阑尾与尿道吻合的回盲肠代膀胱手术远期疗效观察(附11例报告)

目的　评价阑尾与尿道吻合的回盲肠代膀胱手术远期疗效。　方法　应用回盲肠作贮尿囊 ,阑尾代后尿道原位排尿的方法治疗膀胱肿瘤病人 5 6例。　结果　 11例病人术后获 10年以上随访。其中白天完全自控排尿 10例 ,夜间完全自控排尿 8例。伴后尿道假性瓣膜 2例 ,贮尿囊内继发结石 1例 ,后尿道狭窄 1例 ,无输尿管返流 ,无高氯性酸中毒。贮尿囊容量 2 90～ 5 2 0ml,平均 388ml,压力 2 3～ 36cmH2 O(1cmH2 O =0 .0 98kPa) ,平均 2 8cmH2 O。平均尿流率 9.6ml/s。　结论　阑尾与尿道吻合的回盲肠代膀胱术式具有贮尿囊内压低 ,容量大 ,可控性和原位排尿的优点 ,是一种较理想的尿流改道方式。     

以阑尾为流出道的可控性回盲肠膀胱术远期疗效观察

目的 评价以阑尾为流出道的可控性回盲肠膀胱手术的远期疗效。方法 应用回盲肠及部分升结肠作储尿囊，以阑尾为流出道腹壁造口术治疗膀胱肿瘤患者46例，采用尿动力学方法随访5年以上21例。男15例，女6例，平均年龄57岁。G212例，G39例。T3aN0M011例，T3bN0M0 5例，T3bN1M03例，T3bN0M02例。结果 21例患者中能控尿者19例(95％)。白天导尿4～5次，夜间1～2次，每次量250～400ml。膀胱初始感觉压力平均28cmH2O，最大充盈压36cmH2O，储尿囊容量分别为265ml、450ml。阑尾流出道闭合压力45cmH2O。1例患者出现肺转移行手术切除，1例出现肝转移死亡。无输尿管返流，无高氯血性酸中毒。结论 以阑尾为流出道的回盲肠膀胱术储尿囊内压低、容量大、可控性好，是一种较理想的尿流改道方式。     

可控性膀胱术与回肠新膀胱术(附68例报告)

目的　评价不同术式可控性膀胱术及回肠新膀胱术的疗效。　方法　对 6 8例膀胱全切除术后患者采用 4种可控性尿流改道及回肠新膀胱术式 ,术后对患者控尿、导 (排 )尿 ,贮尿囊容积、内压 ,影像学及血生化资料进行比较。　结果　回肠套叠式输出道 3例中有 2例部分脱套致术后尿失禁 ,需再次手术 ;缩窄末端回肠式输出道 44例控尿均良好 ,除 1例插管困难外余均能用 16～ 2 0F尿管自行导尿。去管折叠式贮尿囊 39例 ,其中回肠贮尿囊 3例、结肠 2 2例、回结肠 14例 ,能达到低压贮尿囊要求 ,但早期有 8例发生贮尿囊过度扩张 ,容量 1470～ 16 5 0ml;去带结肠贮尿囊 8例 ,容量 430～6 0 0ml,充盈压 30～ 45cmH2 O(1cmH2 O =0 .0 98kPa) ,有蠕动波 ,术后早期有 2例尿漏。回肠新膀胱2 1例 ,容量 35 0～ 46 0ml,充盈压 12～ 2 0cmH2 O ,日间尿失禁 1例 ,夜间尿失禁 2例 ,其余无尿失禁。　结论　盲升结肠 30cm剖开对折成形可控性膀胱可满足低压贮尿囊要求 ,去带结肠贮尿囊由于易发生术后尿漏或粘连 ,内压较高 ,不够理想。缩窄末段回肠式输出道控尿效果好、内腔大、插管顺利、并发症少 ,明显优于回肠套叠输出道。回肠新膀胱术贮尿排尿功能良好 ,术后生活质量高 ,但应严格选择手术适应证。     

可控性回结肠膀胱术远期疗效的临床研究

目的 对可控性回结肠膀胱术的远期疗效进行评价。方法 对23例回结肠膀胱术术后患者的可控性尿动力学、血清电解质、肾功能等进行随访观察。结果 23例随访4～126个月，平均59个月。白天可控率为100％，夜问可控率96％。贮尿囊容量350～640ml，平均560ml，贮尿囊内压力9．30～32，08cmH2O（1cmH2O=0．098kPa），平均19．20cmH2O。B超、静脉肾盂造影（IVP）及贮尿囊造影显示：单侧输尿管狭窄并肾积水1例。贮尿囊结石2例。血清电解质及肾功能正常。结论 可控性回结肠膀胱术远期疗效可靠、并发症少，是一种较理想的尿路分流术式。     

