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。     

全膀胱切除尿流改道方法的再评

３１例膀胱癌行膀胱全切除后进行６例乙状结肠代膀胱、１８例输尿管乙状结肠吻合及７例输尿管皮肤造口术，随访４～１０年，疗效满意。作者认为上述尿流改道的方法相对简单、安全、有效，而且并发症少，可供临床推广应用。     

阑尾输出道盲升结肠可控膀胱术(附9例报告)

目的　改进膀胱癌患者膀胱全切后贮尿囊及排尿情况。方法　根治性全膀胱切除加阑尾输出道盲升结肠带切断或去管简单重建贮尿囊可控膀胱术。结果　术后随访 2～ 19个月 ,两种术式建立的贮尿囊顺应性均良好 ,平均容积为 3 0 2ml ,内压为 8cmH2 O ,阑尾输出道最大压力为 71cmH2 O ,平均 62cmH2 O ,尿控良好 ,自行导尿容易。结论　阑尾输出道盲升结肠可控膀胱术 ,操作相对简单 ,是一种较理想的尿路改道方法 ,具有较好的临床应用价值。     

膀胱全切术后体外可控性回肠代膀胱术

 目的　探讨膀胱全切术后尿流改道新方法即体外可控性回肠代膀胱术的可行性及疗效。方法　取一段回肠 ,将中间部分折叠成N形并缝制成贮尿囊 ;远端回肠从腹壁造瘘口穿出体外 ,于此处取腹壁皮瓣包绕外露肠管缝制成皮管 ,构建输出道 ;将尿液控制器置于皮管外 ,利用气囊控制排尿。结果　 10只杂交狗顺利度过手术期 ,术后 3月时贮尿囊最大容量为 (15 0± 4 0 )ml,最大充盈压为 (2 4 .4± 5 .3)cmH2 O。临床应用 5例 ,随访 (3～ 14 )月 ,术后 3月时贮尿囊最大容量达 (2 90± 80 )ml,最大充盈压为 (36 .3± 8.2 )cmH2 O ,最大尿流率为 (2 0 .3± 4 .7)ml s,无残余尿。X线影像学检查 ,肾脏显影良好 ,输尿管通畅。尿液控制器的气囊充气后 ,无尿液流出 ;气囊消气后 ,尿液呈粗线条流出。结论　该尿流改道术式具有体外自主控制排尿的特点 ,不必佩戴集尿袋或自行导尿 ,且手术操作比较简单、并发症少、安全可靠。     

采用回肠纵行折叠抗反流抗失禁行可控性回肠膀胱术（附24例报告)

目的：简化及改良可控性回肠膀胱术。方法：自1995年8月至1999年8月采用回肠纵行折叠抗反流及抗失禁代替肠套叠乳头瓣抗反流及抗失禁共完成可控性回肠膀胱术24例。结果：24例随访4-48个月,23例效果满意,白天平均4小时导尿1次,夜间导尿0-2次,插管顺利,无漏尿现象。贮尿囊容量320-560ml,贮尿囊最大充盈压10-22cmH2O。1例因贮尿囊粘连,储尿量小。全部病例无输尿管返流及电解质、酸碱平衡紊乱,肾功能正常。结论：该手术方法相对简化,并发症少,可适用于临床。     

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。     

全膀胱切除和原位新膀胱术治疗女性浸润性胱膀癌患者(附8例报告)

背景与目的全膀胱切除和原位新膀胱广泛用于治疗男性浸润性膀胱癌,效果良好,但用于女性浸润性膀胱癌的经验很少。本研究的目的是探讨女性全膀胱切除和乙状结肠原位新膀胱的临床效果。方法回顾性分析2002年1月至2003年10月中山大学肿瘤防治中心应用全膀胱切除和乙状结肠原位新膀胱术治疗的8例女性浸润性膀胱癌的临床资料。结果手术均获成功。随访6～24个月(平均18个月),6例无瘤生存,2例分别于术后6个月和12个月出现盆腔复发。全部患者均能自主排尿。4例昼夜完全控尿,另4例白天完全控尿,夜间有少许漏尿。1例术后3个月发现肾输尿管轻度积水,观察3个月后自然消退。血电解质和肾功能均正常。结论女性膀胱癌患者行全膀胱切除和乙状结肠原位新膀胱术后,肿瘤控制及新膀胱功能良好,但夜间控尿能力较差。     

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.     

