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。     

腹腔镜下膀胱全切Bricker回肠膀胱术与Studer原位膀胱术的比较研究

pT2bN0M07例,pT2bN0M01例,pT3aN0M02例. 结论 腹腔镜膀胱全切Studer原位膀胱术与Bricker回肠膀胱术具有相似的手术和肿瘤学等方面的结果,但Studer原位膀胱术患者术后生活质量较高,是一种效果良好的膀胱全切尿流改道术式.     

Studer原位回肠膀胱术24例报告

目的 总结Studer原位回肠膀胱术治疗膀胱肿瘤的疗效.方法 2003年2月至2006年12月采用膀胱全切Studer原位回肠膀胱术治疗膀胱肿瘤患者24例,患者均为男性,平均年龄60岁,其中移行细胞癌23例,T1 6例、T2 12例、T3 5例,鳞癌1例.术中近端回肠输入袢改为10cm;远端袢完全去管道化后排列成W形,输尿管直接与回肠输入袢的近段端侧吻合.观察随访术后排尿及肾功能等情况.结果 24例手术时间220～330 min,平均270 min术中出血量400～1600ml,平均600 ml.患者围手术期均无严重并发症发生,术后可自行排尿,13例发生遗尿.患者平均随访18个月(3～36个月).2例膀胱剩余尿＞100 ml,合并输尿管轻度扩张;1例术后12个月出现肾功能不全;23例肾功能正常,无电解质紊乱.结论 Studer回肠代膀胱术技术操作相对简单,并发症少,疗效满意.术中一般不做预防性输尿管抗反流处理.     

完全腹腔镜根治性膀胱切除术+邢氏原位回肠新膀胱的可行性和疗效

目的探讨完全腹腔镜根治性膀胱切除术+邢氏原位回肠新膀胱的可行性和术后临床效果。方法回顾性分析2013年7月至2019年8月41例行完全腹腔镜根治性膀胱切除术+邢氏原位回肠新膀胱患者的临床资料,其中北京朝阳医院31例,中国医学科学院肿瘤医院10例。年龄平均59(44~78)岁。体质指数平均25.3(20.1~34.7)kg/m^2。Charlson合并症指数评分平均3(2~6)分。术前检查均无尿道狭窄,无尿失禁。核素骨扫描、胸部X线片、B超等检查均未发现远处转移。所有患者行膀胱镜检查取活检或行经尿道膀胱肿瘤切除术,术前病理诊断:肌层浸润性膀胱癌30例(73.2%),非肌层浸润性膀胱癌9例(高危或反复复发)(22.0%),原位癌2例(4.9%)。41例均在全麻下先行腹腔镜根治性膀胱切除术+淋巴结清扫术,之后在体腔内采用邢式原位回肠新膀胱进行尿流改道。距回盲部约30 cm向近端截取末端回肠约60 cm,将已截取的回肠近端10 cm移至远端,作为右侧输入襻,之后将中间40 cm肠管去管化,U形缝合后反折缝合成球形,构建成顺蠕动双输入襻回肠新膀胱即邢式原位回肠新膀胱。记录围手术期相关资料、术后<30 d和30~90 d并发症情况、术后尿控恢复情况(日间、夜间控尿满意均定义为需要尿垫≤1个)及预后。比较手术开展的前21例和后20例患者手术时间、出血量的差异。结果本研究41例手术均顺利完成。总手术时间平均324.9(210~480)min。出血量平均177.6(50~700)ml。腹腔镜根治性膀胱切除术+淋巴结清扫术时间平均105.5(60~178)min,邢氏新膀胱构建时间平均179.7(121~298)min。前21例与后20例的总手术时间[(365.1±61.7)min与(290.9±41.8)min,P<0.01]、邢氏新膀胱构建时间[(211.7±44.5)min与(170.1±29.1)min,P=0.001]和出血量[(207.1±144.3)ml与(128.0±63.2)ml,P=0.001]比较差异均有统计学意义。术后病理诊断尿路上皮癌40例(2例合并原位癌),小细胞癌1例。清扫淋巴结数量中位值为19(11~58)枚。淋巴结阳性7例(17.1%)。切缘阳性3例(7.3%),分别为输尿管切缘阳性1例,膀胱切缘阳性2例。病理分期Ta^T1期16例,T2期10例,T3期13例,T4期2例。41例术后下地时间中位值为1(1~4)d,肠道功能恢复时间中位值为3(1~18)d,术后正常饮食恢复时间中位值为7(3~18)d,引流管留置时间中位值为9(3~23)d,输尿管支架拔除时间中位值为15(13~35)d,尿管拔除时间中位值为20(6~30)d,总住院时间中位值为21(11~35)d,术后住院时间中位值为14(7~29)d。术后1例进入ICU病房。术后<30 d Clavien 1~2级并发症19例(46.3%),分别为低白蛋白血症15例、感染2例、低钾血症1例、不全肠梗阻1例,对症处理后均好转;Clavien 3~4级并发症1例(2.4%),为空肠穿孔行手术治疗治愈。术后30~90 d Clavien 1~2级并发症2例(4.9%),分别为切口感染和低白蛋白血症各1例,对症处理后好转,无Clavien 3~4级并发症。术后随访时间平均17.6(2~64)个月。36例(87.8%)生存,其中2例(4.9%)转移,1例(2.4%)复发;5例(12.2%)死亡,死亡原因分别为骨转移1例、多发转移2例,心脏疾病2例。术后12个月复查血肌酐平均77.2(54.3~104.1)μmol/L;影像学检查40例无肾积水,1例出现肾积水。41例拔除尿管后均能自行排尿,无需导尿,术后12个月37例(90.2%)日间控尿满意,29例(70.7%)夜间控尿满意。结论完全腹腔镜根治性膀胱切除术+邢氏原位回肠新膀胱的构建方法简单,术后并发症少,尿控恢复较满意。     