阑尾代后尿道及回盲、升结肠作储尿囊在正位膀胱重建术中应用

目的：探讨阑尾代后尿道及回盲、升结肠作储尿囊在膀胱正位重建术中应用及其疗效。方法：2003年2月—2009年6月应用回盲肠及部分升结肠作储尿囊,以阑尾根部与后尿道吻合原位排尿的方法治疗膀胱肿瘤12例,应用尿动力学方法对其近期疗效进行随访。结果：7例完全控尿,2例有尿失禁,3例有夜间尿失禁。术后6个月排尿次数白天4~6次,夜间1~2次,每次量150~400 mL。尿动力学：平均尿流率10.5 mL/s,平均膀胱初始感觉压力27 cmH2O,最大充盈压35 cmH2O,相应储尿囊容量分别为152 mL和420 mL。后尿道闭合压力为52 cmH2O,残余尿量0~65 mL。结论：阑尾代后尿道和回盲、升结肠作储尿囊正位膀胱重建术,储尿囊内压低,容量大,有可控性和原位排尿的特点。     

右半结肠结肠带切断低压可控膀胱术

对４例根治性全膀胱切除术后患者应用右半结肠结肠带切断建立低压贮尿囊，原位阑尾作输出道的术式进行治疗、结果贮尿囊容量大，压力代，可控性能好，术后随访观察，基本上达到了可失性尿流改道的要求。并分析了输尿管抗反流方法的选择，认为贮尿囊粘膜下隧道式吻合优于回盲部内翻乳头缝合的方法，节省了手术时间，减少术中出血。     

去带盲结肠可控膀胱术

目的　改进膀胱癌患者膀胱全切后贮尿和排尿问题。　方法　对 2 3例全膀胱切除患者行去带盲结肠可控膀胱术。　结果　 2 2例术后随访 3～ 30个月 ,3个月后贮尿囊容量 45 0～ 6 0 0ml,平均 5 5 0ml,平均内压 (14± 8)cmH2 O(1cmH2 O =0 .0 98kPa) ,贮尿囊造影未见输尿管返流 ,IVU示上尿路无积水和输尿管狭窄 ,排尿控制良好 ,插管容易。　结论　去带盲结肠可控膀胱术是一种较为理想的尿流改道方法 ,具有较好的应用价值。     

三种可控性结肠贮尿囊的效果比较

目的　寻求理想的可控性尿流改道术式。　方法　 3 7例患者 ,采用去带盲升结肠贮尿囊者 13例 ,采用penn贮尿囊者 11例 ,采用改良Indiana贮尿囊者 13例。其中 3 5例行尿动力学检查 ,对不同贮尿囊的容量和压力结果进行比较。　结果　去带盲升结肠尿囊组 3个月时的容量和压力与另 2组贮尿囊的结果比较差异有非常显著性意义 (P <0 .0 1) ,3种贮尿囊的容量、囊内压均可随时间的推移得到改善 ,术后 12个月时其容量之间的差异无显著性意义 (P >0 .0 5 )。Penn贮尿囊能有效降低收缩压。阑尾作输出道者均可获得良好的尿控。　结论　Penn贮尿囊和改良Indiana贮尿囊是较理想的可控性尿流改道术式 ,去带盲升结肠贮尿囊有手术操作相对简单的优点     

去带可控盲结肠膀胱术的疗效观察（附30例报告）

目的 评价去带可控盲结肠膀胱术的疗效。方法 采用膀胱全切去带可控盲结肠膀胱术治疗膀胱癌30例。结果 30例随访8－40个月。1年后贮尿囊容量360－580ml,贮尿囊内最大压力19．5－78．5cmH2O。白天完全可控28例,可控率93％;夜间完全可控27例,可控率90％。贮尿囊造影及IVU显示单侧输尿管狭窄并肾脏轻度积水1例,无输尿管返流。血清电解质及肾功能正常。结论 去带可控盲结肠膀胱术操作简单,并发症少,疗效可靠,是一种较理想的尿流改道方法。     

改良可控性盲结肠膀胱术15例报告

目的　提高膀胱肿瘤全膀胱切除的临床疗效。　方法　对 15例膀胱肿瘤患者行可控性盲结肠膀胱术 ,并对术式进行改进。　结果　 15例随访 4～ 2 9个月 ,3个月后贮尿囊容量 45 0～ 6 5 0ml,平均 5 5 0ml,充盈状态下平均囊内压 (11.4± 4.3)cmH2 O(1cmH2 O =0 .0 98kPa) ,贮尿囊造影未见输尿管返流 ,IVU示上尿路无积水和输尿管狭窄 ,排尿控制良好 ,插管容易。　结论　改良可控性盲结肠膀胱术操作简单 ,贮尿囊容量大、内压低、自控排尿良好 ,并发症少 ,具有良好的临床应用价值。     

Detubularized right-hemicolonic continent urinary reservoir with plicated terminal ileum

