膀胱全切原位尿流改道术治疗膀胱非尿路上皮癌的疗效评价

目的：评价膀胱全切原位尿流改道术治疗膀胱非尿路上皮癌的疗效.方法：对17例膀胱非尿路上皮癌患者行根治性膀胱全切,盆腔淋巴结清扫;然后取一段肠管缝制成新膀胱,分别与输尿管和尿道残端吻合,实现原位尿流改道.结果：手术均获成功,手术时间172～380 min,平均310 min.16例获得随访,平均随访67个月（1～16年）.6例因肿瘤复发或转移于5年内死亡,2例死于非肿瘤因素,1例仍在随访,7例存活已达5年.结论：根治性膀胱全切原位尿流改道术治疗膀胱非尿路上皮癌,具有较好的治疗效果,能明显改善患者生活质量.     

Continent Urinary Diversion: The Children's Hospital Experience

Purpose

Continent urinary diversion has become increasingly important for treating childhood urinary tract pathology that cannot be managed by direct reconstructive techniques. We review our 9-year experience with continent diversion.

Materials and Methods

Since 1986 continent diversions were created in 74 patients 3 to 38 years old (mean age 13.7). The underlying pathological condition was the exstrophy/epispadias complex in 34 patients, neurological disorders in 23, malignancy in 13 and other congenital anomalies in 4. Followup averaged 5.2 years after the last procedure. Nonbladder reservoirs in 39 patients (53%) were fashioned from ileocolic (17), colic (7), gastrocolic (6), sigmoid (3), gastrosigmoid (2), ileosigmoid (2), ileal (1) and gastroileac (1) segments. When possible, the native bladder was incorporated into the reconstructive strategy. A total of 26 patients underwent bladder augmentation with intestine or stomach, including ileal (11), gastric (8), sigmoid (3), gastroileac (2) and ileocolic (2) segments. Nine other patients did not require bladder augmentation. Continence mechanisms were a flap valve (Mitrofanoff principle) in 50 patients, nipple valve in 15 and ileal plication (Indiana pouch) in 9. When the Mitrofanoff principle was used with a native bladder reservoir in 30 cases, outlet resistance was altered by bladder neck division (15), fascial sling placement (6) or Young-Dees-Leadbetter bladder neck reconstruction (2). In the remaining 7 patients the bladder neck remained intact.

Results

Excellent continence was obtained. The Mitrofanoff principle initially provided continence in 41 patients (82%). Six of the 9 incontinent patients were dry after a single revision. A total of 13 patients (87%) with nipple valves and 7 (78%) with Indiana pouches were dry, and the remaining 5 were cured after a single revision. Ultimately continence was achieved in 71 of the 74 patients (96%) after a maximum of 2 operations. Of the 48 complications in 29 patients the most common were difficulty in catheterizing (11), stones (11), infection (8) and upper tract deterioration (4).

Conclusions

Many options exist for reconstructing complex anomalies. Choices must be individualized based on patient anatomy. The dry state may be achieved in most cases without resorting to a bag on the abdomen.     

Quality of Life With Urinary Diversion

There continues to be debate about how best to replace bladder function following radical cystectomy. All the usual options currently involve the use of transposed intestinal segments, and all have advantages and disadvantages. The impact of each option on quality of life (QoL) is an important consideration.This review assesses the evidence base that underpins each of the major forms of transposed intestinal segment surgery (ileal conduit diversion, continent urinary diversion, and orthotopic bladder replacement). The meaning, determinants, and measurement of QoL are also explored. We conducted a systematic review searching Medline, PubMed, EMBASE, CINAHL, and the Cochrane Library from 1966 to August 2010. A total of 46 studies (including 8 prospective studies) met the inclusion criteria reporting on 4186 patients. Although the reports suggest a reasonably well-maintained QoL after all transposed intestinal segment surgical options, most were retrospective studies, and the few prospective nonrandomised studies had limitations.From the available published evidence, it still remains unclear if one form of transposed intestinal segment surgery is superior to another in terms of QoL. In light of this continued uncertainty, there is an urgent need to establish the important determinants of QoL for this cohort; to standardise a set of core important outcomes; and, once and for all, to undertake high-quality prospective (ideally randomised) studies comparing the different surgical options to help guide policy and clinical practice in transposed intestinal segment surgical practice. Until such time, care will continue to be individualised, taking into account patient factors, surgeon factors, centre factors, and health provider factors, unsatisfactory as this may be for patients.     

