直肠膀胱-乙状结肠腹壁造口术的疗效观察

目的:探讨直肠膀胱-乙状结肠腹壁造口术的疗效。方法:对47例直肠膀胱-乙状结肠腹壁造口术术后病人的可控性、尿动力学、血清电解质及肾功能等进行随访观察。结果:47例均获随访,随访5~24个月,平均17个月,47例患者白天完全可控,43例患者夜间完全可控,溢尿4例。储尿囊容量为270~450 mL,平均320 mL,储尿囊内压力10.27~30.60 cmH2O(1cmH2O=0.098 kPa),平均20.56cmH2O。B超、IVU及储尿囊造影示无输尿管狭窄及反流。血清电解质及肾功能正常。结论:直肠膀胱-乙状结肠腹壁造口术操作简单、疗效可靠、并发症较少、储尿囊压力较低、控制排尿满意,是一种较理想的尿流分流手术。     

18例MainzⅡ术作为可控性尿流改道的临床应用体会

目的 探讨乙状结肠直肠膀胱术作为可控性尿流改道的临床效果.方法 18例多发性、复发性、浸润性及累及膀胱三角区或膀胱颈、后尿道的膀胱移行细胞癌,男10例,女8例,年龄45～72岁,平均61岁.行根治性膀胱切除术后,以乙状结肠与直肠交界处为中心,沿对系膜缘结肠带向两侧各切开肠壁10～12cm,,缝合成储尿囊,将输尿管与之行黏膜下隧道及乳头式吻合,储尿囊后壁固定于骶前韧带.结果 平均手术时间4.8小时.全部随访1～7年,平均3.5年.术后1.5～2个月,大小便可分开,大便成形.术后3个月,17例可自行控制排尿排便,1例咳嗽或用力时肛门有少许尿液流出.白天平均排尿5次(4～7次),夜间平均排尿1次(0～3次).2例术后6个月出现轻度高氯性酸中毒,未发现有上尿路积水及输尿管返流者.3例术后2～4年死于肿瘤转移.余均无肿瘤复发.结论 乙状结肠直肠膀胱术具有操作简单,并发症少,术后患者生活质量高等特点,可作为一种可控性尿流改道的术式选择.     

输出管悬吊可控膀胱术的临床研究

目的 设计一种控尿可靠、导尿容易、并发症少且操作简单的可控性膀胱输出道的手术方法。方法 20例需行可控性尿流改道的思者采用输出道悬吊的手术方法进行治疗。患者中14例为膀胱恶性肿瘤，2例为已行回肠膀胱术(bricker术)者，3例为重症神经源性膀胱，1例为膀胱阴道瘘。结果 术后随访3—24个月，平均14．4个月，所有患者的腹壁造口均可容易地插入16 F导管。术后仅1例控制尿不完全，其余患者均控制尿完全。16例术后3—12个月行尿动力学检查，膀胱充盈时输出管最大内压为64—134cm H2O(1cm H2O＝0．098kPa)，平均为86cmH2O。腹壁造口逆行造影示输出管被固定在腹壁下，无狭窄。结论 输出管悬吊能明显增强缩窄回肠的控制机制，且手术方法简单。     

回结肠正位膀胱术后下尿路尿动力学研究

目的评估回结肠正位膀胱术后的下尿路储尿囊及流出道尿动力学状况.方法对11例回结肠正位膀胱术患者术后进行储尿囊及流出道的充盈性测压和静态压力图测定,检测储尿囊的压力、顺应性,以及流出道的压力和阻力状态.结果 11例患者储尿囊容量、储尿压、排尿压分别为:(518.5±184.3)ml,(26.7±6.6)cm H2O,(36.2±14.9)cm H2O,储尿囊的顺应性为先高顺应后低顺应.膀胱颈压为(78.6±17.9)cm H2O,最大尿道压为(108.4±32.7)cm H2O.流出道压力中吻合口压力偏高.结论回结肠正位膀胱术储尿囊可正常储尿,术后排尿困难与储尿囊的低压及吻合口的高压状态有关.     

