单层阴道环形皮瓣在经阴道修补膀胱阴道瘘中的临床应用

目的对比经阴道和经膀胱两种入路修补膀胱阴道瘘（Vesicovaginal fistula,VVF）的成功率及预后,重点探讨采用单层阴道环形皮瓣经阴道修补膀胱阴道瘘的技术特点和临床应用价值。 方法回顾性分析2007年1月至2021年12月南京医科大学第一附属医院泌尿外科收治的57例采用经阴道和经膀胱两种入路修补VVF患者的临床资料,对比2组患者的一般信息、瘘的特点、手术资料、手术成功率以及术后并发症等情况。 结果57例患者年龄27~75岁,平均50.4岁。病史7天~8年,平均20个月。主诉均为尿液经阴道漏出。56例（98.2%）VVF继发于妇科盆腔手术,1例（1.8%）继发于经阴道分娩（难产）。11例（19.3%）有既往手术修补失败史。57例手术均顺利完成,其中17例（29.8%）选择经阴道入路,40例（70.2%）选择经膀胱入路。平均手术时间：经阴道（90±8.2）min vs 经膀胱（150±4.3）min;术中出血量：经阴道（40±5.4）ml vs 经膀胱（220±10.2）ml;术后住院时间：经阴道（3±0.4）d vs 经膀胱（7±1.2）d;平均住院费用：经阴道（1.3±0.2）万元 vs 经膀胱（2.5±0.5）万元。术中经阴道组无一例行膀胱造瘘,经膀胱组12例（30%）行膀胱造瘘。2组无一例发生严重并发症。轻度并发症发生率为经阴道组3例（17.6%）vs 经膀胱组13例（32.5%）。随访时间为3~48个月,平均18.5月。一次性修补成功率分别为经阴道组82.3% vs 经膀胱组75%。 结论采用单层阴道环形皮瓣经阴道修补VVF,具有手术操作简便、并发症少、成功率高等优势,值得临床应用推广。     

Transvesical NOTES: Survival Study in Porcine Model

Background and Objectives:

The optimal access route and method for natural orifice transluminal endoscopic surgery (NOTES) has not been established. A transvesical approach, with its low rate of peritoneal contamination, is an effective clean portal of entry, but a safe urinary bladder closure has been a challenge. We developed a new technique for a safe, pure transvesical NOTES approach.

Methods:

Four female piglets were used in the study. With the pigs under anesthesia, a flexible cystoscope (15Fr) was used to make an endoscopic cystotomy; diagnostic peritoneoscopy of the abdominal quadrants was done with biopsies and hemostasis. At the end, a Vicryl loop was pushed to close the bladder incision while the incision edges were pulled inwards. The pigs were euthanized after 2 wk, and necropsies were performed.

Results:

No bowel injury was noted in any of the 4 pigs. Satisfactory bladder closure was done in 2 pigs, while a partial closure was achieved in 1 case. In the postoperative period, the pigs showed no signs of pain or distress, voided normally, and had a good appetite. On necropsy, we noted healed cystotomy incisions, no intraabdominal adhesions, and no adhesions at the site.

Conclusion:

Our new technique for endoscopic cystotomy overcomes previously reported risks for bowel injuries. Using this route gives good spatial orientation and access to all quadrants, including the pelvis. Biopsies with good hemostasis can be easily achieved. Lack of intraperitoneal changes postoperatively indicate that this procedure may be safe for humans.     

Natural orifice transluminal endoscopy surgery: A review

Minimally invasive surgery started spreading worldwide in 1987,when the first laparoscopic cholecystectomy was performed.Meanwhile,improvement of endoscopic equipment and instruments allowed gastroenterologists to attempt more aggressive endoluminal interventions,even beyond the wall barrier.The first transgastric peri-toneoscopy,in 2004,brought to light the concept of natural orifice transluminal endoscopic surgery(NOTES).The idea of incisionless surgery is attractive and has become a new goal for both sur...     

