改良低压可控性回肠代膀胱术

目的建立一种更接近生理的回肠代膀胱术。方法１９９１～１９９８年实施５例全膀胱切除,回肠膀胱与尿道吻合,由外括约肌控制,经尿道排尿的新手术方法。结果术后随访３～８４个月,平均２８．６个月。至随访日,５例无吻合口狭窄,排尿通畅。３个月后４例完全控制排尿,１例仍有不完全性尿失禁。结论该术式具有贮尿囊内压低（２０～３０ｃｍＨ２Ｏ）,容量略小（２５０～３００ｍｌ）,可控性和原位排尿的优点,且无电解质紊乱和肾功能损害。     

全膀胱切除正压可控低压U型回肠代膀胱术101例临床分析

目的 全膀胱切除是浸润性膀胱癌和多发性膀胱癌的标准治疗方法，不同尿流改道方式对生活质量影响差别很大。为解决全膀胱切除后贮尿、控尿和排尿问题，本文总结正压可控性低压U型回肠代膀胱术的手术经验。方法 1994年6月～2005年1月共施行了101例全膀胱切除正压可控性低压U型回肠代膀胱术。回顾性分析这些患者的临床资料，总结该方法的手术指征和临床效果。结果 101例手术顺利，无手术死亡。手术时间为4～6．5h，平均5h，随访3～48个月，平均30个月，101例U型回肠膀胱均能自行排尿，其中96例（95．0％）白天完全控尿，69例（68．3％）昼夜完全控尿，32例（31．7％）夜间尿失禁。术后无并发症，随访期内无肿瘤复发，死亡3例，1例于术后9天死于手术后急性心肌梗死，2例于术后2年死于脑出血。结论 对浸润性膀胱癌和多发性膀胱癌应尽早行全膀胱切除，正压可控性低压U型回肠代膀胱术，操作简单、安全、可靠，术后生活质量提高，且远期效果良好，值得临床广泛应用。     

可控回肠膀胱术远期随访（附10例报告）

可控回肠膀胱术远期随访（附１０例报告）叶林阳，王晓雄，李炎唐１９８５年３月至１９８７年３月对１１例膀胱癌患者实施了根治性全膀胱切除可控回肠膀胱术，随访１０例，获得满意效果，报告如下。临床资料１０例均为男性。年龄３２～６０岁，平均４８．５岁。随访６年９...     

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。     

改良VIP回肠代膀胱术（附12例报告）

为更好地解决膀胱癌患者膀胱全切除术后的贮尿和控尿问题，采用改良ＶＩＰ回肠代膀胱术治疗１２例膀胱癌患者。其方法为截取末段回肠４０ｃｍ进行除管和回肠双重折叠作为贮尿囊，输尿管与回肠行ＬｅＤｕｃＣａｍｅｙ吻合术，回肠与后尿道端端吻合建立尿流输出道。随访６～２８个月，平均１１个月。结果：１０例白天完全控尿，２例增加腹压时有尿失禁；９例晚间完全控尿，２例部分尿失禁，１例完全尿失禁。代膀胱内压低，容量大（平均４００ｍｌ）；无输尿管返流和剩余尿。     