乙状结肠直肠膀胱尿流改道术的临床应用

目的观察膀胱全切后乙状结肠直肠膀胱术作为尿流改道的临床效果。方法 12例膀胱癌患者行膀胱全切术乙状结肠直肠膀胱术尿流改道,利用肛门括约肌控制排尿。术后随访3～24个月,平均7.4个月。结果 12例患者手术均顺利完成,术中出血400～1200 ml,输血400～800 ml,术后拔除肛管后即进行肛门括约肌功能训练1,0～12 d后拔双侧输尿管支架管后均能达到良好的控尿功能。1～1.5 h排尿1次,其中有2例患者短期内出现夜间不能控尿,经过训练在1～2周后均能完全控制排尿排便。随访3～24月,平均7.4个月,患者2个月后每日排尿次数稳定,平均间隔2～3.5 h 1次,术后无1例出现高氯性酸中毒。术后3～6个月行IVP检查上尿路排泄正常,无梗阻、积水、输尿管扩张和返流;代膀胱容量300～400 ml,排尿后残余尿量0～50 ml。结论该术式简单易行,易于掌握,手术时间短,术后并发症少,临床效果肯定,是可控性尿流改道手术可供选择的术式之一。     

升结肠在尿流改道中的应用

目的 评估升结肠在尿流改道中应用的疗效和安全性。方法 对68例全膀胱切除患者取用升结肠分别施行可控性回结肠膀胱术(42例)和升结肠原位膀胱术(26例)，并随访3～96个月。结果 膀胱肿瘤患者术后无局部复发，原位新膀胱组后尿道无肿瘤生长。两种术式贮尿囊造影均无输尿管反流。无肾积水，肾功能无恶化。术后6个月尿动力学检查，可控性回结肠膀胱术和升结肠原位膀胱术平均贮尿囊最大充盈压分别为3．2kPa和2．4kPa，平均容最分别为380mL和420mL；可控性回结肠膀胱术平均输出道最大压力为10。9kPa，原位膀胱术平均后尿道最大压为8．0lkPa。平均最大尿流率17．6ml／s。结论 取用升结肠建立的贮尿囊具有容量大、内压低、无反流、无代谢紊乱等优点。两种手术方式均可自由控制排尿，提高生活质量。     

乙状结肠直肠膀胱术的临床应用

目的：研究乙状结肠直肠膀胱术作为可控性尿流改道术的临床效果。结论：该术式简单易行,易于掌握,手术时间短,术后并发症少,临床效果较肯定,术后生活质量高,是一种较好的可控性肠代膀胱术。     

膀胱癌根治术后N型回肠膀胱替代术的临床应用

目的 探讨膀胱癌根治术后N型回肠膀胱替代术的手术方法和临床应用价值.方法膀胱恶性肿瘤患者23例,腹膜外行膀胱根治性切除,截取35～40 cm回肠纵形切开后折叠形成N型贮尿囊,以改良乳头法将两侧输尿管分别移植于N型新膀胱的上臂两侧,贮尿囊底部与尿道4～6针吻合,将贮尿囊完全置于腹膜外.结果本组23例手术时间5.5～7 h,术中平均出血400 ml,术后随访2～27个月,平均16个月,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返流,血生化检查正常,未发现新膀胱或尿道肿瘤复发.尿动力学检查,新膀胱最大容量为(340.5±65.8) ml,最大尿流率(17.5±6.8) ml/s,充盈期膀胱内压力为0～9 cm H2O,排尿期膀胱内压力为8～16 cm H2O,剩余尿0～55 ml.结论原位N型回肠膀胱替代术具有良好的可操作性;新膀胱容量大,内压低,顺应性好,具有较好的尿控和排尿能力,明显提高了患者术后的生活质量,是一种良好的尿流改道术,值得临床推广应用.     

改良Sigma直肠膀胱术（附6例报告）

目的观察改良Sigma直肠膀胱术可控性尿流改道的临床疗效。方法对6例膀胱癌患者行改良Sigma直肠膀胱术。折叠乙状结肠约25cm后全层切开,缝合成低压袋,顶端固定在骶岬处,两输尿管并腔后从低压袋上方引入,作外翻乳头插入式吻合。结果术后患者尿控率100％,无吻合口狭窄及尿失禁,无上尿路积水,未发生明显酸碱平衡紊乱。结论改良Sigma手术时间短、操作简便、并发症低、术后尿控满意,是一种生理干扰小安全并简单易行的尿流改道方法,可明显提高患者生活质量。     