腹腔镜根治性全膀胱切除+原位回肠新膀胱术对膀胱癌患者的临床疗效及并发症分析

摘 要：目的 比较腹腔镜根治性膀胱全切除+原位回肠新膀胱术与开放手术的临床效果及安全性。方法 选择2010年1月至2015年3月在本院行膀胱全切除+原位回肠新膀胱术的70例患者作为研究对象,其中30例行腹腔镜下手术作为观察组,40例行开放手术作为对照组;对比两组患者围手术期情况、新膀胱功能及并发症发生情况。结果 观察组胃肠道功能恢复时间、术后住院时间明显缩短,术中出血量明显减少,与对照组相比差异具有统计学意义（P＜0.05）,手术时间则明显长于对照组（P＜0.05）;两组患者在控尿率、膀胱内压、膀胱容量、剩余尿量等方面差异无统计学意义（P＞0.05）,观察组最大尿流率显著高于对照组（P＜0.05）。两组患者术后主要并发症有肠梗阻、尿瘘、尿路感染、肺部感染、排尿困难、切口感染等;观察组总并发症发生率为16.7%,显著低于对照组（37.5%）,两组相比差异具有统计学意义（χ2=4.642,P＜0.05）。结论 腹腔镜根治性膀胱全切除+原位回肠新膀胱术具有创伤小、出血少、恢复快、新膀胱功能良好、术后并发生发生率低等优点,值得临床推广。     

完全腹腔镜根治性膀胱切除加体内改良回肠通道术的学习效果分析

目的分析术者对完全腹腔镜根治性膀胱切除(LRC)+改良回肠通道术(MIC)的学习效果。方法回顾性分析首都医科大学附属北京朝阳医院2014年4月至2019年10月42例接受完全LRC+MIC患者的临床资料。男34例,女8例;年龄(63.4±9.1)岁。其中术者1行34例手术,术者2行8例。将术者1的34例按时间顺序分为3组,第1~12例为A组,第13~23例为B组,第24~34例为C组;术者2实施的8例为D组。4组中有腹部手术史者分别为0、1、4、3例,差异有统计学意义(P<0.05);4组年龄、体质指数、美国麻醉医师协会评分等差异均无统计学意义(P>0.05)。改良术式的重要步骤包括光源透射下离断肠系膜、输出袢固定的条件下行输尿管-输出袢反流性对端吻合、缝合后腹膜缺口。比较各组患者手术时间、构建回肠通道时间、出血量、并发症发生比例、淋巴结清扫数量、切缘阳性比例等重要手术指标。结果各组手术均顺利完成,均无中转开放手术。A~C组手术时间分别为330.0(320.0,360.0)、300.0(250.0,308.0)、270.0(216.0,324.0)min,差异有统计学意义(P=0.010);3组构建回肠通道时间分别为136.5(131.3,147.5)、92.0(79.0,119.0)、79.0(72.0,115.0)min,差异有统计学意义(P<0.001)。手术时间和构建回肠通道时间组间两两比较,A、B组,A、C组差异均有统计学意义(P<0.05),B、C组差异无统计学意义(P>0.05)。3组出血量[200.0(125.0,300.0)、100.0(100.0,150.0)、200.0(100.0,400.0)ml]、并发症发生比例[4/12、4/11、3/11]、淋巴结清扫数量[(19.0±10.7)、(16.0±9.8)、(23.3±8.5)枚]、切缘阳性比例(1/12、1/11、2/11)的比较,差异均无统计学意义(P>0.05)。D组手术时间420.0(350.0,450.0)min,与A组比较差异有统计学意义(P<0.05)。D组出血量200.0(112.5,350.0)ml,并发症发生比例2/8,淋巴结清扫数量(13.8±7.1)个,切缘阳性比例1/8,与A组比较差异均无统计学意义(P>0.05)。结论完全LRC+MIC学习效果明显,随着手术例数的增加,手术时间及构建回肠通道时间显著下降;该术式具有较好的可重复性和安全性。     

