浆膜间隧道技术在尿路重建中的临床应用

目的 评价浆膜问隧道技术在原位膀胱、可控尿流改道和回肠代输尿管成形术中的临床应用效果. 方法浆膜间隧道技术是将重建输出道或再植输尿管置于储尿囊的回肠壁浆膜之间以达到可控或者抗反流的目的 .应用浆膜间隧道技术在原位回肠膀胱重建患者中行输尿管再植31例,可控回肠膀胱重建患者中行可控瓣成形和输尿管再植13例,回肠代输尿管成形患者中在输尿管近端应用该技术抗反流3例. 结果平均随访27(12～132)个月.88根植入回肠新膀胱或可控膀胱的输尿管功能良好,造影显示无梗阻或反流,13例可控瓣12例无漏尿,3例回肠输尿管成形患者造影均无回肠输尿管反流,IVU显示肾积水较前明显好转. 结论应用浆膜问隧道技术进行输尿管再植和可控瓣成形临床效果良好,可以作为尿路重建中的常规应用.     

腹腔镜膀胱根治性切除原位回肠新膀胱术

目的分析8例腹腔镜下膀胱根治性切除术加原位回肠新膀胱术的手术经验及术后效果。方法浸润性膀胱癌患者8例,均为男性,年龄61～76岁,平均68.5岁。腹腔镜下行根治性膀胱前列腺切除,延长脐下切口取出标本,于体外选择40cm回肠,对系膜缘切开后W形折叠形成新膀胱,双输尿管乳头状再植于新膀胱,腹腔镜下将新膀胱最低点与尿道残端行端端吻合。结果手术耗时4～7h,平均5.3h;出血量100～1100mL,平均250mL。术后平均肠道恢复时间3.9d。术后随访7～27个月（平均16.2个月）,患者排尿良好,行B超、IVU及新膀胱造影检查示：双肾显影良好,无输尿管返流及梗阻,新膀胱充盈良好,容量约300mL。结论腹腔镜下行膀胱全切原位回肠新膀胱术损伤小、出血量少、术后恢复快、生活质量高,短期随访临床效果满意。     

裂隙状袖套式输尿管乳头再植术:肠段上可靠的预防返流

肠段在下尿路重建和尿流改道中的应用正在日趋增多,因此,往往需要可靠的抗返流输尿管再植。传统方式上,常使用粘膜下隧道技术,这种再植技术在大肠上实施是简单的,但应用到回肠上却很困难,而许多的尿路重建多采用回肠。作者为了预防多种下尿路重建肠道输尿管的返流,采用裂隙状袖套式输尿管乳头再植技术,对18例病人35侧输尿管进行再植,其中包括6例扩大膀胱成形术(4例用回肠,2例用乙状结肠)。Kock's膀胱6例,盲肠膀胱2例,回肠膀胱3例。回盲肠可控性膀胱1例。通过3     

改良全膀胱切除-原位回肠新膀胱术治疗膀胱癌的临床疗效(附12例报告)

目的：评价改良全膀胱切除方法和原位回肠新膀胱术的临床疗效。方法：对12例膀胱癌患者行改良全膀胱切除术．顺行分离膀胱顶部、侧壁上半部、底部,切断输尿管后改逆行分离。示指紧贴前列腺包膜将前列腺与直肠分开后,向上向外将膀胱颈部侧韧带和精囊尾的纤维束钩于示指掌握之中,切断并结扎。女性患者保留内生殖器及尿道内口。尿流改道采用原位回肠新膀胱术,并就手术并发症、术后控尿排尿情况、新膀胱容量、影像学和生化检查进行随访,随访时间8～62个月,平均35个月。结果：切除膀胱时间平均80min,术中平均出血450ml。原位回肠新膀胱控尿、排尿良好,术后静脉尿路造影、B超检查未见上尿路扩张,膀胱造影未发现输尿管反流,血生化检查正常,未发现新膀胱或尿道肿瘤复发。结论：改良膀胱切除术-原位回肠新膀胱术是治疗浸润性膀胱癌的理想方法。     