回肠新膀胱术60例报告

目的　总结１０ 年来行回肠新膀胱术的手术体会。　方法　对６０ 例行回肠新膀胱术患者进行尿流可控性、尿动力学、影像学、核医学及生化检查,手术并发症及生存情况的随访观察。随诊时间６ ～９６ 个月,平均３ 年。　结果　病人白天均可自控排尿,仅有２ 例夜间尿失控。尿动力学检查显示新膀胱容量为２５０ ～４００ｍｌ（ 平均３００ｍｌ） ,膀胱充盈时最大内压１５ ～２５ｃｍＨ２Ｏ（ 平均２０ｃｍ Ｈ２Ｏ） ,排尿膀胱压力为５０ ～７０ｃｍ Ｈ２Ｏ（ 平均５６ｃｍ Ｈ２Ｏ） ,平均最大尿流率１６ｍｌ／ｓ,剩余尿为０ ～１２０ｍｌ（ 平均２０ｍｌ） 。影像学检查仅发现２ 例上尿路轻度扩张,肾功能均正常,无电解质紊乱现象,肾图无梗阻。再次手术修补尿瘘２ 例,肾盂输尿管轻度扩张２ 例,围手术期死亡１ 例。肿瘤转移死亡１２ 例,尿道肿瘤复发１ 例,与肿瘤无关死亡３ 例。　结论　对于肿瘤未侵犯前列腺或尿道的膀胱肿瘤病人和结核性挛缩小膀胱的病人,回肠新膀胱是一种低并发症的膀胱替代手术方法。     

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。     

改良低压回肠代膀胱术16例

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患者,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20g·L~(-1)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5h50min。术后随访11～72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。     

回肠新膀胱术的临床疗效观察

为客观地评价回肠新膀胱术的远期疗效，对５２例术后病人的可控性、尿动力学、肾功能、贮尿囊组织学变化及尿ｓＩｇＡ等进行随访研究。４９例获随访３～６６个月，平均随访３５个月。日间可控率为９４％，夜间为８１％。平均最大膀胱容积为４２４．５ｍｌ，最大内压为２．７０ｋＰａ（１ｋＰａ＝１０．２０ｃｍＨ２Ｏ），平均剩余尿２４．８ｍｌ，最大尿流率为１８．０ｍｌ／ｓ。ＩＶＵ示８例１１条输尿管轻中度扩张，膀胱造影２例轻度返流，血肌酐、尿素氮保持正常，尿ＮＡＧ２例升高。术后病人尿ｓＩｇＡ较高。随术后时间延长，贮尿囊绒毛及微绒毛逐渐萎缩，酸中毒发生率下降，尿内粘液减少。肿瘤尿道复发１例。认为回肠新膀胱术是一种可选择的手术。     

乙状结肠直肠膀胱术

膀胱全切术后采用乙状结肠直肠膀胱术（ＭａｉｎｚＰｏｕｃｈＩＩ）作为可控性尿流改道。该术式以乙状结肠直肠交界为中点将肠管纵行剖开２０～２４ｃｍ，做乙状结肠直肠侧侧吻合形成大容量低压贮尿囊，输尿管采用粘膜下隧道方式做抗逆流吻合，利用肛门括约肌控制排尿。本组１１例，平均随访１０．５个月。肠代膀胱容量平均５５３ｍｌ，基础压力平均１．４７ｋＰａ（１ｋＰａ＝１０．２０ｃｍＨ２Ｏ），最大充盈压力平均２．１６ｋＰａ。在肠袋充盈过程中顺应性良好。拔除肛管１周～２个月后可获得满意的尿便分流，２个月后排尿次数稳定，白天４～５次，夜间０～３次。无夜间尿失禁，无逆行感染及高氯性酸中毒。１例出现双侧输尿管梗阻。该术式满足了可控膀胱的基本条件，易于被患者接受，术后生活质量较高     

Fecal and urinary continence after ileal cecal cystoplasty for the neurogenic bladder

PURPOSE: In patients with a neurogenic bladder augmentation with the ileal cecal segment has generally been disregarded as an option due to concerns regarding fecal incontinence. We report our results using a hemi-Indiana pouch bladder augmentation for neurogenic bladder. MATERIALS AND METHODS: A review of 63 patients with neurogenic bladder dysfunction treated with a hemi-Indiana pouch bladder augmentation was performed. None of the patients had fecal incontinence before surgery. RESULTS: Median followup interval was 6 years (range 1 to 10). Etiology of the neurogenic bladder was spinal cord injury in 42 patients (66%), myelodysplasia in 18 (29%) and sacral agenesis in 3 (5%). One patient (1.5%) died immediately postoperatively from a pulmonary embolus. Of the remaining 62 patients, urinary continence was achieved in 54 (87%) and 8 were incontinent per the abdominal stoma. All 8 patients were treated with Contigen injections into the stoma and 4 (50%) became continent. The 4 patients with persistent urinary incontinence became continent after open surgical revision. Postoperatively, fecal continence was improved in 14 patients (23%), unchanged in 46 (74%) and worse in 2 (3%). In 2 patients with deterioration in bowel function stool frequency and fecal soilage increased in conjunction with antibiotic usage. No patient had chronic fecal incontinence. CONCLUSIONS: In select patients with neurogenic bladder dysfunction ileal cecal bladder augmentation with a continent tapered ileal limb results in a 100% incidence of urinary continence with minimal alterations in fecal continence.     

