膀胱全切后改良Indiana膀胱转流术

目的 探讨—种新式改良Indiana新膀胱术的适应证、手术方法并对疗效进行评估。方法 对5例膀胱癌患者施行全膀胱切除术加改良Indiana新膀胱术。结果 5例患者均获得满意的疗效，自行导尿顺利。随访6-30个月，均尿控满意，排尿次数5-6次/昼，1-3次/夜。其中4例行造影，新膀胱呈球形，容量400-500毫升，无输尿管尿液返流。结论 改良Indiana膀胀术具有操作容易，贮尿囊低压容量大，抗返流机制可靠，尿控满意，并发症少的优点，值得在临床推广。     

去管化回肠S型缝合制作正位新膀胱三例报告

 【摘要】　目的　评价去管化回肠S型缝合制作正位新膀胱的临床应用价值。方法　膀胱癌患者行膀胱全切后，采用带蒂末段回肠片经S形折叠后缝合形成的原位类球形新膀胱，输尿管以乳头法包埋术种植于新膀胱，新膀胱远端与尿道残端吻合。结果　3例患者平均手术时间为5 h，术中平均出血量366 ml，术后随访1～18个月，3例白天均能控尿，夜尿1～3 次，膀胱容量大，压力低，血电解质基本正常。超声检查无上尿路扩张积液，MRI或膀胱镜检查无肿瘤复发，术后随访1～18个月，患者控尿、排尿满意，贮尿囊容量分别为250、320和450 ml，平均340 ml，剩余尿0～40 ml。结论　去管化回肠S型缝合制作正位新膀胱术操作简便，新膀胱容量大、术后并发症发生率低，是治疗浸润性、多发性膀胱癌的好方法。     

原位回盲肠新膀胱术的初步研究

目的:探讨逆行全膀胱切除术后原位回盲肠新膀胱术的手术方式、近期疗效和尿流动力学特点。方法:回顾性分析2018年11月至2019年8月我科收治并行原位回盲肠新膀胱术膀胱癌患者4例,所有患者先行腹膜外逆行根治性全膀胱切除,截取回盲肠构建新膀胱,再将新膀胱与尿道吻合重建尿流通道。术后定期复查尿动力、肾功能、彩超等检查。结果:本组患者随访6~16个月,术后初期患者均有不同程度溢尿现象,3个月后逐步恢复并能良好控尿。1例术后出现尿道吻合口轻度狭窄并输尿管返流。新膀胱最大储尿容量(401.7±53.0)ml,储尿期膀胱内压(19.0±5.7)cmH2O,尿道闭合压(53.6±9.4)cmH2O,储尿期膀胱内压明显小于尿道闭合压,最大尿流率(18.7±1.5)ml/s,平均残余尿量(21.3±4.4)ml。结论:全膀胱切除术后原位回盲肠新膀胱术具有储尿囊容量大、压力低、可控性好、操作简单的优点,是一种较理想的尿流改道方式。     

可控性回结肠膀胱

为探讨一种既尿可控，又少并发症的尿流改道术。１９９２年５月－１９９７年５月对１２例病人施行可控性回结肠膀胱术。随访１个月－５年。全组病人均尿可控，不挂尿袋，除１例外，１１例血生化，肾功均正常，１１例健在，均恢复正常社交活动或劳动。经贮尿囊造影，测压和ＩＶＰ检查，证实本术式具有可靠的抗尿失禁，抗输尿管返流，贮尿囊容量大且压力低，插管导尿容量，及并发症少等优点。     

