全逆行根治性膀胱切除治疗男性膀胱癌的临床应用及110例病例报告

背景与目的：膀胱癌根治手术难度大，围手术期并发症多，且学习曲线长。本研究介绍了全逆行根治性膀胱切除并腹腔重建这一新的系统手术方式，并探讨其临床价值。方法：2012年4月—2013年4月，共有110例男性膀胱癌患者于复旦大学附属肿瘤医院泌尿外科接受该手术治疗，中位年龄64(35~83)岁；整理术前临床资料，分析手术相关参数、并发症、病理特征、远期并发症及复发转移情况。结果：术中清扫淋巴结个数为12(8~16)个；65例保留双侧神经血管束，31例保留单侧；手术耗时4.4(2.2~6.0)h，中位腹腔脏器暴露时间为43.0(5.0~75.0)min，中位出血量140.0(50.0~600.0)mL，4例患者输血；中位盆腹腔引流时间为10.0(6.0~15.0)d，中位术后通气时间为2.5(1.0~12.0)d，中位术后住院时间为17.0(10.0~39.0)d；术后并发症CDC分级为2级即需要药物干预的19例，CDC分级为3级以上的8例；术后轻到中度肠道梗阻5例，对症支持治疗，中位时间2(1~4)周后恢复进食；无围手术期死亡病例。病理诊断结果显示，中位随访9(3~15)个月，无CDC分级3级以上并发症，无复发转移。结论：全逆行根治性膀胱切除手术入路解剖清晰，全程腹腔脏器暴露时间短，肠道与手术野相互干扰少，这一系统手术有效加快患者肠道恢复，降低术后并发症，特别是减少肠道梗阻的发生及严重程度的作用，值得进一步的研究和推广。

Clinical application of complete retrograde radical cystectomy and consequent abdominal cavity reconstruction in male bladder cancer: a report of 110 cases

Background and purpose: Bladder cancer radical surgery is difficult with many perioperative complications, and the learning curve is long. To introduce the clinical application of complete retrograde radical cystectomy and consequent abdominal cavity reconstruction in male bladder cancer, and to provide a standardized surgical procedure with minimum perioperative complications and short learning curve. Methods: From Apr. 2012 to Apr. 2013, 110 cases of male patients with bladder cancer received this procedure in our department, with a median age of 64 (35-83) years; Preoperative characters, surgical parameters, perioperative complications, pathology, long-term complications and short-term prognosis were collected and analyzed. Results: The median number of lymph nodes resected in operation was 12 (8-16); Neurovascular bundles were reserved bilaterally in 65 cases, and unilaterally in 31 cases; The complete procedure including urinary diversion took 4.4 (2.2-6.0) hours, with a median time of opened abdominal cavity of 43.0 (5.0-75.0) minutes; The median blood loss was 140.0 (50.0-600.0) mL, and 4 patients needed transfusion; Median time of abdominal and pelvic drainage was 10.0 (6.0-15.0) days, the median gastrointestinal recovery time was 2.5 (1.0-12.0) days, and the median postoperative hospital stay was 17.0 (10.0-39.0) days; Grade 2 Clavien-Dindo classification (CDC) of surgical complications that required medical intervention were found in 19 cases, CDC grade 3 or above were found in 8 cases; Mild to moderate postoperative ileus happened in 5 cases, all recovered in median 2 (1-4) weeks with supportive treatments; There were no perioperative deaths. All samples were sent to pathological analyses. After a median follow-up of 9 (3-15) months, no complications of or above CDC grade 3 happened, and there were no recurrence. Conclusion: Complete retrograde radical cystectomy in male bladder cancer provided clear anatomical approach, reliable neurovascular bundle preservation, less blood loss, limited abdominal organs disturbance and better surgical exposure; With respect to tumor control, more peritoneal was retained for subsequent abdominal cavity reconstruction. The introduced procedure effectively speeded up gastrointestinal recovery, reduced postoperative complications, especially the incidence of ileus and its severity, and shortened hospital stay. The learning curve of this procedure for urologists was short, and further investigation was warranted.