可控膀胱增强缩窄回肠控制机能的临床研究

目的设计一种控尿可靠,导尿容易和手术方法简单的可控膀胱输出道. 方法对20例尿流改道的患者,采用缩窄的回肠作为输出道,并将部分输出道固定在回肠储尿囊与腹壁之间,输出道的内口与回肠储尿囊作端侧吻合,其外口与脐孔作端端防狭窄吻合的手术方法治疗.术后1.5～3个月和6～ 17个月分别对输出道和储尿囊行尿动力学检查. 结果 1例术后55 d死于心脏疾病,其余19例中,18例术后昼夜能控制尿.术后1.5～3个月尿动力学显示储尿囊充盈时输出道最大闭合压为46～124(92±17)cmH2O(1 cmH2O=0.0 98 kPa),空虚时34～84(67±12)cmH2O,两者间差异有非常显著性意义(t=10.5 9, P＜0.01);6～17个月12例行尿动力学检查,储尿囊充盈时输出道最大闭合压为7 7～154(101±21)cm H2O,空虚时为56～115(74±15) cm H2O,两者差异有非常显著性意义(t=8.54, P＜0.01);储尿囊容量为360～750 (455±111)ml,充盈时内压为16～35(23±6)cmH2O,充盈过程中没有收缩波出现. 结论储尿囊与腹壁的壁外支持可明显增强缩窄回肠的控尿能力,这种术式还具有导尿容易和手术方法简单的特点.     

输出管悬吊增强缩窄回肠控制机制的实验研究

目的 设计探讨可靠、导尿容易、并发症少的可控性膀胱输出道的手术方法。方法 对8条成年杂种狗采用经裁剪后缩小管腔直径的回肠作为输出管,用宽1.5cm的涤纶带以400g的拉力将输出管固定于腹直肌上,术后12周作尿动力学和X线检查。结果 8条狗的腹壁造口可容易地插入14F导管,尿动力学检查示膀胱输出管最大闭合压为117-157cmH2O,平均137cmH2O。腹壁造口逆行造影示输出管被固定在腹壁下,无狭窄,膀胱造影示输出管内无造影剂。结论 输出管悬吊具有明显增强缩窄回肠控制机制和手术方法简单的优点。     

贮尿囊壁外隧道作为输尿管抗反流方法的临床观察

目的：介绍一种抗反流可靠、吻合口狭窄发生率低的输尿管与贮尿囊再植新方法。方法：对17例可控性尿流改道患者采用双输尿管分别在W形贮尿囊壁外隧道或双输尿管末端合并为一根在U形贮尿囊或W形贮尿囊壁外隧道潜行3－4cm,然后与贮尿囊壁端侧吻合作为输尿管抗反流的方法行可控性尿流转向术;对3例回肠通道术后（Bricher术）患者采用保留原输尿管回肠吻合口、缩窄远端回肠后在贮尿囊壁外隧道潜行作为抗反流的方法行可控性尿流转向术。结果：贮尿囊造影示输尿管无反流;静脉肾盂造影示肾盂无积水,输尿管无扩张,蠕动良好。结论：贮尿囊壁外隧道是一种抗反流可靠、吻合口狭窄发生率低的输尿管与贮尿囊再植新方法。     

盲结肠膀胱术加强输出道可控机制的临床研究

目的　改进盲结肠膀胱术输出道手术方法 ,建立一种控尿可靠、插管方便、并发症少的可控输出道。　方法　对 4 7例膀胱癌患者行膀胱癌根治切除 ,37例采用去结肠带建立盲结肠贮尿囊 ,10例非管状化建立盲结肠贮尿囊 (改良Indianapouch) ,截取末端回肠 12～ 14cm ,剖开肠管重叠绕圈缝合成双层肠壁结构 ,回盲肠交界处浆肌层缝合 ,构筑回盲部小乳头状回肠套叠结构 ,建成长 12cm的输出道。盲肠端与盆腔腹壁缝合 ,远端与脐孔吻合 ,全长固定潜行于腹壁下贮尿囊和腹直肌之间。　结果　全部患者插管顺利 ,白天完全可控 4 5例 ,夜间完全可控 4 4例 ,术后 6个月输出道闭合压 4 0 .5～ 12 5 .6cmH2 O ,充盈状态输出道最大闭合压明显高于空虚状态 (P <0 .0 5 )。　结论　改进的缩窄末端回肠输出道是一种较理想的可控输出道。     