乙状结肠直肠膀胱术18例

 【摘要】　目的　评价乙状结肠直肠膀胱术可控性尿流改道的临床效果。方法　对18例膀胱肿瘤患者行全膀胱切除后乙状结肠直肠膀胱术。以乙状结肠直肠交界为中点,将肠管纵行剖开20～24 cm,做乙状结肠直肠侧侧吻合,形成低压贮尿囊,顶端固定于骶骨岬处,两输尿管由贮尿囊上方引入,采用改良黏膜沟法做抗反流吻合,利用肛门括约肌控制排尿。结果　全膀胱切除后的乙状结肠直肠膀胱术平均手术时间为80 min。拔除肛管及输尿管支架管1周～2个月后可获得满意的尿便分流,2个月后排尿次数稳定,白天4～5次,夜间1～3次。术后并发夜间遗尿2例,2个月后自行消失;并发粘连性肠梗阻1例,高氯性酸中毒、低钾血症2例,尿道残端癌1例。无吻合口梗阻、肾功能损害及严重上尿路感染等并发症。结论　该术式操作简便,术后尿控满意,接近正常人的生活,易于被患者接受,是一种比较好的可控性尿流改道方式。     

膀胱全切除术治疗老年膀胱癌

目的 :探讨膀胱全切除术治疗老年膀胱癌的安全性。方法 :2 9例老年膀胱癌患者行膀胱全切除术 ,尿流改道采取直肠膀胱 10例 ,乙状结肠膀胱 9例 ,回肠膀胱 6例 ,输尿管皮肤造瘘术后 4例 ,同时行尿道切除术 5例。结果 :术后发生尿瘘 2例 ,粘连性肠梗阻 2例 ,出血 1例 ,死亡 2例。本组死亡率与同期老年膀胱全切除术患者死亡率相比 (1 37)差异无显著意义 ,P >0 0 5。结论 :膀胱全切除术治疗老年膀胱癌是一种可行的手术方法 ,降低死亡率的关键是做好围手期处理     

回肠原位新膀胱术在70岁以上男性肌层浸润性膀胱尿路上皮癌患者中的应用

背景与目的:原位新膀胱术是肌层浸润性膀胱尿路上皮癌患者行根治性膀胱切除术后生活质量较好的尿路重建术式.但是新膀胱术式较复杂、手术时间较长,70岁以上男性患者的手术承受力和控尿能力的恢复程度值得研究.本研究旨在探讨70岁以上男性肌层浸润性膀胱尿路上皮癌患者应用回肠原位新膀胱术的安全性和控尿能力的有效性.方法:自2006年1月1日-2010年2月20日间,本研究对23例70岁以上男性肌层浸润性膀胱尿路上皮癌患者实施根治性膀胱切除术,术中采取了保护神经血管束、不剪开盆底筋膜、不切断耻骨前列腺韧带、不缝扎阴茎背深静脉丛的方法,以Hautmann技术建立回肠原位新膀胱.结果:23例患者均安全度过手术期,其中3例患者术后出现暂时认知功能障碍,1例患者于术后24 d出现胃肠功能紊乱.23例患者术后16～21 d白天完全自主控尿;术后30、60、90、180和360 d睡眠后完全控尿例数分别为0、4、5、11及16例;均无排尿困难,23例患者均对控尿程度满意.结论:70岁以上男性肌层浸润性膀胱尿路上皮癌患者应用回肠原位新膀胱术安全,控尿效果满意,可作为根治性膀胱切除术后首选的尿路重建术式.     

膀胱全切后改良肠道原位新膀胱下尿路功能性重建(附15例疗效分析)

背景与目的：膀胱全切后患者的生活质量受尿流改道方式影响,可控性或非可控性尿流改道后患者不能自主排尿、生活质量差;而肠道原位新膀胱术后患者可自主排尿,生活质量改善,但有排空不良和控尿不全等问题。本文报告改良肠道原位新膀胱术在膀胱全切后下尿路功能性重建中的经验。方法：对15例局部浸润性膀胱癌患者在根治性膀胱切除后利用改良肠道原位新膀胱术（回肠新膀胱3例,乙状结肠新膀胱12例）做下尿路功能性重建。术后随访3-30个月（其中9例随访超过16个月）,对这些患者术后新膀胱功能、控尿和排尿功能、性功能、上尿路形态和功能、血电解质和生活质量进行评价。结果：全部患者自主排尿,无需导尿。13例患者昼夜完全控尿;1例患者白天控尿良好,夜间有少量漏尿;另1例女性患者有中度张力性尿失禁。膀胱容量240-640ml,残余尿量0-250ml。全部患者总肾功能正常,14例血电解质正常;慢性代谢性酸中毒和输尿管扩张各1例。9例男性患者保留性功能。13例患者恢复工作。全部患者对新膀胱功能满意。结论：改良肠道原位新膀胱术后下尿路的控尿和排尿功能良好,是目前根治性膀胱切除后理想的下尿路重建方法。     