Ileal Neobladder for Bladder Substitution after Radical Cystectomy

Background: Studer's ileal neobladder is technically simple, and favorable clinical results have been reported. However, there have been only a few follow-up studies on this type of ileal neobladder. We reviewed the clinical outcomes of patients who received Studer's ileal neobladder, with a minor modification, in our institution.
Methods: Twenty-five men underwent bladder reconstruction with Studer's ileal neobladder after radical cystectomy. The function of the ileal neobladder and voiding status were evaluated during follow-up. The follow-up period ranged from 3 to 42 months (mean, 24 months).
Results: The ileal neobladder achieved a large capacity at a low basal pressure, associated with a relatively low complication rate directly related to the neobladder. At 12 months after surgery, daytime and nighttime continence rates were 90|X% and 74|X%, respectively. In 5 patients who were incontinent, the maximal urethral closure pressure was statistically lower than in patients with continence.
Conclusion: Studer's ileal neobladder is an easy operative procedure for bladder substitution, and has a relatively low complication rate directly related to the neobladder. Good compliance ofthe pouch and preservation of the external sphincter mechanism are the most important factors for achieving urinary continence, after construction of the ileal neobladder.     

Katheterisierbarer Kontinenzmechanismus für verschiedene Harnableitungsreservoire

In a retrospective multicenter study of four clinics perioperative complications as well as incontinence and stoma stenosis of serosa-lined tapered ileum as catheterizable continence mechanisms for different urinary diversions were analyzed. Between 2008 and 2012 a total of 40 patients received a continent catheterizablestoma, 15 (37.5%) in combination with continent vesicostomy and closure of the bladder neck due to postoperative incontinence and recurrent stenosis including radical prostatectomy, transurethral resection (TUR) of the prostate, bladder neck incision (n=11), neurogenic bladder with reduced capacity and incontinence (n=2), interstitial cystitis (n=1) and recurrent urethral tumor following ileal neobladder (n=1). Of the patients 25 (62.5%) received this continence mechanism in combination with a modified Mainz pouch I, in 19 patients as primary and in 6 patients as secondary efferent segment for trouble shooting. The complications were subdivided according the Clavien classification. In 29 patients information concerning continence and stenosis were obtained, the median follow-up was 25 months (range 1-111 months). In patients with continent vesicostomy (n=11) the incontinence rate was 9.1% (1/11) and the stenosis rate 18.2% (2/11). In 18 patients with an ileocecal pouch, incontinence and stenosis rates were 0% and 11.1% (2/18), respectively. The presented technique is a safe continence mechanism for various catheterizable continent urinary diversions for both primary and secondary indications.     

