经阴道联合腹腔镜下根治性女性全膀胱切除原位回肠新膀胱术

目的 探讨经阴道联合腹腔镜下根治性女性全膀胱切除及原位回肠新膀胱的手术方法.方法浸润性膀胱癌患者6例,平均年龄61(55～73)岁.5孔法先行腹腔镜下手术:游离输尿管后分侧清扫盆腔淋巴结;举宫器配合下,用血管闭合器LigaSure切断子宫相关韧带及膀胱两侧血管蒂;电凝钩分离子宫直肠陷窝及膀胱前间隙;LigaSure切断阴蒂背血管复合体;超声刀切开膀胱颈尿道后游离膀胱颈后壁至阴道前穹窿部.阴道手术:直视下剪开阴道前后穹窿,于阴道取出标本,缝合阴道.回肠新膀胱术:下腹正中4～5 cnl切口,将回肠拉出切口外,游离30～40 cm回肠,剖开后w形折叠缝合形成贮尿囊;插入法植入输尿管后将贮尿囊还纳腹腔.缝合切口后重新开启气腹,腔镜下行新膀胱尿道吻合. 结果 手术时间平均6.2(4～8)h;出血量平均665(400～1200)ml.术后1～3个月患者均恢复较满意的控尿功能,IVU显示双肾功能良好,无膀胱输尿管反流及梗阻.新膀胱最大容量平均427(300～600)ml.无新膀胱阴道瘘等需要手术处理的严重并发症.术后平均随访16(9～30)个月,6例均存活.1例术后8个月发现肝转移. 结论 经阴道联合腹腔镜下根治性女性全膀胱切除回肠新膀胱术治疗女性浸润性膀胱癌可行、有效,应用举宫器及经阴道直视下手术可一定程度上降低腹腔镜下全膀胱切除术的手术难度、缩短手术时间.由于阴道切口整齐、缝合确切,新膀胱阴道瘘等并发症的发生机会减少.

Transvaginal laparoscopic radical cystectomy with orthotopic ileal neobladder in the female

Objective To present the initial experience and results of laparoscopic transvaginal radical cystectomy (LATRC) with orthotopic ileal neobladder. Methods Six female patients with muscle invasive bladder carcinoma underwent LATRC with orthotopic ileal neobladder. The mean age was 61 years (range 55 to 73 years) . The LATRC with orthotopic ileal neobladder consisted of 4 major steps, namely laparoscopic cystectomy, operation on vagina, extracorporeal formation of ileal pouch and laparoscopic urethral pouch anastomosis. With 5 trocars, the bilateral pelvic lymphadenectomy was performed first The ureters were dissected just outside the bladder. Assisted by the uterine manipulator and the LigaSure system, total bladder, uterus and appendage were dissected by the laparoscopic approach. In the transvaginal step, the specimen was removed through the incision of the anterior and posterior vaginal fornix apex and the neovagina was created by the visualized suture. A 30-40 cm ileal loop was taken from the abdominal cavity, isolated, de-tubularized and reconfigured into W shaped pouch with running suture. The anti-refluxing ureter implantation was performed by inserting the 1 cm ureter into the pouch and suturing in place. The urethra neobaldder anastomosis was done under the laparoscope. Results The mean duration of surgery was 6.2 h(range from 4 to 8 h). The estimated blood loss was 665 ml (range from 400 to 1200 ml). All patients achieved urine control and had neither obstruction nor reflux proved by the intravenous pyelography 1-3 months after surgery. The mean value of neobladdermaximum capacity was 427 ml. No vesicovaginal fistula or other serious complication occurred The mean follow-up was 16 months (9-30 months). During the follow-up, there was no mortality. One patient with lymph node involvement developed liver metastasis 8 months post-operatively. Conclusions The LATRC is feasible and effective for the female patients with invasive bladder cancer. Using uterine manipulator and the transvaginal procedure makes the laparoscopic manipulation easier and simpler. The visualized incision and suture on vagina is good for recovery and reducing postoperative vesicovaginal fistula.