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。     

一种输尿管回肠再植新技术：壁外浆膜隧道

一种输尿管回肠再植新技术：壁外浆膜隧道［英］／Ａｂｏｌ－Ｅｎｅｈ　Ｈ…／／　ＪＵｒｏｌ．－１９９４１５１（５）．－１１９３～１１９７本文作者创用回肠壁外浆膜隧道法进行输尿管回肠再植术于１２例病人取得圆满成功。方法：在标准的根治性膀胱前列腺切除后，在...     

输尿管回肠膀胱端端吻合在全膀胱切除术中的应用

目的:探讨全膀胱切除、Bricker术(回肠膀胱术)中输尿管-回肠端端吻合术的优势及临床应用价值。方法:回顾性分析13例全膀胱切除、Bricker术中行输尿管-回肠端端吻合术患者的临床资料:男10例,女3例。术前均行膀胱镜检查并活检确诊为浸润性膀胱癌,病变均位于膀胱颈及以上。结果:所有患者均顺利完成手术,手术时间205~260min,平均230min。输尿管-回肠吻合时间8~10min。术后2周拔除单J管,无漏尿发生。随访1~5年,B超或造影显示无肾积水和输尿管扩张。结论:全膀胱切除、回肠膀胱术中采用输尿管-回肠端端吻合术,操作简单、省时,术后并发症少,方法较为理想,具有良好的临床应用价值。     

改良膀胱全切原位W形回肠膀胱术26例报告

目的评价改良膀胱全切原位W形回肠膀胱术的临床疗效。方法对26例膀胱癌患者行逆行和顺行相结合的全膀胱切除方法，截取40cm带蒂回肠，对肠系膜纵行剖开后W形折叠，缝制成新膀胱，输尿管以乳头法种植于膀胱“三角区”，将贮尿囊完全置于腹膜外；术后随访患者恢复和排尿情况，定期复查生化指标、B超和膀胱排尿造影。结果患者术后均康复，平均随访18个月，白天控尿良好20例，夜间控尿良好18例；5例有不同程度的肾积水和肾功能异常，其中1例出现双肾积水，均行膀胱排尿造影除外返流；无低钾血症和酸中毒。结论改良膀胱全切原位W形回肠膀胱术，具有手术简单、术后并发症少及代膀胱功能良好的特点，是治疗浸润性膀胱癌的理想方法。     

输尿管回肠吻合术在可控性尿流改道中的应用

目的 评价输尿管回肠吻合术在可控性尿流改道术后抗返流及防止上尿路感染中的效果。方法 根治性膀胱切除术后行去带盲升结肠可控膀胱术和新膀胱术的患者10例，采用带回盲瓣的回肠段作为可控性膀胱的输入襻，双侧输尿管黏膜下隧道法与回肠吻合，随访观察患者术后输尿管返流及上尿路感染情况等。结果 10例手术顺利，术后随访6～36个月，均未发生输尿管返流或上尿路感染，1例发生单侧肾积水，为吻合口狭窄所致。结论 黏膜下隧道法输尿管回肠吻合术预防去带盲升结肠可控性尿流改道术后输尿管返流及上尿路感染效果良好。     

输尿管异位开口的诊断与治疗（附32例报告）

目的探讨输尿管异位开口的诊断及治疗。方珐回顾性分析32例异位输尿管开口患者的临床资料，采用B超检查28例，IVU29例，CT13例、MRU7例，膀胱镜检查13例，异位开口插管造影8例，膀胱尿道、阴道造影12例。对其临床特点、诊断及外科治疗方式进行分析。结果术前确诊28例（93．3％）。行单侧肾脏输尿管或上半肾输尿管切除各12例，输尿管膀胱再植术4例，分期行左、右输尿管膀胱再植、左掌长肌移植尿道括约肌成形l例，左上重复肾、输尿管切除及左下、右侧输尿管膀胱再植1例，未行手术2例。30例术后随访3—16年，效果良好。结论输尿管异位开口的诊断需结合病史、体检、B超、IVU、膀胱镜、CT、MRU等检查进行综合分析，必要时行腹腔镜检查。上半肾输尿管切除及输尿管膀胱再植是治疗输尿管异位开口合并上／下尿路畸形的有效方式。     