经膀胱途径单孔腹腔镜下前列腺癌根治术治疗局限性前列腺癌 8 例报告

目的 探讨经膀胱途径单孔腹腔镜下前列腺癌根治术(transvesical single-site laparoscopic radical prostatectomy,TVSSLRP)的手术技巧和疗效. 方法 选取2010年11月至2011年5月局限性前列腺癌患者8例.年龄37 ～ 65岁,平均58岁.体质指数(body mass index,BMI) 20.0 ～26.0 kg/m2,平均22.5 kg/m2.术前PSA 0.98 ～ 10.04 μg/L,平均7.50 μg/L.国际勃起功能指数(IIEF-5)≥21分7例,＜21分1例.术前穿刺活检病理TNM分期T1c期3例,T2a期5例.Gleason评分2+2分4例,3+2分3例,3+3分1例.D' Amico风险分层均为低风险.全麻下行TVSSLRP,手术由同一名术者完成.使用自制3通道单孔套管建立气膀胱操作通道.远离输尿管开口切开膀胱颈后缘,分离并切断双侧输精管,游离双侧精囊,切开狄氏筋膜,分离前列腺后壁.沿前列腺两侧做环形切口方便暴露前列腺侧韧带,筋膜内层面保留两侧阴茎勃起神经血管束.沿前列腺两侧游离至耻骨后,紧贴前列腺表面切断耻骨前列腺韧带,推开耻骨后血管复合体,分离前列腺尖部,切断尿道.为减少膀胱尿道吻合张力,在膀胱颈两侧和6点处切开膀胱黏膜及黏膜下层,用V-LocTM免打结缝线行膀胱尿道吻合. 结果 本组8例TVSSLRP均顺利完成,无增加辅助通道.手术时间75～ 180 min,平均125 min.术中出血量85 ～450 ml,平均140 ml,无输血患者.术中无手术并发症发生.术后病理检查分期pT2a期3例,pT2b期4例,pT2c期1例;Gleason评分2+2分2例,3+2分4例,3+3分2例;手术切缘均阴性.术后拔除尿管时间9～16d,平均14 d,拔管后控尿均满意,无尿失禁.住院天数13～25 d,平均17d.术后随访12 ～18个月,平均14个月,无尿道狭窄和生化复发发生.术后6个月5例患者勃起功能满意,IIEF-5≥21分. 结论 经膀胱途径单孔腹腔镜下前列腺癌根治术能有效保护阴茎勃起神经和控尿神经,肿瘤根治疗效好.     

Intravesical Cu-T emigration: an atypical and infrequent cause of vesical calculus

Transuterine transvesical emigration of an intrauterine contraceptive device is a rare and uncommonly described complication of an intrauterine device. We report and describe the clinical outcome and management of one such case of intravesical intrauterine device that had become calcified leading to the erroneous diagnosis of a vesical calculus. The diagnosis was confirmed after cystoscopic visualization, lithoclasty and extraction of the calcified plaque consisting of the Cu-T. A migrated IUD is a rare and infrequent cause for the formation of secondary vesical calculi. The treating surgeon should be aware of the possibility of such episodic cases of vesical calculi occurring in the women presenting with recurrent unexplained urinary sepsis.     

A novel open surgical approach to transvesical distal ureterectomy in nephroureterectomy

A single-incision transvesical approach to open distal ureterectomy is described herein. The surgical technique has been applied successfully to 6 consecutive patients undergoing laparoscopic nephrectomy with open distal ureterectomy for upper tract transitional cell carcinoma. The technique presented allows easy and effective excision of the ipsilateral distal ureter, ureteral orifice, and bladder cuff as well as closure of the single cystotomy. Further studies with long-term follow-up data are necessary to confirm the satisfactory preliminary clinical experience presented in this report.     