Continent substitution enterocystoplasty using a low-pressure detubularized ileal reservoir

Summary The rate of enuresis after tubular substitution enterocystoplasty is well over 70%. Incontinence is partly due to the persistence of peristaltic activity in the isolated intestinal segment that generates high-pressure waves of over 40 cm H₂O, even at low urinary volumes, which can overcome the distal urethral sphincter mechanism. The use of detubularized intestinal segments has been shown to reduce dramatically these high-pressure waves, secure diurnal continence, and reduce nocturnal leakage. The detubularized ileal low-pressure reservoir, easy to construct, provides continence rates identical to those secured by more complicated pouches. A 30-cm ileal loop, open on its antimesenteric border, is folded in a U shape. Its medial and lateral borders are then sutured so as to form a pouch, the apex is anastomosed to the urethral stump, the ureters are reimplanted on the upper aspect of each limb, and the pouch is closed. This procedure was used in ten patients after radical cystoprostatectomy for infiltrating bladder cancer, seven of whom were submitted to a thorough clinical radiologic and urodynamic evaluation, with a minimum follow-up of 5 months. All seven are continent during the day, with no residual urine, and have a mean flow rate of 15 ml/s. Cystometrograms taken at full bladder capacity failed to demonstrate pressure waves of over 25 cm H₂O. Four patients are continent at night; three are enuretic and await further treatment. A reasonable alternative to other types of substitution enterocystoplasty, the low-pressure detubularized ileal reservoir provides excellent diurnal continence but cannot secure nocturnal continence in more than 50% of incontinent patients. However, the absence of high-pressure peristaltic waves may allow the use of an artificial urinary sphincter activated at night for the patient who remains incontinent.     

Indiana continent urinary reservoir: report of 15 cases

Over the last several years, internal reservoir type urinary diversions have become popular. We have already performed Kock continent ileal reservoir for urinary diversion in more than 80 patients. The experience with the Kock pouch prompted us to try a new form of continent urinary reservoir originally reported by Indiana University group. The Indiana pouch is a composite structure using ileum and cecum. The antireflux mechanism is provided with tunneled ureteral implantation along the tenia of the cecum. Plication of the terminal ileal segment along with the ileocecal valve maintains urinary continence. The tubular configuration of the cecum is completely disrupted with either an ileal patch or Heineke-Mikulicz re-configuration to construct a low pressure reservoir. Between October, 1987 and September, 1988, we performed Indiana continent urinary diversion in 15 cases: 13 males and 2 females, from 47 to 73 years old (mean age 61.3 years), 14 bladder cancer patients and 1 bladder sarcoma patient. The initial 8 patients underwent Heineke-Mikulicz type operation and the subsequent 7 patients ileal patch-type operation. Median followup has been 7 months. There were no major early complications but one postoperative death with blood transfusion related graft versus host disease (GVHD). The late complication occurred in 2 patients: 1 stenosis of the pouch due to insufficient detubularization of the cecum and 1 pyelonephritis required no admission. Serum electrolytes and vitamin B12 remained normal in all patients. Patients perform self-catheterization every 3-5 hours during the day and 0-2 times at night for volumes ranging up to 800 ml. With regard to volume capacity and pressure characteristics, the ileal patch type reservoir seemed to be superior to the Heineke-Mikulicz type pouch as a receptacle for urine. Over-all, 12 of 14 patients (86 per cent) have acceptable continence. The remaining 2 patients have significant daytime leakage requiring pads or a cutaneous bag. Followup examination with excretory urography showed no upper tract obstruction and X-rays of the pouch showed no reflux. Indiana pouch is a relatively simple continent urinary reservoir, since the steps of this technique already are familiar to urologists. It may be an alternative form of continent urinary diversion.     

