腹腔镜下膀胱全切除-乙状结肠新膀胱术初步报告

目的 探讨腹腔镜下膀胱全切除-乙状结肠新膀胱手术方法。方法 浸润性膀胱癌患者4例。均为男性。年龄58—74岁，平均65岁。手术采用气管内全麻、膀胱截石位、头低15℃，下腹部置入5根套管，腹压设定12mmHg（1mmHg=0．133kPa）。在髂总动脉分叉处剪开腹膜，找到输尿管向下游离至膀胱，剪开髂血管鞘，行盆腔淋巴结清扫；游离输精管及精囊，切开狄氏筋膜分离狄氏间隙；分离膀胱前间隙，切开两侧盆筋膜反折和耻骨前列腺韧带，缝扎阴茎背深静脉复合体；切断输尿管及膀胱前列腺侧血管蒂；剪断阴茎背深静脉复合体及尿道，将前列腺及膀胱一并切除。距肛门15cm处切开乙状结肠，将标本经该开口从肛门取出；隔离15cm乙状结肠，将肠道吻合器经肛门插入，乙状结肠近远端作端端吻合。在隔离乙状结肠肠管的中点作一小切口，将该口与尿道断端吻合；插入Foley导尿管，左右输尿管种植在乙状结肠肠管两端，将输尿管末端插入乙状结肠内1cm，4-0可吸收线固定4—6针。关闭乙状结肠两端开口，用剪刀小心剪开前结肠带，形成去带乙状结肠膀胱。结果 手术时间7—9h，出血量200～350ml，术后第3天肛门排气，第2周拔除导尿管。术后1—3个月恢复控尿功能，膀胱容量200—300ml，无上尿路梗阻及返流，无明显围手术期并发症。结论 腹腔镜下膀胱全切除-乙状结肠新膀胱术技术可行，手术效果良好。

Preliminary report of laparoscopic radical cystectomy and orthotopic sigmoid colonic neobladder

Objective To report the surgical techniques and preliminary results of laparoscopic radical cystectomy with orthotopic sigmoid colonic neobladder. Methods Four male patients ( mean age, 65 years; age range, 58 -74 years) with invasive bladder cancer underwent this operation. Intratracheal anesthesia was applied and the lithotomy position with 15 degree head lower was used. A 5-port transperitoneal approach was set up in the hypogastrium with abdominal pressure of 12 mm Hg (1 mm Hg =0. 133 kPa). Laparoscopic pelvic lymphadenectomy was performed. And radical cystectomy was completed in the following steps: mobilizing lower segment of the ureter, exposing Denonvillier's space and posterior aspect of the prostate , exposing Retzius space and anterior bladder surface, dividing lateral pedicles of the bladder and prostate , dividing the apex of the prostate and dorsal vein complex. The specimens were pulled out through the incision of the sigmoid colon at 15 cm above the anus. A segment of 15 cm sigmoid colon was isolated, and end-to-end anastomosis of the colon was performed by the stapler through the anus. The neobladder was constructed intraperitoneally by opening the midpoint of the isolated sigmoid colon, anastomosing it to the urethra stump, implanting the ureters to bilateral end of the isolated colon by inserting 1 cm of distal ureter into the pouch, closing the 2 open ends of the colon, and destructing the anterior teniae coli, then a detenial sigmoid colonic neobladder was formed. Results The operating time was 7 -9 h; the intraoperative blood loss was 200 -350ml. Postoperatively, the bowel movement recovered in 3 d, and the catheter was pulled out at 2 weeks. The urine control recovered in 1 - 3 months. The neobladder capacity was 200 - 300 ml. No perioperative complications such as urinary obstruction, reflux, leakage and ileus occurred. Conclusions Laparoscopic radical cystectomy with orthotopic sigmoid colonic neobladder can be a feasible and effective method for the treatment of bladder cancer.