The serous-lined tunnel principle for urinary reconstruction: a more rational method.

OBJECTIVE: To examine the feasibility of using the serous-lined-tunnel principle for orthotopic neobladder, continent cutaneous diversion and ureteric replacement by an intestinal segment. Patients and methods We created: (i) an orthotopic ileal neobladder using the serous-lined technique for antirefluxing ureteric implantation in 16 patients; (ii) a continent ileal pouch, adopting the principle for continent-valve construction and for ureteric implantation, in 10 patients (another patient with a failed continent valve underwent revision using an adaptation of this principle; and (iii) by applying the same principle an ileal ureter with a proximal antirefluxing mechanism was constructed in two patients (with lower ureteric cancer), and total replacement of the ureter by a tubular segment of the colon in association with a continent transverse colon pouch in one irradiated patient. RESULTS: In all, 52 ureters implanted into ileal neobladders or continent pouches functioned well, with neither obstruction nor reflux; 11 continent valves functioned well with no incontinence. Two patients with ileal ureters showed no ileo-ureteric reflux and had less hydronephrosis than before surgery. The tubularized ureter provided a unidirectional flow into the pouch. Conclusion Ureteric reimplantation and continent valve formation achieved by adopting the serous-lined tunnel principle provided satisfactory results. The versatility of the principle is apparent in the present experience and the creative application of the serous-lined tunnel principle should be possible in urinary reconstruction.     

Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation: experience with 450 patients

PURPOSE: We report functional results of the orthotopic ileal neobladder using a serous-lined extramural tunnel as an antireflux procedure. MATERIAL AND METHODS: One-stage radical cystectomy and orthotopic ileal W-shaped neobladder creation were performed in 353 male and 97 female patients for invasive bladder cancer. The ureters were reimplanted using a serous-lined extramural tunnel for reflux prevention. Of the patients 344 were evaluable at a mean followup plus or minus standard deviation of 38 +/- 25 months. Evaluation included clinical and radiographic studies to determine functional and oncological outcomes. RESULTS: Four patients (0.8%) died in the hospital. Early complications in 42 patients (9%) were treated conservatively but 3 women underwent vaginal repair of a pouch-vaginal fistula. During the observation period there were 90 oncological failures, of which 3 were isolated urethral recurrence. Late complications included pouch stones in 10 cases, outflow obstruction in 11, mucous retention in 2, adhesive bowel obstruction in 3 and hypercontinence in 9 females. The incidence of daytime and nighttime continence was 93.3% and 80%, respectively. The upper tracts remain unchanged or improved in 96.2% of the reimplanted renal units, while reflux was observed in 3%. CONCLUSIONS: The serous-lined extramural tunnel has proved its efficiency and durability as an antireflux technique.     

Outcome of patients with continent urinary reconstruction and a solitary functioning kidney