浸润性膀胱癌腹腔镜下根治性膀胱切除术43例

目的 探讨腹腔镜下根治性膀胱切除的手术方法和临床体会.方法 自2003年12月至2006年10月我们对43例浸润性膀胱癌患者实施了腹腔镜根治性膀胱切除术.手术采用经腹腔入路5部位穿刺法.结果 43例手术中,18例行输尿管皮肤造口术,25例行回肠膀胱术.2例因术中损伤直肠中转开腹行直肠修补术,1例术后放置肛管引流1周,另1例则行乙状结肠造瘘术.41例手术获得成功,腹腔镜下切除全膀胱连同淋巴结清扫的手术时间为140～270 min,平均195.4 min;术中出血150～700 ml,平均273.7 ml,术中术后输血3例;术后2～3 d下床活动;术后病理示3例盆腔淋巴结阳性.结论 腹腔镜根治性膀胱切除术治疗浸润性膀胱癌安全可行,能明显减小手术创伤、减少手术并发症、缩短患者恢复时间.     

腹腔镜下膀胱根治性切除术(附23例报告)

目的探讨腹腔镜下膀胱根治性切除术的手术方法和临床效果。方法浸润性膀胱癌23例,无远处转移,采用5个trocar,腹腔镜下行膀胱根治性切除术、前列腺切除,下腹正中做7cm切口,取出切除的膀胱、前列腺,尿流改道方式包括17例回肠膀胱术、3例回肠代膀胱术、1例输尿管乙状结肠吻合、2例输尿管皮肤造口。结果手术时间4~10h,平均7.5h。出血量100~800ml,平均311ml,1例输血1000ml,余22例未输血。术后2例麻痹性肠梗阻,经保守治疗痊愈,无其他并发症。术后随访2~32个月,2例因远处转移死亡,21例健在,无瘤生存2~32个月,平均17个月,肾功能正常,B超及IVU检查1例轻度双肾积水。结论腹腔镜下膀胱根治性切除术安全可行,创伤小,出血少,恢复快。     

腹腔镜下根治性膀胱切除Studer回肠新膀胱术

目的 介绍腹腔镜下根治性膀胱切除Studer回肠新膀胱术的方法.方法 膀胱癌患者8例.均为男性,年龄51～69岁,平均57岁.浸润性膀胱癌7例,腺癌1例.临床分期:T27例,T21例.经腹取5个穿刺点,腹腔镜下清扫双侧闭孔、髂内及髂外淋巴结;游离膀胱腹侧,剪开双侧盆筋膜,缝扎阴茎背静脉复合体;游离输精管和精囊,剪开狄氏筋膜,分离前列腺与直肠间隙;分离前列腺尖部尿道,切断尿道,将切下的膀胱和前列腺装入标本袋.下腹正中切口6～8 cm,取出标本,于该切口外距回盲部20 cm处截取45 cm回肠.取远端40 cm段对折,纵行切开对系膜缘肠壁,交叉折叠缝制新膀胱,将双侧输尿管吻合于新膀胱近端未剖开的5 cm肠管上.新膀胱颈部与保留尿道断端间断缝合.结果 8例手术顺利,手术时间 6～8 h,平均7.2 h;出血量200～800 ml,平均420 ml;无中转开放手术者.术后病理分期pT2 6例、pT31例、pT2N2M01例,切缘均为阴性.术后发生右侧输尿管套叠1例,经输尿管镜下还纳松解.8例随访3～12个月,生活质量良好.结论 腹腔镜下根治性膀胱切除术切11小、出血少,技术可行,Stueder原位膀胱技术简单、输入袢长、术后功能好.     

