保留勃起和射精功能的改良全膀胱切除术的临床应用

目的探讨保留勃起和射精功能的改良全膀胱切除术在膀胱良、恶性病变患者的临床应用价值。方法本组18例男性患者,年龄18~38岁,平均30.5岁。结核性挛缩膀胱4例,腺性膀胱炎5例,晚期神经原性膀胱5例,复发的多发性非肌层侵犯膀胱移行细胞癌4例,均需行全膀胱切除术,但患者强烈希望保留勃起和生育功能。行改良单纯性全膀胱切除术,保留输精管、精囊、前列腺和双侧神经血管束,以回肠新膀胱(13例)或回结肠新膀胱(5例)替代。结果平均手术时间350min,术中平均出血量420ml,7例患者输血。1例发生尿漏,无其他围手术期并发症。拔除导尿管后均能自行排尿,每次尿量300~500ml,剩余尿量25~65ml。2例神经源性膀胱患者需间歇自家导尿。白天无尿失禁,3例患者晚上有遗尿。平均随访46个月(18~68个月)。17例(94.4%)患者术后阴茎勃起功能恢复良好,均有遗精(未婚者)或顺行射精。尿路造影上尿路功能和新膀胱形态良好,1例轻度肾积水。肿瘤患者无复发。结论对选择性膀胱良、恶性病变患者行保留勃起和射精功能的改良全膀胱切除和原位膀胱术,安全有效,效果满意。尿动力学检查对神经源性膀胱患者的选择至关重要。

Clinical application of modified cystectomy with preservation of erectile and ejaculatory functions for young men with bladder diseases

Objectives To evaluate the clinical value of modified cystectomy with preservation of erectile and ejaculatory functions for young men with nonmalignant and malignant diseases of bladder. Methods Eighteen patiets, with mean age of 30 years (range 18 to 38), presented with bladder disease necessitating cystectomy, including tuberculous contractile bladder(4), extensive polypoid cystitis glandularis (5), late stage of neurogenic bladder (5), and recur-rent multiple non-muscle-invasive bladder cancer (4). All patients strongly wished to maintain their fertility and potency after the operation. Modified simple cystectomy with preservation of the vasa deferentia, seminal vesicles, prostate and neurovascu-lar bundles, as well as construction of an ileocolic substitution of bladder (Goldwasser neobladder) or ileal substitution of bladder (Studer neobladder) were performed. Results Mean operative time was 350 min. Estimated mean intraoperative blood loss was 420 ml, and 7 cases needed blood transfusion. All patients, except 2 cases of nuerogenic bladder, voided spontaneously after removed the catheter. Intermittent self catheterization was needed to eliminate residual urine in 2 cases of nuerogenic bladder. Mean follow-up was 46 months (range 18 to 68 months). Erectile and ejaculatory functions were normal in all cases but one. Patients remained completely continent and voided normally. Upper uninary tracts were in excellent conditions in 3 months and 12 months postoperatively. There was no tumor recurrent in TCC patients. Conclusion Modified cystectomy with preservation of the vasa deferentia, seminal vesicles prostate and neurovascular bundle is an excellent and reliable option for young men who wish to maintain their fertility and potency after surgery, even for low risk cases with malignant bladder tumors.