膀胱癌根治性全膀胱切除术后行不同尿流改道术对患者生活质量的影响

目的:分析膀胱癌根治性全膀胱切除术后行不同尿流改道术对患者生活质量的影响。方法:选取我院2014年7月至2015年12月期间收治的142例行根治性膀胱全切除及尿道改造术患者的临床资料进行回顾性分析。按照不同改道术将患者分成A组（原位新膀胱术组）（71例,其中原位乙状结肠新膀胱术16例,原位回肠新膀胱术55例）与B组（非原位尿流改道术组）（71例,其中输尿管皮肤造口术10例,回肠通道术61例）,治疗结束后记录并比较2组患者近期临床疗效和生活质量。结果:A组手术时间、住院时间均较B组延长（P＜0.05）。B组患者并发症发生率较A组低,但两组患者并发症发生率比较差异无统计学意义（P=0.370）。两组患者术后生活质量比较均存在差异（P＜0.05）,其中在生理机能、生理职能、社会功能、精神健康及情感职能5个方面两组患者比较差异具有统计学意义（P＜0.05）,且均以A组患者得分较高,而在躯体疼痛、一般健康状况、精力的比较上两组患者差异无统计学意义（P＞0.05）。结论:在根治性膀胱全切除术中采用不同尿流改道术对治疗膀胱癌均具有一定的临床疗效和安全性,但采用原位新膀胱尿流改道的方式更利于提高患者术后生活质量,值得临床上推广使用。     

膀胱颈口狭窄与膀胱肿瘤发光关系的研究

目的 探讨膀胱颈口狭窄与膀胱肿瘤的发病关系。方法 检测、对比分析了８０例膀胱肿瘤患者和２０例非肿瘤患者的膀胱颈口及尿流率。结果 ８０例膀胱肿瘤患者的膀胱颈口８５％存在狭窄，而对照组仅为１０％；膀胱肿瘤组的平均最大尿流率及尿产和参数与正常值均有明显差异。结论认为膀胱颈口狭窄、排尿梗阻、尿流异常是膀胱肿瘤发病原因之一。     

Muskelinvasives Blasenkarzinom

The aim of the treatment of invasive bladder cancer with radical cystectomy and subsequent urinary diversion is to combine a safe oncological procedure with a satisfactory quality of life. Radical cystectomy is the treatment of choice for all patients with recurrent or multifocal high-grade T1 bladder cancer, T1 tumors at high risk of progression, failure of bacillus Calmette-Guérin (BCG) treatment and muscle-invasive bladder cancer. Radical cystectomy offers excellent recurrence-free and cancer-specific survival rates as well as local tumor control in patients with organ-confined and node-negative diseases. Tumor control in non-organ-confined tumors is still satisfactory with long-term relapse-free survial rates of about 50%. Nerve-sparing cystectomy is of importance for the lower urinary tract function, including continence rates after orthotopic urinary diversion and for sexual function in males and females. Orthotopic urinary reconstruction using a neobladder achieves good continence rates. Overall quality of life after radical cystectomy remains good in most patients irrespective of urinary diversion type.     

Urinary diversion after radical cystectomy

Opinion statement At most centers with experience in urinary diversion, an orthotopic urinary reservoir is the diversion of choice after radical cystectomy for bladder cancer. The paradigm has shifted in the past 10 years from actively looking for reasons to do an orthotopic diversion to carefully considering why a patient cannot undergo reconstruction to their native urethra. In our institution, any patient who is to undergo a radical cystectomy for bladder cancer is a potential candidate for orthotopic diversion provided they do not have chronic renal insufficiency. In addition, they must have a negative urethral margin on frozen section at the time of cystectomy, and have the mental and physical capacity to understand what is required to manage the reservoir after surgery. Proper patient selection is the key to success. Notably, chronologic age is not an absolute contraindication to orthotopic diversion. Instead, careful consideration of the patient’s comorbid conditions should guide eligibility. In addition, locally advanced disease is not a contraindication to an orthotopic diversion. To have the flexibility to manage whatever situation presents itself intraoperatively, the surgeon performing a urinary diversion after radical cystectomy must be facile with several diversion techniques. At the very least, the surgeon must be comfortable with one type of each major form of urinary diversion, a conduit (incontinent) diversion, a continent cutaneous diversion, and an orthotopic diversion. As a result, radical cystectomy and urinary diversion should be performed at centers with significant experience in all three types of diversions.     