腹腔镜根治性膀胱切除加原位膀胱重建术治疗肌层浸润性膀胱癌的疗效观察(附26例报告)

目的:总结26例腹腔镜根治性膀胱切除、标准淋巴结清扫加尿流改道术的临床经验,评价此术式肿瘤学结果与功能性结果。方法:2005年8月～2011年5月对26例肌层浸润性膀胱肿瘤患者实施腹腔镜根治性膀胱切除、标准淋巴结清扫加原位膀胱重建术,包括13例T型原位回肠膀胱、11例Studer原位回肠膀胱与2例乙状结肠原位回肠膀胱,对手术时间、清扫淋巴结数量、围手术期并发症、术中出血量、输血量、上尿路形态与功能、术后原位膀胱控尿情况进行分析。结果:平均手术时间为6.24(4～8)h,平均出血量为397(100～800)ml,平均输血量为109(0～800)ml,平均清扫淋巴结数15(5～30)个,1例淋巴结阳性,无围手术期死亡。围手术期并发症发生率为16.7%(4/26),其中1例术后血肌酐上升至214.9μmol/L,6天后下降至正常范围;2例新膀胱尿道吻合口漏,经引流治愈;1例输尿管新膀胱吻合口漏行手术修补。随访19.9(1～67)个月,生存率为92.3%(24/26);1例鳞癌死于广泛转移,1例于术后55个月因急性心肌梗塞死亡。原位膀胱重建患者日间完全控尿率达88%(22/25);夜间完全控尿率60%(15/25),小于1块尿垫24%(8/25)。上尿路检查提示19.2%(5/26)术后45天内出现双侧肾盂及输尿管轻度暂时性扩张,其中2例有暂时性血肌酐升高,但均在3个月之内恢复到正常范围。结论:腹腔镜根治性膀胱切除、标准淋巴结清扫加下腹壁小切口行尿流改道术取得了满意的肿瘤学与功能性结果;其长期疗效需要进一步随访。     

Laparoscopic radical cystectomy and continent orthotopic ileal neobladder performed completely intracorporeally: the initial experience

PURPOSE: We introduce the operative technique of laparoscopic radical cystectomy and orthotopic ileal neobladder with a Studer limb performed completely intracorporeally. MATERIALS AND METHODS: The procedure was performed in 1 man and 1 woman. Using a 6 port transperitoneal approach, radical cystectomy in the female patient and radical cystoprostatectomy in the male patient were completed laparoscopically with the urethral sphincter preserved. Bilateral pelvic lymphadenectomy was done. A 65 cm. segment of ileum 15 cm. from the ileocecal junction was isolated, and ileo-ileal continuity was restored using Endo-GIA staplers (U.S. Surgical, Norwalk, Connecticut). The distal 45 cm. of the isolated ileal segment were detubularized, maintaining the proximal 10 cm. segment intact as an isoperistaltic Studer limb. A globular shaped ileal neobladder was constructed and anastomosed to the urethra. Bilateral stented ureteroileal anastomoses were individually performed to the Studer limb. All suturing was done exclusively using free-hand laparoscopic techniques and the entire procedure was completed intracorporeally. An additional case is described of Indiana pouch continent diversion in which the pouch was constructed extracorporeally. RESULTS: Total operative time for laparoscopic radical cystectomy and orthotopic neobladder was 8.5 and 10.5 hours, respectively, with a blood loss ranging from 200 to 400 cc. Hospital stay was 5 to 12 days and surgical margins of the bladder specimen were negative in each case. Both patients with orthotopic neobladder had complete daytime continence. Postoperative renal function was normal and excretory urography revealed unobstructed upper tracts. During followup ranging from 5 to 19 months 1 patient died of metastatic disease, while the other 2 are doing well without local or systematic progression. CONCLUSIONS: Laproscopic radical cystectomy and orthotopic ileal neobladder performed completely intracorporeally are feasible.     

