机器人辅助回肠膀胱扩大术治疗神经源性膀胱的初步经验

目的:探讨机器人辅助回肠膀胱扩大术治疗神经源性膀胱的可行性、安全性和临床疗效。方法:回顾性分析2017年3月至2018年11月浙江省人民医院收治的12例神经源性膀胱患者的病例资料，男11例，女1例。平均年龄38(12~67)岁。12例术前均有尿失禁、排尿障碍以及膀胱安全容量减小、膀胱内压力增高导致输尿管反流等症状，病因...

Primary experience in the treatment of neurogenic bladder with robotic assisted ileum augmentation cystoplasty

Objective To explore the feasibility,safety and clinical efficacy of ileum augmentation cystoplasty assisted by Da Vinci robot for the treatment of neurogenic bladder.Methods Retrospective analysis was performed on the data of 12 patients with neurogenic bladder admitted to Zhejiang Provincial People’s Hospital from March 2017 to November 2018,including 11 males and 1 female,with the mean age of 38(12-67).Preoperative symptoms were urinary incontinence,dysuria,decreased bladder capacity,or increased bladder pressure leading to ureteral reflux.All the 12 patients underwent preoperative intermittent catheterization,including 8 patients with spinal cord injury and 4 patients with spinal cord dysplasia.Preoperative serum creatinine(129.58±44.60)μmol/L and total glomerular filtration rate(61.63±18.04)ml/(min·m2)were observed in 12 patients.Preoperative urodynamic examination showed the safe bladder volume of(95.67±39.10)ml,bladder internal pressure of(63.30±6.02)cmH2O(1 cmH2O=0.098 kPa)at the end of filling period,bladder compliance of(10.24±1.14)ml/cmH2O,residual urine volume of(152.58±80.89)ml,and urine flow rate of(3.88±3.63)ml/s.Bladder contracture was evident on preoperative cystography.Ultrasound examination showed different degree of hydronephrosis and ureter expansion,in all cases,with ureteral reflux gradingⅠin 2 cases,gradeⅡin 4 cases,gradeⅢin 4 cases,gradeⅣin 2 cases.All the 12 patients underwent robot-assisted ileum augmentation cystoplasty with 5-point puncture.Transverse incision of the bladder wall before full thickness,according to the amount of bladder and quality to decide 30 cm(normal),longitudinal cut back loops and one point after suture fixation in the bladder wall midpoint,fixed point as starting point,in turn,will be blind to the bladder stitching on both sides,the bilateral ureteral placing a single J tube respectively,evaluation of surgical success rate(including intraoperative bleeding,interception of bowel loops are no damage adjacent viscera,ureter openings with and without damage,impermeability,match insufflate whether unobstructed),postoperative complications,anastomotic fistula,intestinal obstruction,abdominal bleeding),urine dynamics test parameters,and patients’quality of life.Patients were regularly given anticholinergic drugs(2 mg/d)for 6 months after surgery.Results All the 12 cases in this group were successfully completed without any transfer to open surgery.The operation time was(120.8±12.0)min.Intraoperative blood loss(84.0±23.2)ml.Postoperative intestinal function recovery time(3.3±1.3)d.Postoperative hospital stay(12.1±3.1)d.Postoperative pelvic drainage tube indwelling time(3.8±1.2)d.Catheter and single J tube were removed 2 weeks after operation.Postoperative follow-up averaged 19.4(3-24)months.At 3,12,24 months after surgery,the bladder safety volume was rechecked(435.83±33.56),(450.90±31.09),(462.00±33.72)ml,the bladder internal pressure at the end of filling was(18.60±0.92),(15.70±1.42),(12.96±1.34)cmH2O,the blood creatinine level was(81.43±21.10),(74.34±15.70),(72.90±15.90)μmol/L,and the bladder compliance was(37.94±4.22),(40.40±3.98),(43.42±4.20)ml/cmH2O and the total glomerular filtration rate(91.52±9.49),(102.18±5.65),(112.41±6.50)ml/(min·m2)were significantly improved compared with those before surgery(P<0.001).After 24 months of bladder urination training,1 patient could basically urinate by herself.Three patients were treated with intermittent urinary catheterization supplemented by automatic urination.The remaining 8 patients were completely dependent on urinary catheter for intermittent catheterization.Postoperative complications such as anastomotic fistula,ileus and abdominal bleeding were not found in 12 patients.Conclusions Ileum bladder enlargement assisted by robot can effectively expand bladder volume,reduce bladder internal pressure,improve bladder compliance,prevent ureteral reflux and protect renal function.