输尿管-肠代膀胱"插入式"吻合的动物实验研究

目的探讨输尿管肠代膀胱“插入式”吻合的组织解剖学变化及抗返流效果。方法小型成年猪14头，体质量17～22kg，用盲肠代膀胱，将双侧输尿管与代膀胱作“插入式”吻合。根据输尿管吻合插入深度分3组：A组（n=4）0．5cm、B组（n=5）1．0～1．5CITI、C组（n=5）2．O～2．5cm。术后16周动态观察输尿管种植情况。结果A组吻合口无狭窄，发生Ⅱ度膀胱输尿管返流；B组未发生膀胱输尿管返流及吻合口狭窄；C组未发生膀胱输尿管返流，1条输尿管发生吻合口狭窄。3组乳头长度分别为（0．18±0．12）、（1．22±0．14）、（1．26±0．18）cm，输尿管直径分别为（0．70±0．19）、（0．38±0．04）、（0．37±0．05）cm；组织学检查显示移行上皮由乳头内腔连续爬行至乳头外层，覆盖乳头表面，肠黏膜上皮在乳头根部向乳头爬行，不规则，最高可达乳头的中下1／3。结论输尿管插入肠代膀胱1．0～1．5cm时抗返流效果良好，代膀胱内输尿管段可被移行上皮覆盖形成小乳头。“插入式”吻合法操作简单、手术并发症少，有很好的临床应用前景。     

膀胱黏膜下隧道加膀胱黏膜穿通套入式输尿管膀胱吻合在肾移植中的应用

目的探讨膀胱黏膜下隧道加膀胱黏膜穿通套入式输尿管膀胱吻合法的临床效果。方法42例肾移植采用膀胱黏膜下隧道加膀胱黏膜穿通套入式输尿管膀胱吻合法行移植肾输尿管与受者膀胱的吻合，游离与移植肾同侧的膀胱外侧顶部，用血管钳在膀胱浆肌层与黏膜间钝性分离一长约1cm的隧道，修剪成卵圆形的输尿管残端从隧道穿过，再通过粘膜上钝性穿通的小孔进人膀胱，在输尿管进入隧道处及进入膀胱处，将输尿管非血管系膜侧与膀胱壁各缝合2～3针固定。结果42例的输尿管吻合手术耗时为5～8min。术后随访3个月至5年，除1例因排斥反应出现输尿管坏死，1例术后早期因输尿管残端止血不彻底致血块堵塞导尿管而引发漏尿外，其余患者均未发生手术相关并发症，无尿液返流。结论膀胱黏膜下隧道加膀胱黏膜穿通套入式输尿管膀胱吻合法操作简单，耗时短，并发症少，安全可靠，并能有效防止尿液返流。     

腹腔镜下输尿管乳头法输尿管膀胱再植术的临床应用

目的探讨腹腔镜下插入式乳头法输尿管膀胱再植术的适应证、手术技巧及其应用效果。方法 2004年5月至2007年6月,应用腹腔镜行输尿管乳头法输尿管膀胱再植术治疗输尿管下段病变患者21例（25侧）,其中男14例,女7例,年龄3.5～52岁,平均32岁。病变位于左侧12例,右侧5例。双侧4例,11侧为输尿管末端狭窄,2侧输尿管子宫内膜异位症,3侧为巨输尿管,4侧为重复肾输尿管畸形积水,5侧为输尿管阴道瘘。中度肾积水11侧,重度肾积水10侧。腹腔镜下输尿管近侧断端剖开外翻缝合形成乳头,置入双J管。然后将输尿管外膜肌层与膀胱壁全层作间断吻合。结果 21例（25侧）均腹腔镜下完成,没有中转开放手术。手术时间60～180min,平均136min;术中出血20～50ml,平均32ml;住院9～15d,平均12d;随访3～36个月,平均15个月。超声和静脉尿路造影显示,肾输尿管积水消失或好转19例,术后吻合口再狭窄1例,行输尿管镜内切开后积水消失。膀胱造影检查未见膀胱输尿管反流发生,没有发生吻合口瘘等并发症。结论腹腔镜下乳头法输尿管膀胱再植术治疗输尿管下段病变具有操作简单、手术创伤小、患者恢复快、抗反流效果好、吻合口狭窄及吻合口瘘的发生率低的优点。     