腹腔镜膀胱根治性切除原位回肠新膀胱的随访疗效观察

目的随访探讨腹腔镜膀胱根治性切除原位回肠新膀胱术的疗效。方法 61例行腹腔镜膀胱根治性切除原位回肠新膀胱术的膀胱癌患者,随访1~24个月,每月定期门诊复查、电话等方式详细记录术后自主排尿情况等资料。结果所有患者均未见肿瘤复发。42例患者于拔除尿管后28~35d自控通畅排尿,每次尿量约180~410mL,每次间隔60~180min;13例患者出院后仍有不同程度日间尿失禁现象,6例有夜间尿失禁现象;3例术前性功能正常男性患者出现勃起功能障碍;彩超及静脉肾盂造影检查发现4例单侧肾积水,2例双肾积水。结论腹腔镜膀胱根治性切除原位回肠新膀胱术肿瘤控制好,患者术后可具有较好的控尿功能和较低的尿失禁发生率,部分有效保存性功能,能够有效确保患者的生活质量。     

Laparoscopic assisted radical cystectomy with ileal neobladder: a comparison with the open approach

PURPOSE: To date, there have been only a few reports regarding the feasibility of the laparoscopic approach to radical cystectomy. In none of these cases has the laparoscopic approach been contrasted with a contemporary cohort of open cystectomy and diversion. Recently, we initiated laparoscopic assisted radical cystoprostatectomy and ileal neobladder (LACINB) wherein the cystoprostatectomy and pelvic lymph node dissections are performed laparoscopically and the reconstructive portion is performed via a 15 cm Pfannenstiel incision. We present and compare our initial series of LACINB with radical cystectomy performed by the open approach (OCINB) during the same period. MATERIALS AND METHODS: Between September 2001 and February 2003, 13 men underwent LACINB and 11 underwent OCINB at our institution. RESULTS: There was no statistically significant difference in operative time, blood loss or complication rates between the LACINB and OCINB groups. However, postoperative analgesic use was significantly less in the LACINB group. Time to start of a liquid diet, solid diet and length of hospitalization were also significantly less in the LACINB group vs the OCINB group. All margins in both groups were negative for bladder cancer, although 1 patient in the LACINB group had an incidentally found prostate cancer with a positive apical margin. CONCLUSIONS: LACINB is a feasible and reproducible procedure, which results in decreased postoperative pain and quicker recovery without a significant increase in operative time. However, longer followup is needed to assess long-term oncological and functional outcomes.     

女性保留内生殖器膀胱全切原位回肠新膀胱尿流改道术的临床疗效

目的:探讨女性保留内生殖器膀胱全切患者行原位回肠新膀胱尿流改道术的临床疗效。方法:回顾性分析我院2005年7月~2012年5月48例女性膀胱肿瘤患者的临床资料,均采取保留内生殖器的膀胱全切术并行原位回肠新膀胱尿流改道术。48例患者中移行细胞癌46例,腺癌2例;原发肿瘤32例,复发性肿瘤16例;多发性非肌层侵犯肿瘤17例,肌层浸润性膀胱肿瘤31例。结果:48例患者的平均手术时间260(210~360)min,平均输血量280(0~1200)ml。术后47例患者获得随访,随访6~84个月,平均36个月。术后12个月白天控尿率为97.9%(46/47),夜间控尿率为93.6%(44/47)。新膀胱尿道吻合口漏3例。术后6个月IVU检查输尿管狭窄2例。无子宫、子宫附件及阴道转移复发。结论:对于符合适应证的女性膀胱癌患者,保留内生殖器、阴道前壁、自主神经及完整尿道,行膀胱全切并行原位回肠新膀胱尿流改道术,临床疗效满意,术后患者生活质量高,可作为广泛开展的术式。     

Health related quality of life assessment after radical cystectomy: comparison of ileal conduit with continent orthotopic neobladder