A continent urinary reservoir which consists of 1) detubularized caecum, ascending colon and the right half of transverse colon. 2) anastomosis of ureter and ascending colon with antireflex technique, and 3) plicated terminal ileal segment for continence and catheter insertion was created in 12 patients after radical cystectomy for urothelioma. Our method to create a continent urinary reservoir is simple and technically easy. It can, therefore, provide patients' satisfaction with low incidence of complication. However, such continent urinary reservoir diversion should be performed only for carefully selected patients, taking into consideration the physical status and the character and social status of the patient. This is because some patients who have had such surgery may change their mind to keep a balloon catheter to avoid the intermittent self-catheterization every 3 to 4 hours after surgery.     

The Mainz pouch. Ileocecal reservoir, Mainz pouch

The surgical technique for creation of the Mainz-pouch uses 12cm of cecum and ascending colon and 2 ileal loops of the same length for construction of an urinary reservoir, which has proven to be applicable for bladder augmentation, bladder substitution as well as for continent urinary diversion. For the creation of a continent nipple in urinary diversion 6cm of ileum in addition are necessary. As a modification we use the non-infected submucosal imbedded appendix as continence mechanism. Since 1986 a total of 247 patients underwent a Mainz-pouch procedure: 54 for bladder augmentation, 27 for bladder substitution and 166 for continent diversion. The appendix as continence mechanism was used in 30. Postoperative mortality rested under 1%, early complications have been observed in 4.4% and late complications in 13.7% (mean follow-up of 35 months). In the bladder augmentation group 52 patients are completely dry, 2 patients have urge and frequency and 5 patients are on intermittent self catheterisation to avoid residual urine. In the bladder substitution group all patients are continent at daytime. At nighttime 3 patients have leakage if they don't empty their bladder all 4 hours. In the urinary diversion group all but 3 are completely dry and are on intermittent catheterization. The main problem of our initial series was prolapse of the continent nipple which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve or by using the submucosal imbedded appendix.     

The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion

The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis.     

100 cases of Mainz pouch: continuing experience and evolution

The surgical technique for creation of the Mainz pouch uses 10 to 15 cm. of cecum and ascending colon and 2 ileal loops of the same length for construction of a urinary reservoir. Initial applications of the Mainz pouch were for bladder augmentation after subtotal cystectomy and for continent urinary diversion. Current indications have been extended to complete bladder substitution after radical cystoprostatectomy with anastomosis of the pouch to the membranous urethra. For cosmetic reasons the umbilicus is used as a stomal site for continent urinary diversion, and the technique of intussuscepting the continence nipple has been modified accordingly. A total of 100 patients underwent a Mainz pouch procedure since 1983: 34 for bladder augmentation, 15 for total bladder substitution after cystoprostatectomy and 51 for continent urinary diversion. In the bladder augmentation group 1 patient underwent conversion to a continent stoma, 1 has urge and frequency, and the remaining 32 are completely dry day and night. These patients empty the bladder at normal intervals spontaneously except for 3 who rely on intermittent catheterization. In the bladder substitution group 1 patient has grade 1 stress incontinence and the remainder are completely dry during the day. However, at night 4 patients have leakage and they use a condom urinal. In the urinary diversion group all but 2 patients are completely dry and are on intermittent catheterization. The main problem of the initial series was prolapse of the continence nipple, which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve.     

Mechanical gastric outlet obstruction after continent urinary diversion

A number of complications have been associated with complex continent urinary diversions. We report a case of postoperative mechanical gastric outlet obstruction after continent urinary diversion with distal ileum and ascending colon. Following adequate urinary reservoir drainage gastric outlet obstruction resolved. Such mechanical effects from distended urinary reservoirs must be considered in any patient undergoing continent urinary diversion.     