低张力Roux-y肠代膀胱术13例报告

目的总结低张力抗返流Roux-y肠代膀胱术的疗效。方法采用改良输尿管-结肠、结肠-直肠吻合术对12例膀胱癌和1例膀胱阴道瘘患者行低张力Roux-y肠代膀胱术。于Roux—y吻合口上方1．5cm作抗返流瓣，输尿管与结肠行Leadbetter法吻合，去肠管化做乙状结肠储尿囊。术后观察电解质、酸碱平衡和排尿情况。结果随访0．5～5．0年，除2例偶有发热外，患者无肾积水，电解质和酸碱平衡正常，无尿失禁。结论低张力抗尿粪返流Roux-y肠代膀胱术是一种创伤较小、并发症较少的肠代膀胱术。     

机器人辅助腹腔镜黏膜下隧道法输尿管再植术的临床疗效分析

目的:介绍黏膜下隧道法机器人辅助腹腔镜治疗1例医源性输尿管下段狭窄患者和1例单侧重复肾重复巨输尿管合并肾积水患者的学习经验和手术疗效.方法:回顾性分析机器人辅助腹腔镜治疗1例膀胱肿瘤电切术后左侧输尿管下段狭窄、左肾积水,患者抗反流输尿管膀胱吻合采用黏膜下隧道包埋法;1例(左侧)原发性梗阻重复肾重复巨输尿管症患者,首先分离巨输尿管前面和两侧面,保留输尿管和腹壁间系膜先不离断,测量输尿管,剪裁,放入F7双J管,缝合成形后再离断系膜,采用黏膜下隧道包埋法与膀胱再吻合.结果:2例患者手术均成功,无中转开放,手术时间分别为165.8min、176.2min,其中机器人定位时间30min;出血量分别为12.4ml、20.8ml;术后引流管拔除时间第1例5d,第2例6d,2例患者均无明显漏尿,术后尿管拔除时间为14d.术后随访6个月,复查CT和彩超显示肾积水明显减轻,未见输尿管吻合口狭窄和输尿管反流.结论:机器人辅助腹腔镜黏膜下隧道法输尿管膀胱再植术治疗复杂的输尿管下段狭窄和复杂的巨输尿管症安全有效.     

后腹腔镜治疗先天性梗阻性巨输尿管方法探讨(附5例报告)

目的：探讨后腹腔镜行输尿管成型、膀胱再植术治疗先天性梗阻性巨输尿管的手术方式及并发症。方法：2005～2008年，共完成后腹腔镜下输尿管成型、膀胱再植术治疗先天性梗阻性巨输尿管5例。后腹腔镜下游离输尿管至输尿管开13处，尽可能远端将输尿管结扎，离断。将输尿管经穿刺孔拉出体外，行输尿管成型术后将其再次放回体内。在同侧膀胱顶部以Lich-Gregoir外隧道法3例及输尿管乳头植入法2例在腹腔镜下将输尿管植入膀胱。结果：平均手术时间165min（135～295min），平均出血40ml（20～100m1）。术后轻微尿瘘1例于2周后自行消失，以Lich-Gregoir外隧道法行输尿管再植的2例术后出现反复感染。术后2～3个月拔除双J管，随访6～36个月，梗阻消除。结论：后腹腔镜治疗先天性梗阻性巨输尿管是一种可行的手术方式，具有刨伤小，出血少的优点。腹腔镜下输尿管乳头植入法较Lich-Gregoir外隧道法更易取得良好效果。该手术术前应尽力控制原有的泌尿系感染。     

单侧双乳头输尿管腹壁皮肤造口改良术的临床研究(附29例报告)

目的:探讨单侧双乳头输尿管腹壁皮肤造口改良术的临床疗效。方法:1999年8月~2012年9月对29例膀胱全切者采用单侧双乳头输尿管腹壁造口改良术治疗:膀胱全切,游离两侧输尿管通过皮下隧道拉至右下腹,输尿管至少露出皮肤1cm,两个输尿管穿出皮肤的基底间隔1cm,皮肤与输尿管基底缝合,输尿管乳头状外翻后远端黏膜与输尿管壁缝合,置入单J管引流尿液。结果:29例患者随访3个月~3年,乳头外形良好,未发生造口处狭窄与输尿管乳头内陷。结论:单侧双乳头输尿管腹壁皮肤改良造口术方法简单,术后无造口处狭窄和乳头内陷,置管容易,值得临床推广应用。     