PURPOSE: Health related quality of life after urinary diversion has been increasingly recognized as an important outcome measure. However, few studies have directly compared patients with an ileal conduit with those with a continent orthotopic neobladder and even fewer have used validated quality of life instruments. Therefore, we compared health related quality of life in patients who underwent neobladder versus ileal conduit creation using validated questionnaires. MATERIALS AND METHODS: We mailed 2 validated questionnaires that are measures of health related quality of life, namely the RAND 36-Item Health Survey (SF-36) and Functional Assessment of Cancer Therapy-General (FACT-G), to patients who underwent radical cystectomy for urothelial carcinoma between January 1995 and December 1999. Statistical analysis was performed, including univariate and multivariate analysis. RESULTS: A total of 112 patients were available for assessment. A total of 72 (64%) questionnaires were returned, including 23 (32%) and 49 (68%) from patients with an ileal conduit and neobladder, respectively. On the SF-36 questionnaire there were significant univariable relationships between treatment and age (p <0.001 and 0.01, respectively). Younger patients and those with a neobladder had higher health related quality of life scores, including significant differences in 5 of the 9 SF-36 domains (general health, physical functioning, physical health, social functioning and energy/fatigue). There was no relationship between health related quality of life and the final pathological stage (p = 0.25). On multivariate analysis adjusting for age led to a suggestive but nonsignificant difference in health related quality of life scores favoring neobladders (p = 0.09). On the FACT-G there were no significant differences in health related quality of life due to treatment (p = 0.28), pathological stage (p = 0.5), age (p = 0.72) or current disease status (p = 0.27). On the FACT-G 2 of the 4 domains (emotional and functional well-being) were significantly in favor of neobladders. Overall satisfaction was high in the 2 groups with 96% and 85% of patients with a neobladder and ileal conduit, respectively, reporting that they would make the same choice of diversion. CONCLUSIONS: Based on validated health related quality of life instruments these findings suggest that patients with an orthotopic neobladder have marginal quality of life advantages over those with an ileal conduit. However, differences in health related quality of life in the 2 types of urinary diversion are confounded by age since patients who underwent orthotopic diversion were younger and as a result of age would be expected to have a higher health related quality of life score. A prospective longitudinal study of health related quality of life after adjusting for differences in age among patients undergoing urinary diversion is currently underway to extend further these observations.     

Laparoscopic hand assisted radical cystectomy with ileal conduit urinary diversion

PURPOSE: Hand assisted laparoscopy was originally described in the early 1990s. Since then many studies have shown that hand assisted techniques have the same advantages of laparoscopy including decreased need for postoperative narcotics and rapid return to routine activities. Laparoscopic techniques are advancing rapidly and intracorporeal laparoscopic cystectomy is reported. To our knowledge we report the first case of hand assisted, laparoscopic radical cystectomy with ileal conduit urinary diversion. MATERIALS AND METHODS: A 68-year-old male with rapidly recurring grade III transitional cell carcinoma elected to undergo hand assisted radical cystectomy. We performed a radical cystectomy with bilateral pelvic lymph node dissection removing the specimen through the hand port site. The ileal loop urinary diversion was constructed by pulling the small bowel through the hand port incision. We made another separate hole for the stoma and a drain was placed through a port site. The incisions were closed in the standard fashion.RESULTS: Operative time was 7 hours with 750 cc of blood loss and no complications. All surgical margins were negative. The patient did well and was discharged from the hospital on postoperative day 7 with return to normal activity without limitations at 4 weeks. CONCLUSIONS: To our knowledge this is the first reported case of hand assisted laparoscopic radical cystectomy with ileal loop diversion. Hand assistance facilitated this technically demanding surgery resulting in a good outcome without significant added operative time.     

腹腔镜下腹膜外膀胱根治和原位新膀胱术的初步体会

目的 评估腹腔镜腹膜外全膀胱切除和原位新膀胱术的安全性及疗效。方法 回顾性分析安徽医科大学第二附属医院2021年3月至2022年2月行腹腔镜腹膜外全膀胱切除和原位新膀胱术的8例膀胱癌患者,收集患者的基本资料、手术相关数据及术后随访相关情况。结果 所有患者均顺利完成手术,年龄为[65(40～78)]岁,BMI为[23.85(19.59～29.07)]kg/m2,手术时间为[280.5(235.0～366.0)]min,术中出血量为[100(50～200)]ml,通气时间为[3(2～4)]d,术后住院时间为[11.5(10.0～20.0)]d,淋巴结清扫数目为[13.5(8.0～29.0)]枚。术后分别有一例患者出现切口愈合不良和漏尿。6例患者进行了术前新辅助治疗,其中2例患者术后病理为T0期。中位随访时间为11个月,其中1例出现骨转移,1例出现泌尿道感染,1例出现肾积水。结论 腹腔镜下腹膜外全膀胱切除及原位新膀胱术是安全可行的,因其极大程度地保留了腹膜的完整性及避免长时间经腹腔操作对肠道造成干扰,有利于减少肠道并发症,缩短住院时间,值得临床推广。     

