保留部分前列腺的全膀胱切除术治疗浸润性膀胱癌

背景与目的：经典的根治性膀胱切除术将膀胱和前列腺全部切除,术后阳痿和尿失禁发生率高。在肿瘤没有累及前列腺的情况下,根治术中保留部分前列腺可改善术后性功能和控尿功能,但对预后是否有影响尚不清楚。本文报告10例保留部分前列腺的改良全膀胱切除术的经验,阐述改良术式对术后性功能、控尿功能和肿瘤控制的影响。方法：对10例男性浸润性膀胱癌患者,先经尿道电切除部分前列腺,全膀胱切除时保留部分前列腺包囊。下尿路重建采用肠道新膀胱术,新膀胱与残留的前列腺包囊吻合。术后随访评价肿瘤控制、尿液控制和性功能情况。结果：术后病理分期均为T2NOM0。随访3～12个月(平均9个月),9例无瘤生存,l例低分化移行细胞癌患者术后2个月出现全身骨骼及淋巴转移;全部患者自主排尿,完全控尿9例,部分控尿l例;术前有性功能的8例中,术后6例保持阴茎勃起功能。结论：保留部分前列腺的改良全膀胱切除术可以较好保留下尿路控尿功能和阴茎勃起功能,但对肿瘤控制的远期影响有待进一步观察。     

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.     

原位低压回肠代膀胱术的技术改进及临床应用

目的：探讨低压回肠代膀胱术的技术改进及远期疗效。方法;对１６例全膀胱切除的膀胱癌病人,施行回肠袋近端肠管人工套迭加隧道式输尿管肠吻合术,同时用２％碘酊处理回肠袋粘以减少肠粘膜的分泌与吸收。结果：手术时间平均５小时５０分钟。术后随访１１－７２个月,全部病人白天均能自控排尿,无输尿管返流,无代谢性酸中毒,无手术死亡及再次手术。     

腹腔镜根治性膀胱切除+原位回肠新膀胱术治疗浸润性膀胱癌的临床疗效分析

目的:探讨腹腔镜根治性膀胱切除+原位回肠新膀胱术治疗浸润性膀胱癌的临床疗效.方法:回顾性分析2010年2月至2015年11月于蚌埠医学院第一附属医院行腹腔镜根治性膀胱切除+原位回肠新膀胱术的32例浸润性膀胱癌患者的临床资料,对手术方法(腹腔镜根治性膀胱切除+原位回肠新膀胱术)、围手术期资料、新膀胱功能、术后并发症以及肿瘤控制情况等进行分析.结果:成功随访32例,随访时间12 ～ 53个月,平均随访27个月,均为男性;所有患者手术均由同一术者顺利完成,手术时间310 ～530 min,平均370 min;术中出血300～ 850 ml,平均485 ml;术后3～5天肠道开始恢复功能;淋巴结清扫数目8～31个,平均16个;手术切缘均无阳性结果;术后12个月与6个月相比较,最大尿流率(15.2±1.3vs11.4±1.2 ml,P＜0.01)、最大膀胱容量(372.8±52.2 vs 247.9±60.3 ml,P＜0.01)、残余尿量(23.8 ±9.6 vs 39.6±11.7 ml,P＜0.01)、最大膀胱充盈压(33.7 ±5.7 vs 25.1±6.8 cmH2O,P＜O.01)、最大膀胱排尿压(63.7±15.9 vs62.9±17.6 cmH2O,P＞0.05)、膀胱顺应性(26.2±12.6 vs 25.7±13.3 cmH2O,P＞0.05)以及昼/夜控尿率(91％/81％ vs 84％/72％).术后近期并发症发生率为18.8％(6/32),远期并发症发生率为25.0％(8/32);随访期间,肿瘤局部复发率和远处转移率分别为6.3％ (2/32)和12.5％(4/32).结论:腹腔镜根治性膀胱切除+原位回肠新膀胱术是安全可行的,具有术后控尿效果好、满意的新膀胱功能和肿瘤控制效果等优点,是治疗浸润性膀胱癌的优先选择.     

