness, presence of ileal folds and urodynamic data. Absorbed dose due to the two additional scans of our CT protocol was 10 mSv for 4-row CT and 15 mSv for 16-row CT. CONCLUSIONS: MDCT of the contrast-filled neobladder is useful for the morphological and, in part, functional evaluation of the neobladder during postoperative follow-up and helps detect surgical complications. Radiation protection concerns do not, however, support the routine use of the method, even if the MDCT data are in part correlated to the urodynamic data and may in many cases provide a morphological explanation to the presence of functional alterations.     

Orthotopic neobladder reconstruction: findings on excretory urography and CT

OBJECTIVE: The excretory urographic and CT appearance of orthotopic ileal neobladder reconstruction after cystectomy and its complications are described. MATERIALS AND METHODS: We retrospectively reviewed the excretory urograms and CT scans of 32 patients (29 men and three women, 35-76 years old) with transitional cell carcinoma of the bladder who underwent orthotopic neobladder reconstruction with anastomosis to the native urethra after cystectomy. The radiologic review consisted of 25 excretory urograms in 20 patients and 37 CT scans in 21 patients. RESULTS: On excretory urography, the afferent segment of the neobladder was identified as a contrast-filled structure in all 20 patients, and was located in the right lower quadrant in 18 (90%). On CT, the afferent segment and the neobladder were identified in all 21 patients. Delayed imaging performed after initial scanning in 12 (57%) of 21 patients was helpful for revealing detailed anatomy such as the ureteral-afferent limb anastomoses. Complications occurred in two patients and were caused by a lymphocele in one and a urine leak from the neobladder in the other. In six other patients we found evidence of recurrent or metastatic tumor or both: two had local pelvic recurrence and pelvic nodal metastases, two other patients had metastatic nodal disease, one patient had a malignant distal ureteral stricture, and the sixth patient had distant osseous metastases. CONCLUSION: Orthotopic neobladder reconstruction after cystectomy has a characteristic appearance on both excretory urography and CT. Knowledge of this appearance and the altered anatomy is useful to recognize complications and tumor recurrence. Delayed images during excretory urography and CT are useful to define the ureteral-afferent limb anastomosis with the neobladder and also to differentiate between postoperative collections.     

An evaluation of orthotopic ileal neobladders by dynamic digital urography

PURPOSE: To report on the diagnostic capabilities of dynamic digital urography in the evaluation of orthotopic ileal neobladders. MATERIAL AND METHODS: Ten male patients (aged 61.3 +/- 14.7 years) with orthotopic ileal neobladder (4 Studer, 4 Camey type II with spiralized ileal segment and 2 classic Camey type II) underwent dynamic digital urography using an angiographic unit (Philips DVI/ARC-A). Eight patients were asymptomatic and two presented mild nycturia. All patients should have undergone follow-up conventional urography, which was replaced, for the purposes of our study, by dynamic digital urography. The intestinal cleansing regimen usual for the double contrast barium enema was used in all the patients. Ninety mL of a nonionic iodinated contrast agent were administered i.v. with an automatic injector. After precontrast mask images, two postcontrast sequences were acquired 15 s and 30 min after the injection (each made of 20 images acquired every 10 seconds). Postprocessing consisted of digital image subtraction and videorecording. RESULTS: Renal pelvis and calyceal systems were well visualized in 18/20 excretory systems. Eighteen of 20 ureters were visualized completely up to the ureteral jet, and two were only partially visualized. Calyceal, pyelic and ureteral enlargement with ureteral kinking were observed in a patient with classic Camey type II. High motility was seen in 11 ureters, moderate in 5 and mild in 4. The orthotopic ileal neobladder was well opacified in 8/10 patients. Effective peristalsis of the afferent ileal segment was seen in all the Studer type neobladders. Ureteral reflux was not observed in any patient. DISCUSSION: After orthotopic ileal neobladder reconstruction, the most frequent complications include urinary leakage, intestinal obstruction, venous thrombosis, stenosis of the neobladder anastomoses, incontinence, cancer recurrence, stone formation. In the follow-up, many diagnostic tools are used: intravenous urography, retrograde cystography, urodynamic studies, transabdominal and transrectal ultrasonography. With dynamic digital urography the nephrographic evaluation was possible in all patients, as well as the evaluation of calyceal, pyelic and ureteral opacification and even ureteral peristalsis. Moreover, this diagnostic tool allows the morphofunctional dynamic study of the ureteral-neobladder anastomoses and of the orthotopic ileal neobladder, even evaluating the residual peristalsis of the detubularized ileal segment. A major drawback of the new method is the relatively high radiation dose given to the patient. A limitation of the study is the selection of a population of completely or nearly asymptomatic patients. CONCLUSIONS: Dynamic digital urography provides useful morphologic and functional information in the follow-up of patients with orthotopic ileal neobladder and could replace conventional urography in symptomatic patients.     