Short ileal segment for orthotopic neobladder: A feasibility study

Objectives: The objective of this study was to present the construction of a neobladder with a modified pouch technique using 25–35 cm of terminal ileum. Methods: Thirty‐eight patients whose pouch was constructed from 25–35 cm of terminal ileum (short pouch [SP] group) were prospectively evaluated vs 41 patients whose pouch was constructed from 50–70 cm of terminal ileum (long pouch group). Pouch volume, post‐void residual (PVR) volume, need for catheterization, continence and voiding frequency were evaluated at 3 and 12 months after surgery. Results: SP group patients had significantly smaller pouch capacity (440 vs 840 mL, P < 0.001) at month 12, and smaller PVR at postoperative months 3 (11 [0–43]vs 40 [0–147] mL, P < 0.001) and 12 (10 [0–90]vs 72 [0–570] mL, P < 0.001). SP group patients had significantly higher voiding frequency on postoperative month 3 (10 vs 9, P < 0.001) and 12 (7 vs 6, P < 0.005). Continence was significantly improved in the SP group compared with the long pouch group after 12 months (63.2% vs 34.1%, respectively, P = 0.034). Full continence improved significantly over time (P < 0.001) in the SP group, from 26.3% at month 3 to 63.2% at month 12. Conclusion: A pouch constructed from 25–35 cm of terminal ileum provides adequate capacity, smaller PVR, satisfactory continence and a better 24‐h voiding frequency pattern during the first postoperative year.     

The orthotopic T pouch ileal neobladder: experience with 209 patients

PURPOSE: A serous lined extramural ileal flap valve technique called the T limb was developed to prevent reflux of urine in an orthotopic bladder substitute called the T pouch. We evaluate our intermediate clinical and functional experience with the orthotopic T pouch ileal neobladder. MATERIALS AND METHODS: From November 1996 through May 2000, 209 patients (169 men [80%], 40 women), with a mean age of 69 years (range 33 to 93) underwent construction of an orthotopic T pouch ileal neobladder after cystectomy. The indication for cystectomy included bladder cancer in 198 patients (95%). Median followup for the entire cohort was 33 months (range 0 to 69). Data were analyzed according to perioperative mortality, early (within 3 months) and late diversion related and diversion unrelated complications, radiographic evaluation of the upper urinary tract and urinary reservoir, and determination of renal function. RESULTS: Three patients (1.4%) died perioperatively. A total of 63 (30%) early complications occurred, 53 (25%) diversion unrelated and 10 (5%) diversion related. The most common early diversion unrelated complication was dehydration (10 patients). The most common early diversion related complication was urine leak in 6 patients. There were no early complications directly related to the antirefluxing T limb. Late complications occurred in 68 (32%) patients including 30 (14%) diversion unrelated and 38 (18%) diversion related. The most common late diversion unrelated complication was incisional hernia in 16 patients. Of the 38 late diversion related complications the most common were pouch calculi in 17 and ureteroileal obstruction in 9 patients. The only late complication directly related to the T limb was stenosis in 4 patients, 3 of whom received adjuvant pelvic radiation. A total of 181 patients had radiographic evaluation of the upper urinary tract including 162 (90%) with a normal radiographic study or evidence of postoperative decompression. An abnormal upper tract study was seen in 18 patients (10%) including 9 with ureteroileal obstruction and 4 with afferent T limb stenosis. Gravity cystography of the neobladder was normal in 143 of 158 (90%) evaluable patients. Reflux was seen in 15 patients (10%). Renal function as determined by serum creatinine was stable or improved in 96% of patients. Good daytime and nighttime continence was reported in 87% and 72% of evaluable patients, respectively. Overall 75% of patients complete void while 25% required some form of intermittent catheterization to empty the neobladder completely including 20% of men and 43% of women. CONCLUSIONS: With intermediate followup the functional results of the T pouch ileal neobladder are acceptable. The antirefluxing T limb provides unobstructed urinary flow in 95% and reflux prevention in 90% of patients. Although these results are encouraging, further followup is required to assess the long-term results of the T pouch ileal neobladder.