Studer回肠新膀胱的手术改良探讨

目的:对Studer回肠新膀胱术进行技术改良并评价其临床效果.方法:采用根治性膀胱全切、改良Studer回肠新膀胱术治疗5例男性浸润性膀胱癌患者.结果:5例患者手术顺利.拔除尿管后4例患者恢复生理性排尿,1例不能自主排尿.随访6～12个月,4例患者昼夜控尿良好.5例患者静脉肾盂造影未见输尿管新膀胱吻合口狭窄及上尿路积水.结论:改良Studer回肠新膀胱术操作相对简单,手术并发症低,可以取得满意的临床效果.     

Transitional cell carcinoma of the urethra in men and women associated with bladder cancer

Multifocal tumor occurrence in the entire urinary tract in time and space is a well-recognized characteristic of transitional cell carcinoma. Synchronous and asynchronous urethral transitional cell carcinoma, in relation to bladder cancer in male and female patients, is the subject of the present mini-review. It is imperative to rule out male and female patients having a high risk for urethral involvement or urethral recurrence. In male patients, prostatic urethral involvement and stromal invasion mainly due to in situ extension of carcinoma seems to be the most important risk factor. In female patients, bladder neck involvement by cancer seems most important. By excluding male and female bladder cancer patients having these characteristics for simultaneous urethrectomy, other patients are good candidates for reconstruction of the urinary tract after cystectomy by an orthotopic neobladder which will offer a good quality of life to bladder cancer patients.      

原位回肠膀胱对上尿路功能影响的回顾性分析

目的:探讨原位回肠膀胱对上尿路功能的影响。方法:评估2006年3月至2011年6月陕西省核工业二一五医院泌尿外科收治的34例肌层浸润性膀胱尿路上皮癌行膀胱全切W形原位回肠代膀胱患者的上尿路功能,所有病例随访时间5年以上,均无复发及转移。评估项目包括肌酐测定、泌尿系B超测定膀胱残余尿量及肾积水量、膀胱造影明确有无尿液返流。结果:术后2年,膀胱造影5例（14.7%）患者出现反流致轻度肾积水,与术前比较差异无统计学意义（χ2=2.110,P>0.05）,术后5年,膀胱造影6例（17.6%）患者出现反流致轻度肾积水,与术前比较差异无统计学意义（χ2=1.531,P>0.05）;术前血肌酐（77.32±13.78） mmol/L,术后2年血肌酐（78.50±12.37） mmol/L（t=-1.93,P>0.05）;术后5年血肌酐（82.15±22.49） mmol/L（t=-2.36,P>0.05）,无统计学差异,且均在正常范围。术后2年膀胱容量（413±19） ml,残余尿量（57.3±36.1） ml,术后5年膀胱容量（423±17） ml,残余尿量（53.3±33.7） ml,残余尿量差异无统计学意义（t=-0.29,P>0.05）。结论:原位W型回肠膀胱可作为膀胱全切术后理想的代膀胱术式,对上尿路功能影响较轻。     

腹腔镜根治性膀胱切除+回肠原位新膀胱术疗效分析

目的:回顾分析腹腔镜下全膀胱切除+回肠原位新膀胱术的临床疗效与经验.方法:随访了2006年1月-2012年2月采用腹腔镜下根治性膀胱切除术+回肠原位新膀胱术治疗的87例患者,手术方法为腹腔镜下膀胱全切术+开放新膀胱构建及吻合,并对随访3年的临床数据进行总结分析.结果:大多数患者恢复良好,所有的新膀胱漏尿并发症均被有效处理;仅有1例患者因肠瘘行肠造口,3个月后行肠回纳;术后3年整体生存率为88.5％(77/87),无瘤生存率为92.2％ (71/77);整体控尿功能及肾功能保护方面取得良好效果.结论:腹腔镜下根治性膀胱全切+回肠原位新膀胱术,具有良好的控尿功能和较好的保肾功能,可以明显提高患者生活质量.     