经尿道辅助单孔腹腔镜下根治性膀胱切除联合原位回肠新膀胱术的疗效及安全性

目的:探讨单孔腹腔镜下根治性膀胱切除术联合原位回肠新膀胱术的疗效及安全性。方法:选取2017年01月至2019年12月于本中心收治的17例膀胱癌患者,其中7例患者在经尿道途径的辅助下行单孔腹腔镜根治性膀胱切除术联合原位回肠新膀胱术;另外10例为对照组,行多孔腹腔镜下根治性膀胱切除术联合原位回肠新膀胱术,并对两组患者围手术期资料、手术并发症以及术后随访情况进行分析。结果:两组共17例膀胱癌患者均顺利完成手术,无中转开放手术。两组患者的年龄、体质量指数（body mass index,BMI)等差异均无统计学意义（P＞0.05）。单孔组与对照组平均手术时间分别为（341.4±52.1）min和（333.0±59.5）min,术中平均出血量分别为（206.4±104.6）mL和（190.5±82.3）mL,盆腔淋巴结清扫平均个数分别为17（7~22）个和18（12~23）个,术后平均住院天数分别为（25.1±5.4）d和（26.8±6.0）d,差异均无统计学意义（P＞0.05）。而单孔组在术后VAS疼痛评分和切口满意度评分上则优于对照组（P＜0.05）。其中单孔组患者术后随访12个月时患者的最大尿流量、最大膀胱容量、最大膀胱充盈量均明显比6个月时高,而随访12个月时患者的残余尿量较6个月时低,差异均具有统计学意义（P＜0.05）。结论:经尿道辅助单孔腹腔镜下根治性膀胱切除术联合原位回肠新膀胱术是安全可行的,且术后的新膀胱功能较为良好。     

原位低压回肠代膀胱术的技术改进及临床应用

目的：探讨低压回肠代膀胱术的技术改进及远期疗效。方法：对１６ 例全膀胱切除的膀胱癌病人,施行回肠袋近端肠管人工套迭加隧道式输尿管肠吻合术,同时用２ ％ 碘酊处理回肠袋粘膜以减少肠粘膜的分泌与吸收。结果：手术时间平均５ 小时５０ 分钟。术后随访１１ ～７２ 个月,全部病人白天均能自控排尿,无输尿管返流,无代谢性酸中毒,无手术死亡及再次手术。结论：本术式具有成功率高,并发症少,病人术后生活质量高等优点     

原位回肠代膀胱的临床应用体会

[目的]探索选择一种能为医患双方共同接受的代膀胱术。[方法]对12例膀胱癌病人行根治性切除术后施行原位回肠膀胱术,并进行跟踪随访。[结果]本组无1例出现永久性尿失禁及肾功能损害,亦无新膀胱颈口与尿道断端吻合口狭窄。[结论]原位回肠膀胱自控性强,容量大,生活质量好,是一种理想的代膀胱术。     

腹腔镜全膀胱切除术加回肠原位膀胱术的临床疗效观察 （附15例报告）

目的：总结腹腔镜下膀胱肿瘤根治术加回肠原位膀胱术的经验。方法：15例患者中男11例, 女4例, 年龄46～72岁,平均61.8岁, 采用5点穿刺法, 腹腔镜由脐部下缘导管进入, 手术者经左侧2个套管操作, 助手经右侧2个套管操作。从右到左分别游离输尿管中下段并进行盆腔淋巴结清扫, 输尿管暂不离断。男性患者先游离并离断输精管、 精囊, 前列腺后壁及前壁, 紧贴前列腺尖部离断尿道, 再行膀胱前列腺全切; 女性患者在行膀胱全切除的同时作子宫及附件切除。在下腹正中线上作长4～5 cm切口, 取出标本, 回肠拉出切口外, 取回盲部交界15 cm近侧隔离50 cm回肠段纵行剖开该肠后M形折叠形成贮尿囊, 将输尿管末段1 cm插入贮尿囊后顶部作吻合。贮尿囊最低位开口与尿道断端行6针吻合。结果：手术耗时5～8 h, 平均6.3 h, 出血量400～800 mL, 平均447 mL, 术后所有患者3～4 d肠道功能开始恢复,1个月行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300 mL,15例患者均于术后4～6周内均恢复控尿能力, 无排尿困难及尿失禁症状。结论：腹腔镜下行膀胱全切除视野清楚, 有助于精确地处理盆底深部的重要结构, 术中出血少, 尿道括约肌损伤概率较小, 有助于减少术后肠粘连, 保护身体的免疫机制, 减少术后感染, 小切口取出标本, 体外构建贮尿囊, 吻合输尿管, 可缩减手术时间, 减少腹腔内污染。     

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。     

National Trends and Impact of Regionalization of Radical Cystectomy on Survival Outcomes in Patients with Muscle Invasive Bladder Cancer