OBJECTIVE: To evaluate the outcome of patients with continent urinary diversions who had a solitary functioning kidney at the time of surgery. PATIENTS AND METHODS: In all, 62 patients with continent urinary reservoirs and a solitary functioning kidney were reviewed (51 men and 11 women). The indications for surgery were bladder cancer in 54 and a contracted bladder in eight. The surgical procedures included an orthotopic ileal neobladder in 36 patients, a continent cutaneous ileal reservoir in 13 and rectal diversion in 13. Kidneys were evaluated using serum creatinine level, ultrasonography, intravenous urography and other radiological studies. RESULTS: The follow-up was 6-173 months; 44 renal units (71%) remained stable during this period. Serum creatinine was increased in four patients with an orthotopic neobladder, with no evidence of obstruction or reflux, in one with preoperative renal impairment and one with voiding dysfunction, reflux and bacteriuria. Six renal units deteriorated because of uretero-intestinal strictures; of these patients, two were treated endoscopically, two with open ureteric reimplantation, one with conversion from a rectal reservoir to an ileal loop conduit, and one was maintained on JJ stenting. Six patients with a rectal diversion had renal deterioration because of chronic pyelonephritis. CONCLUSIONS: A regular follow-up of renal function is mandatory in patients with a continent urinary diversion. Rectal diversion is associated with a higher risk of renal deterioration (54%) than are orthotopic (28%) and cutaneous reservoirs (8%).     

A Simplified Method of Ureteral Implantation into the Orthotopic Ileal Neobladder

Purpose: A simple non antireflux technique is described for ureteral implantation in to the orthotopic ileal neobladder. Materials and methods: Forty-nine ureteroileal anastomoses into the orthotopic ileal neobladder were performed on 25 adult male patients undergoing radical cystectomy and bladder substitution. The operative technique is described in detail. Results: Surgery-related complications were found to be 3 cases of ureteral dilatation. The cause was anastomotic obstruction (stricture) in one of the cases, and ureteric angulation and periureteritis on the middle third, in two of the cases. None of the patients showed signs of reflux be means of neocystography. Conclusion: Ileal neobladder as low pressure bladder substitute does not require antireflux manoeuvering on ureteral implantation. The technique of the method described is very easy to perform. Long-term follow-up of a larger number of patients is indicated.     

Serous-lined extramural tunnel technique for uretero-ileal implantation in urinary diversion

PURPOSE: We present our initial experience of a serous-lined extramural tunnel technique for anti-refluxing uretero-ileal anastomosis in five cases of orthotopic ileal bladder and four cases of continent ileal pouch. METHODS/RESULTS: Ureters were implanted into serous-lined tunnels formed from a detubularized W-configurated ileal segment. Neither upper tract dilatation nor reflux were observed in any patient postoperatively. CONCLUSION: The technique can provide an effective uretero-ileal anastomosis for reflux prevention with minimal use of the ileal segment and without the use of any artificial materials.     

A multi-institutional study of orthotopic neobladders: functional results in men and women

OBJECTIVES: To analyse the incidence of diurnal incontinence (DI) and nocturnal incontinence (NI), the need for intermittent catheterization (IC),and the rate of ureteric obstruction (UO) among a group of men and women with ileal and colonic orthotopic neobladders in four countries. PATIENTS AND METHODS: In all, 138 patients (113 men and 25 women) had an orthotopic neobladder constructed after radical cystectomy for carcinoma. The mean(range) age was 61.3 (28-76) years and the follow-up 41 (6-144) months. All patients underwent surgery by experienced surgeons associated with the Confederation of American Urology. A retrospective evaluation was designed to review the functional results and the incidence of UO. The technique of orthotopic neobladder construction was at each surgeon's discretion. Various detubularized bowel segments were used, including ileum, colon or sigmoid. Patients were followed by chart reviews and personal interviews at 1, 3 and 6 months after surgery and then every 6 months, and were evaluated by a physical examination, urine analysis, cytology and renal ultrasonography. RESULTS: An ileal or colonic neobladder was constructed in 74 and 64 patients, respectively.Five (7%), 23 (31%), 10 (14%) and 14(9.6%) with an ileal neobladder developed DI, NI, IC and UO, respectively; the respective values for patients with a colonic neobladder were eight (12%), 19 (30%), seven (11%)and 15 (12%). Statistical analysis by Fisher's exact test showed no significant differences between the ileal and colonic neobladder groups or with gender. CONCLUSIONS: Using this specific protocol for evaluating many men and women with ileal and colonic orthotopic neobladders showed no significant differences in the incidence of DI, NI, IC or UO. Neobladders constructed from detubularized bowel, irrespective of bowel segment(s) used, can provide satisfactory diurnal results. A moderate incidence of NI and UO continue to be a problem.     