腹腔镜膀胱癌根治术联合快速康复外科理念治疗浸润性膀胱癌临床效果研究

目的探讨腹腔镜膀胱癌根治术联合快速康复外科理念治疗浸润性膀胱癌的临床效果。方法回顾性分析2014年1月至2015年12月收治的56例浸润性膀胱癌患者的临床资料,其中,采用传统开放性膀胱癌根治术进行治疗的28例患者作为A组,采用腹腔镜膀胱癌根治术联合快速康复外科理念进行治疗的28例患者作为B组。比较两组患者手术平均时间、术中平均失血量、术后首次排气时间、术后疼痛持续时间、术后切口感染率及术后平均住院时间。对两组患者随访6~12个月,记录并发症发生例数并计算发生率。结果 B组手术平均时间、术中平均失血量、术后首次排气时间、术后疼痛持续时间、术后切口感染率及术后平均住院时间均明显低于A组,差异有统计学意义(P<0.05)。所有患者治愈出院后随访6~12个月,B组随访6个月、12个月的并发症发生率均明显低于A组,差异有统计学意义(P<0.05)。结论采用腹腔镜膀胱癌根治术联合快速康复外科理念治疗浸润性膀胱癌安全有效,可加速患者术后康复,与传统开放性膀胱癌根治术比较,具有一定的优势,值得临床推广应用。     

不稳定型股骨转子间骨折人工股骨头置换和股骨近端髓内钉内固定疗效分析

目的回顾分析老年骨质疏松性不稳定型股骨转子间骨折的人工股骨头置换、股骨近端髓内钉(PFNA)内固定的疗效。方法 66例股骨骨质疏松性转子间粉碎骨折的老年患者分别行骨水泥型人工股骨头置换31例和PFNA内固定35例,比较两组平均手术时间、围手术期平均出血量、平均患肢完全负重时间,Harris髋关节功能评分。术后随访12~27个月,平均21个月。结果人工股骨头置换组平均手术时间(60±16)min,围手术期平均出血量500ml,平均患肢完全负重时间6d。Harris髋关节功能评分:优28例,良3例,差0例;优良率100%,平均住院费用(38846±5329.6)元。PFNA组平均手术时间(79±13)min,围手术期平均出血量514ml,平均患肢完全负重时间32d。Harris髋关节功能评分:优25例,良6例,差4例;优良率88.6%,平均住院费用(36126±6316.6)元。手术时间、平均负重时间、Harris评分两组间比较有显著差异(P0.05)。围手术期出血量和平均住院费用比较无显著差异(P0.01)。结论两种方式均能很好地治疗不稳定型股骨转子间骨折,但人工股骨头在术后髋部疼痛缓解、早期下床、功能锻炼方面具有明显的优势。     