体外可控性回肠膀胱术的实验研究及临床应用

目的　提高体外可控性回肠膀胱术的治疗效果。　方法　距回盲部约 2 0cm处切取一段回肠 ,中间部分折叠成N形并缝制成贮尿囊 ;近端回肠为输入道 ,近贮尿囊 4～ 5cm回肠纵形折叠缝合以缩窄管腔 ;远端 8～ 10cm回肠从腹壁造瘘口处穿出体外 ,于造瘘口处取双片梯形皮瓣包绕外露肠管缝制成皮管 ,构建输出道。将尿液控制器置于皮管外 ,利用气囊控制排尿。 12只犬应用研究后对 5例膀胱癌患者采用此术式治疗。　结果　 10只犬手术顺利 ,术后 3个月时贮尿囊平均最大容量 (15 0± 4 0 )ml,最大充盈压 (2 4 .4± 5 .3)cmH2 O。 5例患者术后随访 3～ 14个月。术后 3个月时贮尿囊平均最大容量 (2 90± 80 )ml,最大充盈压 (36 .3± 8.2 )cmH2 O ,最大尿流率 (2 0 .3± 4 .7)ml/s ,无剩余尿。影像学检查肾脏显影良好 ,输尿管通畅。尿液控制器气囊充气后无尿液流出 ,气囊消气后尿线粗。　结论　该尿流改道术式可达到体外控尿效果 ,不必佩戴集尿袋及导尿 ,手术操作比较简单、并发症少。     

体外可控性回肠代膀胱术的实验研究

目的 探讨体外可控性回肠代膀胱术的可行性及效果。方法 距回盲部 20 cm处取35 cm回肠,中段折叠成 N形并将其对系膜缘纵形剪开,缝制成贮尿囊;近端回肠作为输入道,远端回肠作为尿流输出道,将此段回肠于下腹壁造瘘口处穿出体外,于造瘘口处取双片梯形皮瓣包绕外露肠管缝制成皮管,制成输出道。将尿液控制器置于皮管外,利用气囊控制排尿。结果 10例动物顺利度过手术期。术后6个月内肝肾功能、电解质、血糖及血脂均与术前差异无显著性(P>0.05)。尿动力学检查:术后 3个月时平均贮尿囊最大容量为(150±40)ml,最大充盈压为(24.4±5.3)cm H_2O(1 cm H_2O=0.098 kPa),贮尿囊顺应性好。X线影像学检查:肾脏显影良好,输尿管通畅,贮尿囊充盈良好,无输尿管逆流。尿液控制器的排尿效应:气囊充气后,无尿液流出;气囊消气后,尿液呈粗线条流出。结论 该尿流改道术式可达到体外控制排尿的效果,手术操作比较简单、并发症少。     

可控性膀胱术与回肠新膀胱术(附68例报告)

目的　评价不同术式可控性膀胱术及回肠新膀胱术的疗效。　方法　对 6 8例膀胱全切除术后患者采用 4种可控性尿流改道及回肠新膀胱术式 ,术后对患者控尿、导 (排 )尿 ,贮尿囊容积、内压 ,影像学及血生化资料进行比较。　结果　回肠套叠式输出道 3例中有 2例部分脱套致术后尿失禁 ,需再次手术 ;缩窄末端回肠式输出道 44例控尿均良好 ,除 1例插管困难外余均能用 16～ 2 0F尿管自行导尿。去管折叠式贮尿囊 39例 ,其中回肠贮尿囊 3例、结肠 2 2例、回结肠 14例 ,能达到低压贮尿囊要求 ,但早期有 8例发生贮尿囊过度扩张 ,容量 1470～ 16 5 0ml;去带结肠贮尿囊 8例 ,容量 430～6 0 0ml,充盈压 30～ 45cmH2 O(1cmH2 O =0 .0 98kPa) ,有蠕动波 ,术后早期有 2例尿漏。回肠新膀胱2 1例 ,容量 35 0～ 46 0ml,充盈压 12～ 2 0cmH2 O ,日间尿失禁 1例 ,夜间尿失禁 2例 ,其余无尿失禁。　结论　盲升结肠 30cm剖开对折成形可控性膀胱可满足低压贮尿囊要求 ,去带结肠贮尿囊由于易发生术后尿漏或粘连 ,内压较高 ,不够理想。缩窄末段回肠式输出道控尿效果好、内腔大、插管顺利、并发症少 ,明显优于回肠套叠输出道。回肠新膀胱术贮尿排尿功能良好 ,术后生活质量高 ,但应严格选择手术适应证。     