Oncological outcome after radical cystectomy and orthotopic bladder substitution in women

Aim

The pathological outcome after radical cystectomy and orthotopic bladder substitution in women and the possibility of genital sparing are studied in a prospective way.

Methods

Between January 1995 and June 2003, 180 women with bladder cancer (mean age 50.6 years) underwent orthotopic neobladder reconstruction. Histopathologic assessment of the cystectomy specimens was performed. Involvement of the internal genitalia by primary or secondary cancer was evaluated by preoperative CT or MRI. Histopathological evaluation of these organs was made in the cystectomy specimens.

Results

Mean follow-up was 57 months. At follow-up, isolated urethral recurrence developed in two patients. Local pelvic recurrence developed in 30 patients, distant metastasis in 14 and both in nine. Uterine infiltration, which was suspected by preoperative CT, was confirmed by definitive histopathology after radical cystectomy in only two cases; otherwise there were no primary or secondary malignancies of the internal genitalia. Isolated recurrence of bladder cancer in the vaginal remnant during follow-up after cystectomy was not noted in any woman.

Conclusions

The rate of urethral recurrence and oncological failure after orthotopic bladder substitution in women is low and acceptable and thus justifies the continued performance of this type of diversion. Proper selection of cases is mandatory. In women with absence of malignant involvement of the internal genitalia on preoperative imaging, the risk of secondary malignant involvement of these organs in cystectomy specimens is very low. Therefore, preservation of the uninvolved gynecologic organs during radical cystectomy in premenopausal women with unifocal, organ-confined tumor above the bladder base, is justified.     

Prevention and treatment of complications in patients after cystectomy with enterocystoplasty

Surgical outcomes have been analysed for 211 patients with urinary bladder tumors. The operation consisted in cystectomy with one- or multistage creation of intestinal neocystis. Causes of early and late postoperative complications were studied. Original surgical techniques with creation of orthotopic intestinal bladder preventing complications of cystectomy are proposed.     

Surgical treatment of advanced baldder carcinoma

Radical cystectomy is the treatment of choice for patients with muscle-invasive or locally advanced bladder carcinoma. Alternative treatment options are simultaneous radiochemotherapy following transurethral tumor resection or percutaneous definitive radiotherapy. To prevent early tumor progression, treatment decision should be made within 6 months after initial diagnosis. Extended lymphadenectomy seems to have an impact on progression-free survival, as determined in retrospective analyses. Excellent long-term results exist for urinary diversion using ileal neobladder or ureter bowel implantation into an augmented colon sigmoideum segment. Similarly good results are reported for female patients. Quality of life (QoL) in correlation to type of urinary diversion is under discussion. Ileal conduit seems to be of advantage for QoL especially in elderly patients. Surgical removal of metastases is controversially discussed, especially in those patients without tumor-related symptoms. An age of more than 70 years seems to be no exclusion criterion for radical cystectomy. Treatment morbidity and mortality are similar to those of younger patients. Long-term results confirm the excellent results of orthotopic bladder replacement.     

Urodynamics of artificial urinary bladder

Radical cystectomy with creation of orthotopic reservoir from various segments of gastrointestinal tract was made in 120 patients (99 males, 21 females, age 37-74 years) with muscular-invasive cancer of the urinary bladder (UB) in 1996-2004. Replacement of UB was made according to the Studer and Hautmann method in 38 and 27 patients, respectively. S-cystoplasty was performed in 31 patients. The gastric segment was used for creation of the reservoir in 24 patients. Three patients died. Three to twelve month follow-up recorded the best functional results in patients after Studer cystoplasty.