ObjectiveTo evaluate national trends and the effect of surgical volume on perioperative mortality and overall survival (OS)in patients undergoing radical cystectomy (RC) for muscle invasive bladder cancer (MIBC).MethodsWe investigated the National Cancer Database to identify patients with localized MIBC (cT2a-T4, M0) who underwent RC from 2004 to 2014. Demographics, 30- and 90-day mortality rates, as well as OS were analyzed. Hospitals were stratified into low-, medium-, and high-volume centers according to median number of RCs performed per year. Multivariate logistic regression models were fitted to identify independent predictors of perioperative mortality. Kaplan-Meier survival curves were generated to evaluate OS. Cox proportional hazard modeling was performed to identify independent predictors of OS.ResultsA total of 24,763 patients with localized MIBC who underwent RC from 2004 to 2014 were included in the study. Overall, most (70.85%) RCs occurred at low-volume hospitals, whereas only 15.83% were performed at high-volume hospitals. Thirty-day mortality rates were 2.87%, 2.19%, and 1.83% (P < .01); and 90-day mortality rates were 8.25%, 6.9%, and 5.9% (P < .01) at low-, medium-, and high-volume hospitals, respectively. Multivariate analyses identified RC volume as an independent predictor of 30- and 90-day mortality. RC in high-volume hospitals was associated with a 35% risk reduction in 30-day mortality (odds ratio 0.65, 95% confidence interval [CI] 0.49-0.85; P < .01), and a 26% risk reduction in 90-day mortality (0.74, 95% CI, 0.63-0.87; P < .01).ConclusionsTreatment at high-volume centers offers improved outcomes and OS benefit. However, in the United States, only 16% of RCs are performed in high-volume hospitals.     

腹腔镜根治性膀胱癌切除术后行回肠膀胱术和输尿管皮肤造口术的疗效比较

目的 比较腹腔镜根治性膀胱癌切除术后行回肠膀胱术和输尿管皮肤造口术的疗效.方法 选择行腹腔镜根治性膀胱癌切除术后患者90例,随机分为A组和B组,均45例.A组采取回肠膀胱术,B组采取输尿管皮肤造口术.比较2组手术时间、术中出血量以及术后住院时间、术后并发症、术后生存质量.观察2组患者的胃肠道功能恢复情况.结果 B组患者的手术时间、术中出血量及术后住院时间均明显低于A组(P＜0.01).2组术后尿路感染和肺感染的发生率差异无统计学意义(P＞0.05),B组的切口感染、肠梗阻发生率均明显低于A组,而漏尿发生率明显高于A组(P＜0.05).2组患者术后生理状况、社会/家庭状况、情感状况、功能状况评分比较无统计学差异(P＞0.05).B组胃肠功能恢复的优良率为44.44％,显著高于A组22.22％,差异有统计学意义(x2 =4.05,P＜0.05).结论 膀胱癌切除术后回肠膀胱术和输尿管皮肤造口术各有优、缺点,可根据患者个体情况选择合适的手术方式.     

腹腔镜全膀胱根治性切除术治疗膀胱癌(附4例报告)

目的:探讨腹腔镜全膀胱根治术的手术方法及其临床效果。方法:均采用气管插管麻醉。腹腔镜下切除膀胱和前列腺。结果:手术时间为256～476分钟,平均为368分钟;术中出血量为100～400ml,平均为248ml。肠道恢复时间为术后1～3天,平均为1.5天。术后2～4天开始进食。手术后8～13天痊愈出院。手术后病理报告:4例均为膀胱移行细胞癌Ⅱ～Ⅲ级,其中3例浸润浅肌层。手术中和手术后均未发生并发症。手术后随访6～9个月,一般状况良好,无肿瘤复发及转移。结论:腹腔镜全膀胱根治术具有创伤小、解剖清晰、术中出血少和术后恢复快等优点,是一种安全、有效的治疗方法。     

Comparative Effectiveness of Bladder-preserving Tri-modality Therapy Versus Radical Cystectomy for Muscle-invasive Bladder Cancer

Introduction

There are limited randomized data comparing radical cystectomy (RC) with bladder-sparing tri-modality therapy (TMT) in the treatment of muscle-invasive bladder cancer (MIBC). Both strategies are thought to have similar survival outcomes with different morbidity profiles. We compare the effectiveness of TMT and RC using decision-analytic modeling and the endpoint of quality-adjusted life years (QALYs).