回肠正位代膀胱的尿动力学检测

目的：从尿动力学角度阐明回肠代膀胱的尿动力学特点，并为该术式提供动力学依据。方法：对1991年6月-1998年9月间作回肠代膀胱术26例患者用Dantec-Menuet尿动力仪行尿流率，代膀胱压力。容积和尿道压等检查。结果：最大尿流率为16.4(5.0-28.0)ml/s。代膀胱的最大容积为424.5(240-803)ml。贮尿囊最大内压为2.695(2.060-4.606)kPa。排尿时贮尿囊内压为7.918(4.508-10.486)kPa。最大尿道闭合压为6.292(4.900-7.742)kPa。结论：回肠代膀胱具有较大的容积。能满足贮尿功能，有足够大的尿道压和较低的膀胱压，保证了可控性，排尿期膀胱压远大于尿道压，为原位排尿提供了保障，是一种理想的膀胱替代术。     

膀胱内粘膜沟固定法增强缩窄回肠控制的实验研究

我们将输尿管与代膀胱再吻合时常用的膀胱内粘膜沟固定法作为可控膀胱的控制机制的一种新方法 ,现报道如下。一、材料与方法雌性杂种成年犬 8条 ,重 13～ 2 3ｋｇ ,平均 17.6ｋｇ。全麻下 ,取末段回肠 7ｃｍ左右 ,并以 14Ｆ号导管为基点缩窄后作为输出管。在膀胱侧壁切一小口 ,分离并剪开粘膜长 2ｃｍ ,将缩窄回肠的一端套入膀胱 ,并放在无粘膜的沟内 ,长 2ｃｍ ,其内口的下半部分与膀胱粘膜作间断吻合 ,已分离的膀胱粘膜与输出管的两侧壁作间断缝合 ,另一端作腹壁防狭窄造口。术后 10周作尿动力学和Ｘ线检查 :先排空膀胱 ,注入 2 0ｍｌ生理…     

经脐造口式可控性结肠膀胱术

１９９１年１１月－１９９４年６月为９例膀胱癌患者施行了膀胱全切除、经脐造口式控性结肠膀胱术，即将盲升结肠３０ｃｍ剖开后Ｓ形折叠重组形成贮尿囊，输尿种植于贮尿囊后壁，利用缝合器缩窄末段８ｃｍ回肠形成抗尿失禁输出道，经脐部作平坦式腹壁造口。．     

Enhanced continent mechanism of tapered ileum by extramural support from the pouch and abdominal walls: a preliminary report of a clinical study

PURPOSE: We constructed a reliable continent tube that is easy to catheterize and surgically simple. MATERIALS AND METHODS: Eight patients with bladder cancer underwent a procedure in which ileal segment was tapered as an efferent tube, of which a part was placed between the back surface of the rectus muscle and the ileal pouch wall. The internal orifice of the tapered ileum was anastomosed to the ileal pouch and its external orifice was anastomosed to the umbilicus. Urodynamic and radiological studies were done postoperatively in 7 cases. RESULTS: The stoma was easily catheterized with a 16Fr catheter in all cases. One patient died of heart disease 55 days postoperatively, while 6 of the remaining 7 were completely continent day and night. Urodynamic study of the efferent tubes showed that maximum close pressure with the pouch full was significantly higher than with the pouch empty (p <0.001). Retrograde radiography of the efferent tubes demonstrated perfect canalization without stenosis. CONCLUSIONS: This study indicates that the continent mechanism of tapered ileum may be greatly enhanced by fixing it between the abdominal and pouch walls. This maneuver also provides easy catheterization and surgical simplicity.     