肠代膀胱术中回肠反套入抗输尿管返流方法的临床研究

目的 评价肠代膀胱术中回肠反套入的抗输尿管返流作用。方法 患者5例，男4例，女1例。年龄48～67岁，平均61岁。均为浸润性移行细胞癌，行膀胱全切、回肠正位膀胱术。距回盲部屈氏韧带15cm处切取回肠30cm，近端回肠反套入4cm，回肠段远端肠管对系膜缘纵形剖开，U形缝合；套入肠管与对应肠片均切除1cm宽之黏膜，相应浆肌层可吸收线固定4针，对应黏膜缘缝合，防止套入肠管滑脱；双侧输尿管远端剖开6cm，侧侧吻合后经套入肠管引入，吻合口与套入肠管口间断缝合；U形肠管对折成储尿囊，与尿道吻合。术后定期行血生化、双肾B超、排泄性膀胱造影和尿动力学检查。结果 5例患者随访10～33个月。排尿次数白天3～5次，夜间0～3次；日间控尿100％，夜间控尿80％；尿动力学检查：最大尿流率9．5～31．5ml／s，膀胱容量350～710ml，平均433ml；剩余尿50～305ml；最大膀胱排尿压23～52cmH2O；膀胱出口无梗阻。B超检查双肾无积水。膀胱造影未见输尿管返流。结论 回肠正位膀胱术中回肠反套入方法有良好的抗输尿管返流作用。     

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。     

改良肠道原位新膀胱术

本组8例浸润性膀胱癌采用逆行法行全膀胱切除后作改良肠道原位新膀胱术，其中6例用改良乙状结肠原位新膀胱，2例用改良回肠原位新膀胱做下尿路重建。输尿管吻合用改良Le Duc和粘膜下隧道法。手术时间240-360min。术中出血量300-1200ml，输血5例，输血量200-400ml。术后平均住院18（8-20）d。平均随访14（3-24）个月。全部病人自主排尿，6例昼夜完全控尿，2例白天完全控尿，夜间偶有失禁。肾功能正常8例，电解质正常7例。改良肠道原位膀胱功能良好，是膀胱全切后尿路重建的理想方法之一。     

Evaluation of direct versus non-refluxing technique and functional results in orthotopic Y-ileal neobladder after 12 years of follow up

OBJECTIVES: We report on the long-term functional results of the orthotopic Y-ileal neobladder and compare the outcome of the antireflux technique for ureteral implantation versus direct anastomosis. PATIENTS AND METHODS: Between 1990 and 2002, 120 patients underwent cystoprostatectomy and orthotopic Y-shaped ileal neobladder for invasive bladder carcinoma. The direct Nesbit technique for ureteral reimplantation was applied in 58 patients (group 1) and in 62 patients the ureters were reimplanted using the Le Duc antirefluxing technique (group 2). The mean follow-up period was 72 months (range, 36-144 months). RESULTS: Of 62 patients who underwent the Le Duc technique, six (9.7%) had unilateral uretero-ileal anastomotic stricture and four (6.5%) had reflux. Of 58 patients who underwent direct anastomosis, six (10.3%) patients had unilateral reflux, four of them had dilated ureters preoperatively and no patient had uretero-ileal anastomotic stricture. The incidence of stricture formation in the Le Duc technique is significantly higher than direct anastomosis (P = 0.04). There was no significant difference in the overall incidence of reflux in both groups. However, the incidence of reflux in preoperatively dilated ureters was significantly higher in direct ureteral anastomosis than Le Duc technique (40% in group 1 vs 16.7% in group 2; P = 0.045). The incidence of stone formation, azotemia, pyelonephritis and bacteriuria was comparable in both groups. The urodynamic findings showed a mean increase in the neobladder capacity at 6 and 18 months after surgery by 340 and 560 mL, respectively. The mean of the maximum pressure was 22 +/- 10 cm H2O, 18 months after surgery. Daytime and nighttime continence was good or satisfactory in 93.3% and 85.5% of the patients, respectively, after 3 years of follow-up. CONCLUSIONS: The functional and voiding results of a Y-shaped neobladder pouch using 40 cm of ileum are similar to the more sophisticated larger pouches. Direct uretero-ileal anastomosis in orthotopic bladder replacement is more reasonable than the Le Duc antireflux technique in non-dilated ureters. The benefit of the antireflux technique has been overestimated despite of the frequency of stricture formation.     