Induction Chemotherapy Followed by Surgery Versus Upfront Radical Cystectomy in Patients With Clinically Node-positive Muscle-invasive Bladder Cancer

BackgroundThe aim of this study was to compare survival outcomes in patients with clinically node-positive muscle-invasive bladder cancer receiving induction chemotherapy (IC) followed by surgery and those who underwent upfront radical cystectomy (RC).Patients and MethodsOutcomes were reviewed in patients with cT2-4N1-3M0 bladder cancer treated with IC followed by surgery or upfront RC between January 1995 and June 2017. Survival outcomes were analyzed using a propensity score matched cohort analysis.ResultsOf the 340 eligible patients, 106 received IC and 234 underwent upfront RC. The overall 3-year metastasis-free survival rate and 5-year cancer-specific survival rate of patients in the IC and RC groups were similar (49.4% vs. 46.0% and 49.6% vs. 49.8%, respectively). The 5-year cancer-specific survival rate of cN1-2 patients was higher in the IC group than the RC group (68.1% vs. 52.9%; P = .035). However, the 5-year cancer-specific survival rate of patients with cN3 cancers was significantly lower in the IC group than the RC group (19.2% vs. 44.5%; P = .015).ConclusionsIn this study, IC was seen to improve cancer-specific survival in patients with cN1-2 muscle-invasive bladder cancers but was associated with poorer survival outcomes than upfront RC in patients with cN3 cancers. Further investigation in prospective, randomized studies is warranted.     

Short-term Mortality Associated with Definitive Chemoradiotherapy Versus Radical Cystectomy for Muscle-invasive Bladder Cancer

BackgroundMuscle-invasive bladder cancer (MIBC) may be managed with radical cystectomy (RC) or chemoradiotherapy (CRT). Because patient selection for RC is important to avoid treatment-related mortality, this study addressed a knowledge gap by quantifying short-term mortality with both approaches, as well as predictors thereof.Materials and MethodsThe National Cancer Database was queried (2004-2014) for clinically staged T2-4aN0M0 MIBC that received either CRT or RC. Statistics included cumulative incidence comparisons of 30- and 90-day mortality between patients treated with either CRT or RC and Cox regression to evaluate predictors thereof.ResultsOf 16,658 patients, 15,208 (91.3%) underwent RC and 1450 (8.7%) CRT. Crude rates of post-treatment mortality at 30 days were 2.7% versus 0.6% (P < .001) and at 90 days were 7.5% versus 4.5% (P = .017) for patients treated with RC and CRT, respectively. When stratifying by age, worse 30- and 90-day mortality with RC was observed for patients aged ≥ 76 years.ConclusionsThis study describes 30- and 90-day mortality following RC versus CRT. Both approaches yield statistically similar treatment-related mortality rates in patients ≤ 75 years of age; however, worse post-treatment mortality was observed with use of RC in patients ≥ 76 years of age. These results may be utilized to better inform shared decision-making between patients and providers when weighing both RC and CRT for MIBC.     

全膀胱切除术治疗高危非肌层浸润性膀胱癌的研究进展

目的非肌层浸润性膀胱癌(NMIBC)主要由三种不同类型的肿瘤组成:乳头状尿路上皮癌局限于黏膜层(Ta),高级别原位癌局限于上皮层(CIS)以及侵犯黏膜下层或固有层的肿瘤(T1).NMIBC的首选治疗方案是彻底的经尿道膀胱肿瘤电切术(TURBT)和(或)膀胱灌注治疗.但是,仍有部分高危患者具有肿瘤进展的风险,因而需要接受...     

膀胱癌荧光原位杂交检测及其临床意义

目的:分析膀胱移行细胞癌的染色体畸变情况,探讨荧光原位杂交(FISH)技术在膀胱癌的临床应用价值.方法:采用3、7、17号染色体着丝粒探针和9号染色体p16基因位点探针对56例膀胱移行细胞癌患者和20名健康人群的新鲜尿液进行FISH检测,统计染色体的畸变并分析其与病理分级、分期的关系.对所有病例同步进行尿细胞学分析.结果:膀胱癌患者尿脱落细胞核中3、7、17号染色体及9号染色体p16基因畸变率分别为58.9%、39.3%、58.9%和75.0%,各染色体畸变在膀胱癌不同分期之间的差异无统计学意义(P>0.05),3、7、17号染色体畸变在不同分级之间的差异具有统计学意义(P<0.05),四染色体探针组合诊断膀胱癌的总阳性率为80.4%;膀胱癌尿脱落细胞的FISH检出率明显高于尿细胞形态学.结论:膀胱癌的发生发展与染色体的畸变有关,膀胱癌尿脱落细胞的FISH检测,对膀胱癌的早期诊断、预后评估及复发监测等具有重要价值.