球形可控回肠贮尿袋代膀胱术研究及临床应用

目的：研制贮存尿液和排除尿液功能近似正常膀胱的原位膀胱重建术，方法：取带系膜回肠段30cm，乙醇浸泡肠粘膜，制成球形贮尿袋，输尿管与贮尿袋行抗返流吻合，贮尿袋下端与尿道断端吻合，临床应用26例，结果：获得随访26例，随访时间3－36个月，平均21个月，25例健在，排尿可控率100％，术后12月20例平均尿量585．6ml/次，残余尿22ml,Qmax17.3ml/s。膀胱测压18例，平均半充盈，充盈和排尿压力为12cmH2O,17.6cmH2O,53cmH2O。尿常规正常，尿培养（一），肾功能及血生化正常，无肾，输尿管积水，病理示新膀胱粘膜变,上膜腺体减少，绒毛消失，部分区域固有膜腺体消失，呈鳞状化生结构，PAS染色阳性，HSP阳性，P53阴性，结论：球形可控回肠贮尿袋代膀胱术具有容量大，压力低，可控性好，对机体干扰轻，并发症少，病人易接受等优点。是原位膀胱重建的好术式。     

Modified Ureterosigmoidostomy

Objective To introduce an operation procedure and evaluate the coutinence diversion results of the modified ureterosigmoidostomy after radical cystectomy. Methods Fourteen cases of bladder cancer or prostate carcinoma were operated on with modified Sigma pouch from Feb, 1998 to Dec, 1999. A longitudinal incision about 25 cm on the sigmoid uall was done to form a low pressure pouch. The vertex of the new pouch was fixed to sacrum. Both ends of ureters were anastomosed side to side and to form a big nipple and inserted into the top of pouch for 2 to 3 centimeters. Results It took about sixty five minutes to create a new low pressure pouch after radical cystectomy. Early complication of was found in two cases postoperatively, and cured with temporary colonostomy. Hydronephrosis and hypokalemia in one patient were cured by percutaneous anterograde ureter dilatation with balloon and oral replacement of potassium salt. A~ patients displayed urinary continence. No symptomatic renal infection or hypercholoraemic acidosis occurred. Conclusion Modified ureterosigmoidostomy is a safe procedure of urinary diversion and provides a big volume, low intravesical pressure pouch. The patients are free from the troublesome urine-bag, intermittert catheterization , and upper urinary tracts are protected effectively. The quality of life is satisfied.     

Modified Ureterosigmoidostomy

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T型原位回肠新膀胱:尿动力学与上尿路功能初步评价

目的 评价T型原位回肠新膀胱尿动力学特征及对上尿路功能的影响.方法 2004年6月至2009年9月,90例T2a～T4a膀胱肿瘤患者接受根治性膀胱切除加T型原位回肠新膀胱重建术,采用肌酐测定、超声、膀胱造影、静脉尿路影或增强CT等方法进行上尿路功能的检查,对患者进行尿控情况的随访与尿动力学评价.结果 术后3周拔除导尿管之前行膀胱造影检查,未发现明显造影剂外溢,4例(4.4%)输入袢显示清楚,但未见输尿管显示,其他均未见反流.上尿路超声、静脉尿路造影或CT检查,提示18例(20.0%)术后45 d内出现双侧肾盂及输尿管的暂时性轻度扩张,其中1例(1.1%)出现术后一过性肾功能不全,肌酐最高达57 mg/L,但在随访过程中肾盂输尿管恢复正常形态;4例(4.4%)术后3年出现双侧肾盂输尿管轻度扩张,但肾功能保持正常;其他患者血尿素氮、肌酐均在正常范围之内.日间94.4%(85/90)患者能完全控尿,5.6%(5/90)控尿满意,满意率达100%;夜间41.1%(37/90)患者完全控尿,41.1%(37/90)控尿满意,17.8%(16/90)控尿不满意,满意率达82.2%.尿动力学结果显示,平均灌注末压力为(16±10)cm H2O(1 cm H2O=0.098 kPa),最大膀胱容量为(316±96)ml;排尿呈腹压排尿模式,最高压力为(87±25)cm H2O,平均最大尿流率为(17±10)ml/s,残余尿量为(33±29)ml.结论 T型原位新膀胱输入袢的抗反流效果令人满意,充分保护了上尿路功能;新膀胱具有良好顺应性,患者控尿能力、尿流率及残余尿量也令人满意.     