Improvement of ureteroileal anastomosis in orthotopic ileal neobladder with modified le duc procedure: short submucosal tunnel technique

PURPOSE: A modified Le Duc procedure with a short submucosal tunnel was applied for ureteroileal implantation in ileal orthotopic neobladder and bladder augmentation with the ileum. We assessed the rate of stenosis and ureteral reflux at the ureteroileal anastomosis after this procedure. MATERIALS AND METHODS: Two women and 22 men underwent radical cystectomy and creation of a Hautmann ileal neobladder for invasive bladder cancer. Another woman underwent ileal bladder augmentation with bilateral ureteral reimplantation into the ileal segment. Ureteroileal anastomosis was performed using the modified Le Duc technique in 48 renoureteral units. Followup in all patients included retrograde cystography done before discharge home and excretory urography, renal ultrasonography or abdominal computerized tomography every 4 to 6 months. Followup was 11 to 39 months in 23 of the 25 cases. RESULTS: Retrograde cystography before discharge home revealed no urinary reflux in any reimplanted ureter. There was no ureteral stenosis or reflux in 20 male and 3 female patients (44 renoureteral units) who voided successfully without catheterization. A unilateral ureteral stricture at the ureteroileal anastomotic site in 1 man who voided successfully was treated with endoscopic surgery. Bilateral slight upper urinary tract dilatation caused by ureteral reflux was present in another man who did not void successfully. CONCLUSIONS: The modified Le Duc technique is simple and safe for forming an ureteroileal anastomosis in ileal orthotopic neobladder creation. It appears to have a low ureteral stenosis and reflux complication rate in patients who successfully void postoperatively.     

Wallace direct versus anti-reflux Le Duc ureteroileal anastomosis: comparative analysis in modified Studer orthotopic neobladder reconstruction

Objectives: To investigate and compare Wallace direct ureteroileal anastomosis with Le Duc anti‐reflux procedure in modified Studer orthotopic neobladder reconstruction after radical cystectomy. Methods: A total of 72 consecutive patients who underwent modified Studer orthotopic bladder reconstruction after a radical cystectomy for bladder cancer were investigated. They were examined for vesicoureteral reflux, hydronephrosis, and pyelonephritis at 6 months after surgery according to the type of ureteroileal anastomosis. Results: Vesicoureteral reflux occurred in 29 ureters (38.2%) after the Wallace procedure compared to six ureters (9.6%) with the Le Duc (P < 0.05). Hydronephrosis was detected in 12 ureters (18.8%) in the Le Duc patients compared to seven (9%) in the Wallace patients (P > 0.05). Six months after the operation, all three patients with vesicoureteral reflux‐related hydronephrosis improved using clean intermittent catheterization in the Le Duc patients; five of seven patients were cured by clean intermittent catheterization and two improved without any treatment in the Wallace patients. Seven of nine cases of ureteroileal anastomosis stenosis causing hydronephrosis were cured without any treatment but one case resulted in a non‐functional kidney despite treatment of the stenosis. Conclusions: Direct ureteroileal anastomosis using the Wallace method is effective for minimizing ureteroileal anastomosis stenosis and it represents a simple surgical procedure when combined with a modified Studer procedure.     

Experience and functional outcome of modified ileal neobladder in 95 patients

AIMS: We took advantage of the Goodwin method to develop a modified ileal neobladder. We present the operation procedure and assessed the functional results. METHODS: From April 1997 and May 2005, 95 patients (75 men and 20 women), mean age 64.6 years (range: 36-80 years) underwent orthotopic ileal neobladder replacement with application of the Goodwin method. The Le Duc technique was used for antireflux procedure. However, for the last 35 patients, antireflux procedure was not carried out. The median follow-up period was 37 months (range: 3-98 months). We reviewed the surgical outcome and complications. Continent status and urodynamic profile were also measured. RESULTS: The mean operation time for the neobladder formation was 130 mins (range: 65-285 mins). There were no perioperative deaths. Leakage from the ileourethral anastomosis leak was found in four patients (4.2%), wound infection in nine patients (9.5%), ileal anastomosis leak in two patients (2.1%) and paralytic ileus in two patients. No hydronephrosis, neobladder-ureteral reflux or deterioration of renal function was seen. The maximum neobladder pressure was 21 +/- 13 cm (mean +/- SD) at 6 months and 12 +/- 11 cm at 12 months after surgery. The neobladder capacity was 293 +/- 118 mL at 6 months and 312 +/- 85 mL at 12 months after surgery. Of the 95 patients, 87 (91.6%) maintained complete dryness day and night. CONCLUSIONS: These results suggest that the present orthotopic ileal neobladder is simple to be carried out and achieves acceptable voiding function. Longer observation for neobladder and upper urinary tract function is necessary.     