尿NMP22在诊断尿路上皮癌中的应用

评估尿核基质蛋白22(NMP922)作为尿路上皮癌肿瘤标记物的临床诊断价值。应用免疫酶标记法(ELISA)检测24例尿路上皮癌，20例非尿路上皮癌，6例膀胱全切术后肠道膀胱患者尿NMP22水平。结果发现，尿路上皮癌组的尿NMP922平均为39．49U／ml，明显高于非尿路上皮癌组的4．33U／ml(P＜0．01)，尿路上皮癌治疗后患者尿NMP922水平下降至5．08U／ml(P＜0．01)，膀胱癌全切术后肠道膀胱患者尿NMP922水平极高。提示尿NMP922作为尿路上皮癌的肿瘤标记物具有较高特异性，其含量测定有助于尿路上皮癌的诊断。     

机器人辅助关节镜下重建前交叉韧带的疗效

目的比较机器人辅助关节镜下重建与单纯关节镜下重建前交叉韧带(ACL)的临床疗效。方法采用回顾性队列研究分析2020年1月至2020年9月西安交通大学附属红会医院收治的37例ACL撕裂患者的临床资料,其中男24例,女13例;年龄16~45岁[(30.7±9.8)岁]。17例在机器人辅助关节镜下行ACL重建(机器人组),20例在单纯关节镜下行ACL重建(单纯关节镜组)。比较两组手术时间、导针钻孔次数、骨道位点的准确性(骨道中心点距理想解剖点的距离)、围术期并发症情况。术前、术后4个月及末次随访时采用Lachman试验、KT-2000测量数值评估膝关节稳定情况,采用Lysholm评分、国际膝关节文献委员会(IKDC)评分及关节屈伸活动度评估膝关节功能恢复情况。结果患者均获随访12~18个月[(13.1±4.1)个月]。机器人组手术时间为(83.8±11.3)min,明显长于单纯关节镜组的(50.4±9.1)min(P<0.01)。机器人组导针钻孔次数为(2.2±0.5)次,较关节镜组的(2.5±0.4)次少(P<0.05)。机器人组骨道中心点距理想解剖点的距离为(1.3±0.3)mm,关节镜组为(1.4±0.3)mm,两组差异无统计学意义(P>0.05)。两组均未见围术期并发症。术前、术后4个月及末次随访时两组间Lachman试验、KT-2000测量数值、Lysholm评分、IKDC评分及关节屈伸活动度差异无统计学意义(P均>0.05);两组内术后4个月及末次随访时以上相关指标较术前显著改善(P均<0.01),术后4个月与末次随访时以上相关指标差异无统计学意义(P均>0.05)。结论机器人辅助关节镜下重建ACL较单纯关节镜下重建ACL手术时间稍长,但可一次性制备具有良好位点及方向的骨道,获得与单纯关节镜下重建ACL相似的关节稳定性及功能恢复。     

颈外动脉栓塞术联合鼻内镜切除富血供鼻咽部血管纤维瘤

目的评价颈外动脉栓塞术联合鼻内镜切除术治疗富血供鼻咽部血管纤维瘤的临床疗效,并与单纯鼻内镜切除术进行对比分析。资料与方法搜集本院收治的富血供鼻咽部血管纤维瘤患者33例,其中采用颈外动脉栓塞术联合鼻内镜切除术治疗20例(A组),单纯鼻内镜切除术治疗13例(B组),回顾性分析两组病例切除术中失血量、手术时间、术后住院时间等差异,对术后1年复发情况进行随访。结果 A组切除术中失血量为(154.5±84.3)ml,手术时间为(75.0±30.9)min,术后住院时间为(3.5±1.3)天,动脉栓塞术后6例发生轻度并发症,经对症治疗后消失,随访1年有1例复发;B组切除术中失血量为(623.1±142.3)ml,手术时间为(100.8±62.2)min,术后住院时间为(5.7±2.1)天,随访1年有1例复发。结论颈外动脉栓塞术联合鼻内镜切除术是治疗富血供鼻咽部血管纤维瘤微创、安全、有效的方法,与单纯鼻内镜切除术相比,具有术中失血量少、手术时间短、术后恢复快的优势。