乙状结肠全去带原位膀胱术12例

 【摘要】　目的　分析乙状结肠全去带原位新膀胱术的应用价值。方法　膀胱癌12例，均采用根治性膀胱切除及乙状结肠全去带新膀胱术治疗。结果　12例患者随访6～29个月，平均18.6个月。患者血肌酐（Cr）、尿素氮（BUN） 均正常，未出现酸中毒。膀胱造影仅1例出现单侧输尿管反流。白天可自控排尿11例（91.7 ％），夜间尿失禁2例（16.7 ％），1例可通过夜间唤醒控制。新膀胱容量220～550 ml（平均350 ml），新膀胱充盈时最大压力15～55 cm H2O（平均35 cm H2O，1 cm H2O = 0.098 kPa）。结论　乙状结肠全去带原位新膀胱术式操作简单，并发症少，患者原位排尿，疗效可靠。     

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。     

应用TUR术治疗膀胱癌膀胱全切术后复发性尿道癌

目的：探讨膀胱癌行膀胱全切术后尿道复发的治疗方法.方法：回顾性分析膀胱癌行膀胱全切术患者216例,其中术后复发尿道癌15例（6.9％）,复发平均时间18（3-46）个月.15例患者术后因肉眼血尿（7例）、血性分泌物（3例）及排尿不畅（5例）再次就诊.均经尿道膀胱镜检查及尿道冲洗细胞学检查确诊.尿道镜活检报告为尿道尿路上皮癌,病理分期为Ta-T1.15例均行TUR术,术后辅以羟基喜树碱灌注治疗.结果：15例患者术后平均随访36（6-52）个月.其中12例患者健在,未见肿瘤复发及转移;1例术后14个月肿瘤复发,行全尿道切除＋尿液转流术,随访至今未见肿瘤再次复发及转移;1例术后8个月肿瘤复发,行全尿道切除＋阴道前壁、侧壁、子宫及附件切除＋盆腔淋巴结清扫术,术后9个月死于肿瘤多发转移;1例死于心肌梗死.结论：膀胱癌膀胱全切术后复发尿道癌可应用TUR术治疗,临床效果良好且生活质量较高.早期诊断与治疗是保证预后的关键.     

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.     

Neobladder long term follow-up

One of the commonest forms of orthotopic bladder substitution for bladder cancer survivors, used in our institute, is the use of ileocecal segment. Sometimes, the need for Indiana pouch heterotropic continent diversion arises.AimTo compare the long-term effect of orthotopic ileocecal bladder and heterotropic Indiana pouch following radical cystectomy in bladder cancer patients.Patients and methodsBetween January 2008 and December 2011, 91 patients underwent radical cystectomy/anterior pelvic exentration and orthotopic ileocecal bladder reconstruction (61 patients) and Indiana pouch (30 patients), when orthotopic diversion could not be technically or oncologically feasible.ResultsConvalescence was uneventful in most patients. All minor and major urinary leakage cases, in both diversions groups, where successfully conservatively treated. Only one patient in the ileocecal group with major urinary leak required re-exploration with successful revision of uretro-colonic anastomosis. Only one patient in the Indiana pouch group had accidentally discovered sub-centimetric stone, which was simply expelled. The overall survival proportion of ileocecal group was 100% compared to 80% in the Indiana pouch group (p < 0.001). The disease free survival proportion of ileocecal group was 90.8% compared to 80% in the Indiana pouch group (p = 0.076). Effective comparative daytime and nighttime urinary continence as well as renal function deterioration were not statistically significant between both reconstruction types.ConclusionBoth ileocecal bladder and Indiana pouch are safe procedures in regard to long-term effects over kidney function following radical cystectomy.     

An ileal neobladder for a female patient after a radical cystectomy to ensure voiding from the urethra: a case report.

An ileal neobladder construction realizing normal micturition was successfully performed after a total cystectomy, with preservation of the urethra, for a 69-year-old female patient with invasive bladder cancer. Approximately 60 cm of terminal ileum was selected, detubularized and re-sutured to create an oval-shaped intestinal pouch to which the bilateral ureters were anastomosed. The bottom of the pouch was anastomosed to the urethral remnant. Three months after surgery, the patient achieved daytime continence, and now enjoys almost the same lifestyle as before. This is the first case of successful neobladder construction to be precisely reported for a female patient. For normal micturition, the ileal neobladder will be one of the possible choices for urinary diversion in not only selected male, but also female, patients.     

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.     

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.     

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。     

Radical cystectomy for invasive bladder cancer in the octogenarian.

The incidence of bladder cancer increases with age. As the population lives longer, an increasing number of patients 80 years of age or older will develop invasive bladder cancer. In this study, we reviewed the outcome of 33 patients age 80 years or older treated with radical cystectomy and ileal conduit urinary diversion. Five patients received neoadjuvant chemotherapy, and 2 had salvage cystectomy after failure of external beam radiation therapy. The median age was 82 years, and the median hospital stay was 12 days. There were no perioperative deaths. Twenty-seven complications occurred in 20 patients (60.6%), of which 17 were minor (63%) and 10 were major (37%). There was no difference in the rate of complications in patients receiving neoadjuvant treatment compared to the group treated with cystectomy alone. The median survival was 3.5 years. Our results demonstrate that radical cystectomy and ileal conduit urinary diversion should not be withheld from patients on the basis of age.