The continent ileal reservoir (kock pouch) for urinary diversion

Summary Urinary diversion via a continent ileal reservoir was performed in 31 patients. The diversion was a primary procedure in 11 patients, while in 18 it was performed to convert an existing urinary diversion to a continent diversion. In two patients, malfunctioning cecocystoplasties were converted to continent ileum reservoirs. There were no operative mortalities and few early complications. Late complications causing malfunction of the nipple valves required revisional surgery in 15 patients. Postoperative follow-up presently is between 6 months and 10 years. Two patients have died: one in an accident and one of metastatic bladder carcinoma. The remaining 29 patients are continent and without reflux to the upper urinary tract. The reservoir is emptied by catheterization 4–5 times daily, not at night. The volume capacity of the reservoir is around 700 ml. One-third of our patients had constantly negative quantitative urine cultures, whereas two-thirds either had intermittent or constant bacteriuria. Dilatation of the upper urinary tract, progressive renal deterioration or metabolic disturbances have not been encountered. All patients are very satisfied with this type of urinary diversion.Urinary diversion is performed in non-malignant as well as malignant bladder diseases; the majority because of bladder carcinoma. However, long-term studies of conventional urinary diversion procedures have shown that there is a high incidence of late complications with progressive deterioration of renal function [11, 13]. As a result, indications for urinary diversion have been critically reconsidered and alternatives have been sought. Bladder replacement is one method which has been suggested. In non-malignant disease, intermittent catheterization and/or uropharmacological manipulation may be auspicious alternatives. The trend against diversion has also led to reconstruction of the urinary tract in cases previously regarded as suitable only for diversion. In this era of critical reappraisal of conventional urinary diversion procedures a new method for continent urinary diversion was elaborated and introduced for clinical use in 1982 [8]. The low-pressure ileal reservoir originally devised for urinary bladder augmentation or replacement [4] and later used for rendering the ileostomy continent in patients after proctocolectomy [7] has, since 1975, been used in our institution for continent supra-vesical urinary diversion. In this paper the operative method is described and our results and experience obtained during a 10-year period are reported.Supported by grants from the Medical Research Council (Project No 577)     

The Kock continent ileal reservoir for supravesical urinary diversion: An early experience

The most commonly employed urinary diversion operations are associated with a high incidence of complications and the disadvantage of requiring an external appliance to collect urine. The Kock continent ileal reservoir, introduced in 1975, provides an intraabdominal receptacle for storage of urine and two nipple valves which maintain continence and prevent ureteral reflux. The reservoir is emptied by self-catheterization; no external appliance is necessary. This operation provides a more ideal substitute for the lower urinary tract than any other urinary diversion procedure thus far reported.The seven patients reported herein have been followed for up to 3 years and enjoy completely continent ileal reservoirs. Follow-up studies have demonstrated that the kidneys are adequately protected from ureteral reflux and ascending infection. Metabolic acidosis has presented no serious problem. All of the patients enjoy a far better quality of life since discarding their external appliances.     

Urinary diversion in gynecologic oncology

Urinary diversion in gynecology is performed primarily in conjunction with cancer surgery, but at times, it is required for women with intractable urinary fistulas or other urologic disorders. After 1950, ileal conduits replaced ureterosigmoidostomies as the most widely used form of urinary diversion. Transverse colon conduits have gained popularity because these nonirradiated bowel segments offer less risk for postoperative urinary leaks and small bowel complications associated with bowel and ureteral anastomoses. In 1978, Kock et al described the use of detubularized segments of ileum and the intussuscepted nipple valves to create a continent pouch that is still advocated by urologists in some centers. Ileocolonic continent pouches, originally suggested in 1908, have received considerable attention in the past 10 to 15 years because of ease of construction, lower revision rates, and higher continence rates compared with the Kock ileal pouches. At the Division of Gynecologic Oncology at the University of Miami, the authors have been using the Miami pouch as the preferred form of continent urinary diversion since 1988, with acceptable results. Women who need urinary diversion can be offered at least two major choices: (1) the traditional bowel (ileum or colon) conduit, which requires an external ostomy appliance, or (2) a continent pouch, such as the Miami ileocolonic reservoir. In choosing between non-continent and continent conduits, the patients must be made aware that the continent pouches are available in only a few centers in the United States and carry a slightly higher risk for complications because of the relatively higher complexity. Nonetheless, data strongly suggest that most of these complications can be managed noninvasively and that these patients retain a closer to normal quality of life. The age, disease status, and general health of the woman and the likelihood of her long-term survival after diversion weigh heavily in the final decision.     

可控回肠袋代膀胱术40例随访报告

为探讨可控回肠袋代膀胱术的远期效果，对１９８８年１０月～１９９６年１２月收治的４０例病人进行随访分析。随访１２～９６个月。结果：白天完全自控排尿４０例（１００％），夜间完全自控排尿３４例（８５％）。偶有遗尿４例，需垫尿垫２例（５％），输尿管返流２例（５％），代谢性酸中毒２例（５％），无再手术和手术死亡病例。认为可控回肠袋代膀胱术具有手术成功率高，可控性好，远期并发症少的优点，是尿路改道的较理想术式     

The continent ileal bladder for urinary tract reconstruction after cystectomy: a survey of 44 patients

The continent ileal bladder is an ileal pouch that is anastomosed to the urethral stump for urinary diversion after radical cystectomy. The ureters are implanted by an antireflux nipple ureteroileostomy. We report our results in 44 patients who underwent this type of diversion. The perioperative morbidity and mortality were comparable to those of an ileal conduit diversion. Urodynamic evaluation showed the ileal bladder to be a low pressure reservoir with a capacity that increased to more than 300 ml. The ileal bladder was emptied by straining without significant residual urine in all patients. After a training period of a few months all patients were continent in the daytime. However, some patients required pads at night because of occasional loss of urine.