膀胱癌根治术后N型回肠膀胱替代术的临床应用

目的 探讨膀胱癌根治术后N型回肠膀胱替代术的手术方法和临床应用价值.方法膀胱恶性肿瘤患者23例,腹膜外行膀胱根治性切除,截取35～40 cm回肠纵形切开后折叠形成N型贮尿囊,以改良乳头法将两侧输尿管分别移植于N型新膀胱的上臂两侧,贮尿囊底部与尿道4～6针吻合,将贮尿囊完全置于腹膜外.结果本组23例手术时间5.5～7 h,术中平均出血400 ml,术后随访2～27个月,平均16个月,原位回肠新膀胱控尿、排尿良好,术后静脉尿路造影、B超检查未见上尿路扩张,膀胱造影未发现输尿管返流,血生化检查正常,未发现新膀胱或尿道肿瘤复发.尿动力学检查,新膀胱最大容量为（340.5±65.8） ml,最大尿流率（17.5±6.8） ml/s,充盈期膀胱内压力为0～9 cm H2O,排尿期膀胱内压力为8～16 cm H2O,剩余尿0～55 ml.结论原位N型回肠膀胱替代术具有良好的可操作性;新膀胱容量大,内压低,顺应性好,具有较好的尿控和排尿能力,明显提高了患者术后的生活质量,是一种良好的尿流改道术,值得临床推广应用.

The clinical application of N - shaped orthotopic ileal neobladdder operation after the radical correction of carcinoma of bladder

Objective To explore the operation method and its clinical application value of N - shaped orthotopic ileal neobladder operation after the radical correction of carcinoma of bladder. Methods A total of 23 patients with malignant bladder tumors underwent N - shaped orthotopic ileal neobladder after extraperitoneal radical correction of carcinoma of bladder. A segment of 35 to 40 em ileal loop was isolated, detubularized, and reconfigured in ＂N＂ - shape to form a pouch. Bilateral ureters were reimplanted by means of inserting the 1 cm distal segment into the pouch. The bottom of pouch was opened aml anastomosed with the urethra. Rusults The cystectomy takes 5.5 to 7 hours on average with a mean bleeding volume of500 ml. The time of following up was from 2 to 27 months with a mean of 16 months. The patients have excellent urine control and micturition. Patient with hydrocele of upper urinary tract was not found by BUS and IVU. Voiding cystography revealed no patient with ureterovesical reflux. Renal function,electrolyte and other laboratory findings were normal. No patient suffered from tumor rocurrence in aeobladder or urethral. The maximum cystometric capacity was （340.5 ± 65.8） ml and the maximum flow rate was （ 17. 5 ± 6. 8 ） ml/s. The bladder pressure was 0 to 9 mn H2O during filling phase while 8 to 16 cm H2 O during voiding phase, and the residual urine was from 0 to 55 ml. Conclusion The N - shaped orthotopic ileal neobladder has the advantages of a large capacity, low intrareservior pressure,good continenceand and it is a more feasible and good urinary diversion with good voiding ability and continence is worth spreading applying.