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.     

The "B-bladder"-an ileocolonic neobladder with a chimney: surgical technique and long-term results

OBJECTIVES: A modified version of the "Le Bag" ileocolonic neobladder with a "Studer"-like ileal chimney (B-bladder) is presented. The surgical technique, perioperative complications, and long-term results, including cancer control and continence, are described. METHODS: Twenty-nine patients underwent radical cystectomy and urinary diversion to an orthotopic ileocolonic neobladder with an ileal chimney. All operations were done by a single surgeon. Preoperative, perioperative and postoperative data were recorded. Median duration of follow-up was 3.4 years. RESULTS: The operation was technically successful in all cases. Late complications included recurrent urinary tract infection (17%) and uretero-neobladder anastomotic stricture (3%), both at acceptable rates. Postoperative daytime continence was excellent. Cancer control was satisfactory during follow-up; 11 patients (38%) died of disease progression with distant metastases. Median survival was 71.1 months. CONCLUSIONS: The B-bladder maintains the simplicity of preparation of the original "Le-Bag" neobladder while gaining the advantages of ureteral anastomosis to an ileal chimney. The incidence of perioperative complications is low and long-term results with regard to cancer control, continence, and complications are excellent.     

Anatomic variations in patients operated for bladder substitution

Authors review the anatomic variations observed throughout orthotopic ileal neobladder formation in 38 cases following radical cystectomy. A part of the variations was necessitated because of deviation from the classic Hautmann-type surgical technique: in 6 cases the site of ileal resection was modified due to abnormal mesenterial art. course, on 2 occasions Meckel diverticules were detected while cutting the ileal neobladder, in 13 cases the laterally adhered sigma bladder necessitated the left-sided ureter to be pulled through beneath the mesosigma for the purpose of making sure the ureter--ileal neobladder anastomosis became free of any tension, while on 1 occasion the left ureteral preparations went with some injury. Since the left ureter became short, ureter replacement variation was needed, similar to the Studer method of ileal neobladder formation. All these variations, however, did not implicate the essence of the Hautmann technique. Follow-up of the patients did not reveal high frequency of occurrence of any complications.     

Does the Success of Ureterointestinal Implantation in Orthotopic Bladder Substitution Depend More on Surgeon Level of Experience or Choice of Technique?

Purpose

We attempted to determine the relative risk of ureterointestinal anastomosis using 2 antireflux techniques of orthotopic bladder substitution, and we assessed the degree to which success is determined by surgeon experience.

Materials and Methods

A total of 120 patients underwent surgery, including 74 with the Hautmann (Le Duc) technique and 46 with a somewhat modified Studer (Nesbit/Studer) technique. The urologists who performed the operations were classified as expert, skilled and learner. Evaluation was done retrospectively. All patients in the Studer group, except 3 who died and 1 who was lost to followup, were monitored a minimum of 12 months.

Results

There was a 20.4% rate of nonneoplastic obstructions in the 142 ureters reimplanted with the Le Duc technique (Hautmann group). The variation in obstruction rates of 16.7, 18.2 and 25%, respectively, for expert, skilled and learning surgeons was statistically insignificant. Only 3 nonneoplastic obstructions (3.6%) developed in the 83 ureters reimplanted with the Nesbit/Studer technique (Studer group). The variation in obstruction rates of 5.1, 0 and 3.6%, respectively, for expert, skilled and learner surgeons was statistically insignificant.

Conclusions

The Nesbit/Studer technique results in a generally lower rate of ureterointestinal anastomotic stricture than the Le Duc technique. Using the Le Duc technique there was no statistically significant correlation between incidence of obstruction and surgeon level of experience, indicating that obstruction with this technique probably arises from other factors.     

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.