Study of efferent tube suspension as a continent diversion mechanism. an experimental study in dogs

PURPOSE: To construct a reliable continent tube, which is easy to catheterize and surgically simple. MATERIALS AND METHODS: 8 adult female mongrel dogs underwent a procedure in which an ileal segment was tapered as an efferent tube. The tapered ileum was fixed to the back surface of the rectus muscle with a polyester taper 1.5 cm in width and a suspension tension of 400 g. The internal orifice of the tapered ileum was anastomosed to the bladder and the external orifice of the tapered ileum was brought out to the abdominal skin. Urodynamic and radiological studies were carried out postoperatively in all dogs. RESULTS: All stomas in dogs could be easily catheterized with a 14-french catheter. Urodynamic study of the efferent tubes showed that the maximum closure pressure ranged from 117 to 157 (mean 136.75) cm water. Retrograde radiogram of the efferent tubes showed perfect canalization without stenosis. CONCLUSION: This study suggests that the continent mechanism of the tapered ileum can be greatly enhanced by a suspension technique.     

Efferent tube suspension as a continent diversion mechanism: a preliminary report of a clinical study

PURPOSE: We constructed a reliable continent tube that is surgically simple. MATERIALS AND METHODS: In 12 patients with malignant bladder tumor we performed radical cystectomy with isolation of a 50 cm. ileal loop with pedicle. The proximal segment (8 to 10 cm.) was tapered over a 16Fr catheter as an efferent tube, the remaining segment was detubularized to create a W-shape pouch and the tapered ileum was fixed to the back surface of the rectus muscle with 2 polyester tapers 1 cm. wide with a suspension tension of 500 g. The external orifice of the tapered ileum was anastomosed to the umbilicus. In 2 patients with neuropathic bladder a 15 cm. ileal loop with pedicle was isolated, the proximal segment (8 cm.) was tapered as an efferent tube with 500 g. suspension tension, and the remaining segment was detubularized and anastomosed to the bladder. RESULTS: The patients were followed for 6 to 17 months (mean 11.4) and were completely continent day and night. The stoma was easily catheterized with a 16Fr catheter in all cases. Urodynamic study of the efferent tubes revealed maximum pressure of 84 to 159 cm. water (mean 114). Retrograde radiography of the efferent tubes demonstrated perfect canalization without stenosis. CONCLUSIONS: This study suggests that the continent mechanism of the tapered ileum can be greatly enhanced by a suspension technique. This maneuver also provides easy catheterization and surgical simplicity.     