Urinary Diversion for Incontinence in Women

Urinary incontinence is a common condition affecting up to 50% of the female population, but only a third seek medical help. Although the majority of these are satisfactorily managed with conservative or conventional surgical treatment, 10%–15% continue to remain incontinent despite intervention. Urinary diversion is a management option for this group. The different techniques of urinary diversion, their results, complications and long-term sequelae are discussed, with a review of the literature.     

Continent Catheterizable Pouches for Urinary Diversion

ContextCatheterizable pouches represent a good alternative in patients with continent urinary diversion (CUD) when neobladder reconstruction is contraindicated.ObjectiveThis review summarizes the different techniques, indications and contraindications, functional results, outcomes, and complications of continent catheterizable pouches.Evidence acquisitionA PubMed Medline database research was performed, identifying publications of CUD using a catheterizable pouch after radical cystectomy for treatment of bladder cancer.Evidence synthesisIn some patients with infiltrating bladder cancer, a continent cutaneous diversion is indicated when the urethra is involved. Some authors also recommend a catheterizable pouch in patients with carcinoma in situ and in female patients. Different bowel segments have been used to build the reservoir: ileocecum, colon, and ileum. Especially in patients with previous pelvic irradiation, the transverse colonic pouch represents a feasible urinary diversion. Reservoirs with high volume and low pressures can be fashioned by antimesenteric opening and spherical reconfiguration of the bowel. The need for antirefluxive ureteral implantation is questioned and there is a trend towards refluxive implantation. Simple and reproducible techniques (eg, appendix stoma, flap-valve T mechanism, serosa-lined extramural tunnel) have been developed for creation of a continence mechanism. Satisfactory continence rates >90% are reported for most techniques and quality of life is comparable with orthotopic continent diversion. The overall incidence of complications varies from 28–57%. However, most urinary tract complications (eg, pouch calculi, ureteroenteric anastomotic strictures, efferent limb strictures, mucous retention) are corrected by endoscopic means. Open surgery is mainly performed in strictures of the afferent limb.ConclusionsCutaneous catheterizable pouches represent an established and good opportunity for CUD after radical cystectomy for treatment of bladder cancer. Most of the problems that occurred during creation of continent cutaneous reservoirs in the past have been solved. Long-term data of different surgical techniques show excellent continence and acceptable complication rates.     

尿流改道与膀胱重建术现状及展望

浸润性膀胱癌公认的标准治疗方案是行根治性膀胱切除加尿流改道.本文对各种常用的尿流改道和膀胱重建术及人工膀胱的研究进行了回顾,并对其发展予以展望.     

Quality of Life Survey of Urinary Diversion Patients: Comparison of Continent Urinary Diversion Versus Ileal Conduit

Background Continent urinary reservoirs (CUR) have become one of the major options for patients requiring urinary diversion to improve their quality of life (QOL). To assess whether CUR enhanced postoperative QOL, we surveyed patients with CUR and ileal conduit (IC) using a questionnaire sent by mail.
Patients and Methods The questionnaire consisted of 133 questions that covered physical and mental status, social life, sexual habits and symptoms related to urinary diversions. A total of 1 72 questionnaires were sent out, and 137 (80%) patients (74 CUR and 63 IC patients) responded.
Results Basic physical conditions were similar in the 2 groups, except for sleeping habits. Regarding social life, however, the CUR group showed better scores in bathing habits and frequency of overnight travel. Parasternal dermatitis was more frequent in the IC group and the patients were more hesitant to show their stoma to others. On the other hand, about half of the patients in the CUR group complained of troublesomeness in self-catheterization, especially at night. Overall, 74% and 41% of the patients in the CUR and IC group were satisfied with their urinary diversion. When the Kock pouch and Indiana pouch were compared, no statistically significant differences were found in average capacity, maximum capacity, or frequency of self-catheterization.
Conclusions CUR recipients have enhanced QOL regarding the stoma, travel and sleeping habits as compared to ileal conduit. However, troublesomeness of night time self-catheterization was noted in the CUR group. Individualized selection of the type of urinary diversion with informed consent is essential.