Clinical experience of Kock pouch continent urinary diversion

Kock continent ileal reservoir for urinary diversion was performed in 53 patients with invasive bladder cancer (52) or neurogenic bladder (1). The postoperative follow-up period was from six to thirty-nine months. The clinical results showed no metabolic disturbance of blood electrolytes or acidity. Prolapse of efferent nipple valve developed in 4 patients (7.6%); and 2 underwent revisional surgery with a good result. Another 4 patients (7.6%) suffered from poor continence and relatively frequent catheterization to empty the pouch was necessary to prevent urine leakage through the stoma. Urodynamic study of the Kock pouch in these 4 patients showed a short functional nipple valve length and small pouch capacity. The other 45 patients (84.8%) had good continence. Urodynamic study of the pouch in 20 patients showed low pressure (mean of 13.3 cm H2O) in the pouch and high pressure (mean of 72.1 cm H2O) at the efferent nipple valve. Three patients had unilateral hydronephrosis in the follow-up intravenous urography. Corrective surgery for stenosis at the right ureteroileal anastomosis was done in 1 patient with normalization of the upper urinary tract afterward. The other 2 patients were managed by close observation for the mild hydronephrosis. Symptomatic bacteriuria developed in only 3 patients (5.7%) and responded well to antibiotic management. Reservoirography demonstrated no reflux into the upper urinary tract in all the follow-up patients. There was no significant change of the renal function at twenty-four months after operation detected by radionuclide (131I-Hippuran) renal functional study. All patients were satisfied with Kock urinary diversion.     

100 cases of Mainz pouch: continuing experience and evolution

The surgical technique for creation of the Mainz pouch uses 10 to 15 cm. of cecum and ascending colon and 2 ileal loops of the same length for construction of a urinary reservoir. Initial applications of the Mainz pouch were for bladder augmentation after subtotal cystectomy and for continent urinary diversion. Current indications have been extended to complete bladder substitution after radical cystoprostatectomy with anastomosis of the pouch to the membranous urethra. For cosmetic reasons the umbilicus is used as a stomal site for continent urinary diversion, and the technique of intussuscepting the continence nipple has been modified accordingly. A total of 100 patients underwent a Mainz pouch procedure since 1983: 34 for bladder augmentation, 15 for total bladder substitution after cystoprostatectomy and 51 for continent urinary diversion. In the bladder augmentation group 1 patient underwent conversion to a continent stoma, 1 has urge and frequency, and the remaining 32 are completely dry day and night. These patients empty the bladder at normal intervals spontaneously except for 3 who rely on intermittent catheterization. In the bladder substitution group 1 patient has grade 1 stress incontinence and the remainder are completely dry during the day. However, at night 4 patients have leakage and they use a condom urinal. In the urinary diversion group all but 2 patients are completely dry and are on intermittent catheterization. The main problem of the initial series was prolapse of the continence nipple, which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve.     

The Mainz pouch (mixed augmentation ileum 'n zecum) for bladder augmentation and continent urinary diversion

A new technique for fashioning an ileocecal pouch, applicable for both bladder augmentation and continent urinary diversion, is described. A low pressure reservoir is achieved by antimesenteric longitudinal transsection of ileum and cecum and formation of a pouch from the cecum and two ileal loops. The antireflux procedure consists of submucosal tunnel implantation of the ureters into the cecum. Clinical application of the operative technique in 4 cases for bladder augmentation and in another 6 cases for urinary diversion has proven the validity of our functional concept: all patients with Mainz pouch bladder augmentation are completely dry day and night with normal intervals of bladder evacuation. Of the 6 patients with Mainz pouch urinary diversion, 2 rely on a an all alloplastic stomal prosthesis for continence, another 2 have achieved continence with isoperistaltic ileo-ileal invagination, and the remainder are awaiting implantation of a sphincteric device.     

Complications of the Miami pouch.

The Miami pouch, a continent colonic urinary reservoir, was constructed in 75 patients after cystectomy for invasive bladder tumor (44), gynecological tumor (25), neurogenic bladder (4) and conversion of an ileal conduit (2). Continence was achieved by tapering the distal ileum over a 14F catheter and reinforcing the ileocecal valve with 3 circumferential silk sutures in a pursestring fashion. Ureterocolonic anastomosis was performed in a nontunneled fashion. There were 5 perioperative deaths. One or more early (perioperative) complications occurred in 19 patients (26%). Late complications (beyond 6 weeks) were found in 16 patients (23%). Total continence rate was 98.6% and the success rate of the ureterocolonic anastomosis was 90%. Followup was 7 to 69 months. We present a review of the technical aspects of the construction of the Miami pouch, and the early and late complications associated with this procedure.