带蒂腹直肌瓣包绕缩窄回肠输出道增强控尿机制的实验研究

目的 改良可控输出道术式,增强可控输出道的长期控尿能力.方法 1～2岁杂种犬10只,雄性2只,雌性8只.分别截取30～40 cm末端回肠U形折叠制成储尿囊,另取2段6 cm回肠段缩窄为可通过12 F导管的输出通道.切取6 cm×3 em腹直肌,保留神经m管束,自1条缩窄同肠输出道的肠系膜血管间穿过,包绕十输出道外作为控制管;另1条输出道直接连接腹壁皮肤作为对照管.术后1、3、6个月分别测定储尿囊空虚和充盈时输出道压力(MIP)及功能性压力段长度(FPL).分析储尿囊充盈前后控制管与对照管MIP与FPL的差异.结果 1条犬术后6个月储尿囊允盈中液体经对照管溢出,无法完成实验.其余9条均行3次测压.储尿囊充盈前后,控制管MIP均70 cm H2O(1 cm H2O=0.098 kPa);对照管分别为<30、40<45 am H2O,均明显低于控制管.术后1、3、6个月,储尿囊充盈前后,控制管MIP平均值分别为(73.51±24.01)与(77.68±25.15)、(71.16±19.35)与(79.78±21.25)、(70.28±18.30)与(75.93±17.53)cm H2O,FPL平均值分别为(4.78±0.78)与(4.60±0.75),(4.71±0.61)与(4.61±0.54)、(4.49±0.65)与(4.24±0.97)cm,充盈前后差异均无统计学意义(P0.05);对照管MIP平均值分别为(29.04±7.02)与(42.90±7.66)、(28.10±8.09)与(41.63±8.98)、(26.63±6.89)与(43.36±9.79)cm H2O,FPL平均值分别为(5.04±0.44)与(4.59±0.53)、(4.98±0.82)与(4.42±0.85)、(4.63±0.69)与(3.97±0.53)cm,充盈前后差异均有统计学意义(P<0.05).术后6个月造影显示输出管与对照管形态无明显差异,无扭曲、狭窄或瘘道形成;组织学检查可见控制管回肠浆膜层外明显横纹肌组织结构.结论 带带腹直肌肌瓣翻转包绕输出道可有效提高输出道的控尿能力,凡有利于同定输出道,方便插管.     

缩窄回肠输出道外支持可控腹壁尿流改道：5年随访报告

目的：评价缩窄回肠可控输出道外支持腹壁可控尿流改道的围手术期及远期并发症发生率及远期控尿效果。方法：对84例患者手术中采用两种方式加强缩窄回肠输出道的控尿能力：①39例通过两条1cm宽的涤纶补片以500g拉力将4～5cm的输出道悬吊于腹直肌下方;②45例以3—0尼龙线将一段4～5cm连接储尿囊的管状回肠贴合于腹直肌背侧,使输出道在腹直肌与管状回肠之间穿过,固定于腹直肌背侧。结果：本组1例术后55天死于心脏疾病,8例（9．6％）出现围手术期并发症,其中2例（2．4％）需再次手术,其余患者均经对症处理缓解。27例（32．5％）出现术后远期并发症,5例（6．0％）需再次手术纠正。在完成最近一次随访的52例患者中,43例可实现尿控,其中37例可日夜满意控尿。涤纶补片组与额外回肠段组的满意控尿率分别为77．3％和76．9％。结论：虽然缩窄回肠可控输出道外支持腹壁可控尿流改道的并发症仍较常见,但其发生率在可以接受的范围,且大多数并发症的处理都较为简单,再手术的概率并不高。长期随访结果显示该手术可使缩窄回肠输出道获得持久、可靠的控尿能力。     

Ileal Pouch with an Umbilical Stoma: A Continent Mechanism Created by the Extramural Tunnel Technique

We present an initial experience of creating an extramural continent valve in the ileal pouch in 4 patients who required continent urinary diversion. Using the appendix or a tapered ileal segment, the continent valve was created by the extramural tunnel technique along the anterior suture line of the pouch to facilitate the umbilical anastomosis. All patients were continent postoperatively with easy catheterization. This technique can provide a simple and effective continent pouch formed entirely from the ileum.     

Continent ileal pouch using the serous-lined principle

OBJECTIVES: The flap valve principle is not easily applicable to an ileal pouch since a submucosal tunnel is difficult to create. We attempted to construct an ileal pouch with an umbilical stoma applying the serous-lined principle for both ureteral implantation and construction of a continent valve. METHODS: In 9 patients, a continent pouch with an umbilical stoma was created entirely from an ileal segment. Adopting the serous-lined principle, a continent valve was created by appendix in 2 cases, tapered ileum in 3 cases, and reconfigured ileum in 4 cases. These were implanted into the anterior suture line of the pouch and embedded into the serous-lined tunnel formed by the pouch wall. RESULTS: Patients can catheterize the pouch easily with a 14-Fr catheter. Postoperatively, pouch capacity is over 400 ml with complete continence. CONCLUSION: This technique can provide a simple and effective continent ileal pouch facilitating umbilical anastomosis. As a continent valve, the reconfigured ileal segment seems most useful for application of the serous-lined principle.