Urodynamic study of enhanced continent mechanism using tapered ileum as continent urinary reservoir

Objective To investigate the effect of extramural support from the pouch and abdominal wall to enhance the continent mechanism of tapered ileum. Methods A total of 24 patients underwent a procedure in which an ileal segment was tapered into 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. A urodynamic study of the efferent tubes and pouch was done 1.5 to 3 months and 6 to 24 months postoperatively. Results One patient died of heart disease 55 days postoperatively, while 22 of the remaining 23 were completely continent day and night. At 1.5 to 3 months, the urodynamic study of the efferent tubes demonstrated that the maximum closure pressure with a full pouch was 46-124 cmH20 （91.26±15.71 cmH20）and with an empty pouch was 34-84 cmH20 （67±10.60 cmH20）. The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t=-11.78 and P=0.00001). At 6 to 24 months, a second urodynamic study was performed on 18 cases, demonstrating a reservoir capacity of 420 to 750 ml (481.67±78.83 ml). Reservoir pressure was 6 to 9 cmH(2)O (7.17±1.17 cmH20) when the pouch was filled to 50 ml, and 16 to 35 cmH(2)O (24.12±5.61 cmH20) when it was filled to maximum capacity. There was no contractive wave during the filling in any patient. Maximum closure pressure in the efferent tube was 80 to 194 cm H(2)O (98.89±26.34 cmH20) when the pouch was filled with saline, and 64 to 128 cmH(2)O (74.78±14.54 cmH20) when the pouch was empty. The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t=-7.58 and P=0.00003). Conclusions This study indicates that the continent mechanism of tapered ileum may be greatly enhanced by extramural support from the abdominal and pouch walls.     

腹腔镜下膀胱全切除原位乙状结肠代膀胱术(附12例报告)

目的:探讨腹腔镜下膀胱全切除原位乙状结肠代膀胱手术的方法与治疗效果。方法:对12例浸润性膀胱癌患者采用腹腔镜下全膀胱切除术,前列腺切除或子宫次全切除。经腹壁造口取出切除物,行乙状结肠去带原位新膀胱术。结果:12例手术成功,手术时间5~10 h,平均6.5 h;出血量200~1 000 ml,平均387 ml,代膀胱充盈良好,容量约300 ml,术后4~6周患者恢复控尿功能,无排尿困难及尿失禁。结论:腹腔镜下行膀胱全切除视野清晰,可减少出血,缩短手术时间。     

腹腔镜下全膀胱切除并去带乙状结肠新膀胱术（附26例报告）

OBJECTIVE: To review our experience with intracorporeal laparoscopic radical cystectomy and sigmoid colon orthotopic neobladder reconstruction. METHODS: The clinical data of 26 cases of bladder carcinoma treated with the indicated surgical procedures were reviewed. RESULTS: The surgeries were successful in all the cases with the operating time ranging from 240 to 390 min, blood loss of 400 to 800 ml and red-cell transfusion of 0-4 U. Oral food intake was allowed 4-8 days after the operation, ureteral stents were removed in weeks 3 to 8 and the pouch catheter was removed in week 4 postoperatively. Daytime urinary continence was excellent and urinary incontinence at night occurred in 8 patients 3 months after the operation. CONCLUSION: Sigmoid colon orthotopic neobladder reconstruction can be effective for urinary diversion to ensure good quality of life of the patients.     

腹腔镜下全膀胱切除并去带乙状结肠新膀胱术(附26例报告)

目的 介绍腹腔镜下全膀胱切除、去带乙状结肠新膀胱术的经验。方法 对2002年7月~2004年9月间26例膀胱癌患者的临床资料进行总结与分析。结果 26例患者的手术时间为240~390min,其中腹腔镜下全膀胱切除术120~270min。腹腔镜手术中及术后未见明显出血,出血量<200ml。开放性原位新膀胱术出血量400~800ml,输浓缩红细胞0~4个单位。术后4~8d恢复饮食,3~8周拔除输尿管支架管,4周拔除尿管。术后3个月患者白天可完全控制排尿,8例夜间偶有尿失禁。结论 腹腔镜下膀胱癌根治切除术创伤小、出血少、恢复快,是全膀胱切除手术中的一种很有前景的方法。全去带可控性乙状结肠新膀胱术具有手术操作简单、需用肠段短、贮尿囊在原位、尿液自尿道可控排出、术后并发症少等优点,具有较好的应用价值。     

去带盲升结肠可控膀胱术的临床分析

目的:探讨膀胱全切后一种较理想、并发症少的贮尿囊的建立。方法:对10例膀胱癌患者行根治性膀胱全切术后,取盲升结肠150～200 mm,间隔5 mm切断结肠带,输尿管直接植入与结肠吻合,以阑尾或回肠作输出道。结果:手术成功,控尿满意。贮尿囊容量平均460 ml,血生化检查正常,无肾积水发生。结论:去带盲升结肠可控膀胱术是一种较为理想的尿流改道手术方式。