Simultaneous adenomectomy and preperitoneal repair of inguinal hernias by a single incision with the application of polypropylene mesh

Preperitoneal inguinal herniorraphy inconjuction with other pelvic procedures has been described in the literature, but it hasnot gained wide popularity mainly due to thehigh recurrence rate. Recently, there has beena resurgence of interest in the preperitonealrepair of inguinal hernias with the applicationof mesh on the deficiency of the inguinal wallusing the method commonly known as the Stoppaprocedure. We evaluated the results andcomplcations of 22 patients who underwent opensurgical prostatectomy (adenomectomy) andsimultaneous preperitoneal application ofpolypropylene mesh. Nineteen (86.4%) patientssuffered from unilateral inguinal herniawhereas the remaining 3 (13.6%) had bilateralprotrusions. Primary hernias only and notrecurrences were included in our series. Themedian clinical follow-up was 20.4 months (range 9–50 months). The hernioplasty itself prolongedthe whole procedure for only a few minutes andit did not affect the patients' hospitalizationtime (mean 6.7 days). Wound infection withsubsequent development of cutaneous fistulaoccurred in one patient (4.5%) and treatedconservatively. During follow-up onerecurrence (4.5%) at the side of the previousrepair of the left inguinal hernia wasrecorded; the protrusion was insignificant andleft untreated. In all but one patient (21/22,95.5%), the surgical results were excellent.In our experience, simultaneous transvesicaladenomectomy and mesh preperitonealhernioplasty is a convenient and safe procedurewhich can easily be performed by urologists injust a few minutes. The procedure which is bothcost and time effective for the surgeon,achieves long-lasting beneficial results forthe vast majority of patients.     

前列腺增生症经膀胱切除术与经尿道电切术的比较与选择

为寻找治疗前列腺增生症有效的手术方法。对９６例采用耻骨上经膀胱前列腺切除术，同时对１４３例采用经尿道前列腺电切术，并将两者的临床资料进行比较。结果显示；两组术中输血例数，输血量及膀胱冲洗转清时间，保留尿管时间，并发切口感染例数均有极显著性差异，而两组并发尿失禁，尿道狭窄的例数无显著性差异。     

经膀胱途径机器人辅助单孔腹腔镜膀胱憩室切除术一例报道

南京中医药大学附属医院2020年12月7日收治1例确诊为“膀胱憩室”的患者,于2020年12月9日在局部麻醉下行膀胱镜检查+膀胱造影术,镜下示膀胱右侧壁见一憩室,膀胱内注入造影剂,X线片下见膀胱右侧壁憩室,大小约7cm。明确手术指征,完善术前准备,排除手术禁忌证后,于2020年12月11日在全身麻醉下行“经膀胱途径机器人辅助单孔腹腔镜膀胱憩室切除术+腹腔镜下膀胱修补术”。患者总手术时间为125min,机器人操作时间为35min,备机时间为15min,术中出血量为30ml。术中未发生任何并发症,术后恢复良好,术后6d出院。结果表明,经膀胱途径机器人辅助单孔腹腔镜膀胱憩室切除术的手术效率更高,操作简便、精细,安全性高,疗效值得肯定。     

单孔腹腔镜下经膀胱根治性切除猪前列腺的初步尝试

目的尝试单孔腹腔镜下经膀胱根治性切除猪前列腺,探讨其可行性,总结操作难点,为后续临床应用奠定基础。方法采用雄性未阉割香猪,全麻下进行膀胱外翻皮肤造口;将TriPort单孔多通道系统经造口处置入膀胱并固定;建立气膀胱后,用传统腹腔镜器械模拟人经膀胱前列腺根治性切除术;经膀胱完成膀胱内口与尿道吻合,经皮肤造口取出前列腺标本后关闭膀胱和腹腔。结果共完成了6例动物实验,前3例失败,原因为膀胱操作空间无法保证、吻合操作失败等;后3例均顺利完成,手术时间分别是190、160、110min,前列腺完整切除,间断吻合6针恢复尿道连续性。结论单孔腹腔镜下经膀胱猪前列腺根治性切除技术可行,但操作难度较大,鉴于猪解剖结构与人存在较大差异,需进一步在尸体模型上进行类似尝试,目前尚不适合向临床阶段过渡。