Health-related quality of life after radical cystectomy for bladder cancer: a comparison of ileal conduit and orthotopic bladder replacement

OBJECTIVE: To compare the health-related quality of life (HRQoL) after radical cystectomy in patients with an ileal conduit or an orthotopic neobladder. PATIENTS AND METHODS: The study included 85 men who underwent radical cystectomy for bladder cancer, comprising 48 with an orthotopic neobladder (26 with an ileal and 22 with a colon neobladder) and 37 with an ileal conduit. HRQoL was evaluated using the Short Form-36 survey containing 36 questions assessing eight aspects, including physical functioning, role-physical functioning, bodily pain, general health, vitality, social functioning, role-emotional functioning and mental health. RESULTS: The mean follow-up periods for patients with a neobladder (ileal and sigmoid) and with an ileal conduit was 45.9 (38.2 and 53.1, respectively) and 130.9 months, respectively. Scale scores were not affected by the duration of follow-up in either group. There was no significant difference in any scale scores between the neobladder and ileal conduit groups. However, general health and social functioning in both the neobladder and ileal conduit groups appeared to be significantly lower than those in the general population in the USA. Furthermore, patients with a colon neobladder had a significantly higher score for role-emotional functioning than those with an ileal neobladder, while there was no significant difference in the remaining seven scores between patients with ileal and colon neobladders. CONCLUSIONS: Six of the eight scales of HRQoL were favourable in both patients with a neobladder or an ileal conduit, and there was no significant difference between these groups. In addition, the HRQoL of patients with an orthotopic neobladder (except for role-emotional functioning) was unaffected by the segment of the intestine used for neobladder construction. Therefore, patients with both types of urinary diversion were generally satisfied with their overall health and quality of life.     

Postoperative morbidity, functional results and quality of life of patients following orthotopic neobladder reconstruction

AIM: To evaluate postoperative morbidity, functional results and health-related quality of life of patients with an orthotopic neobladder. METHODS: A total of 37 patients with orthotopic neobladder (modified Studer method: 35 cases; Hautmann method: one case; sigmoid neobladder: one case) were included in the present study. Postoperative morbidity and neobladder function were analyzed. To determine quality of life, the Sickness Impact Profile questionnaire was used. The quality of life of patients who underwent orthotopic neobladder was compared with that of patients who underwent ileal conduit. RESULTS: In 37 consecutive patients with neobladder reconstruction, early complications included 10 cases of pyelonephritis (27.0%) and one of stenosis of ureterointestinal anastomosis (2.7%). Two patients died of ARDS and sepsis following peritonitis and pneumonia in the perioperative period. Late complications included pyelonephritis in three patients (8.6%). In 32 cases, except for an early postoperative case and those that died, complete daytime and night-time continence was achieved in 31 patients (96.9%) and 16 patients (50.0%), respectively. Concerning health-related quality of life, the mean sum scores per category of the Sickness Impact Profile were calculated for 32 patients with orthotopic neobladder and 30 patients with ileal conduit. There were no significant differences in overall satisfaction, however, the scores for patients with orthotopic neobladder reconstruction were significantly higher than those for patients with ileal conduit in the three categories of emotions, feelings and sensation, social interaction and recreation. CONCLUSION: Orthotopic neobladder reconstruction exhibited good functional results with acceptable complications. Patients who underwent neobladder reconstruction were satisfied with their voiding. Assessment of quality of life using the Sickness Impact Profile questionnaire demonstrated that orthotopic neobladder improved their quality of life better than ileal conduit, especially with regard to mental, physical and social functioning in daily life.