改良腹膜外腹腔镜根治性膀胱切除+回肠膀胱术的临床应用

Clinical application of modified extraperitoneal laparoscopic radical cystectomy with ileal conduit

目的:探讨腹膜外入路腹腔镜根治性膀胱切除+回肠膀胱术(Bricker术)的可行性及安全性。方法:选择2020年3月至2023年12月收治的42例肌层浸润性膀胱癌男性患者作为观察组,60~84岁,平均(69.2±4.9)岁,行腹膜外入路腹腔镜根治性膀胱切除术,延长正中切口约5 cm取出标本,再行Bricker术,将回肠袢完全隔离于腹腔外。选择同期同一术者团队开展的38例经腹腔入路腹腔镜根治性膀胱切除+回肠膀胱术作为对照组,比较两组手术时间、出血量、淋巴结清扫数量、术后肠功能恢复时间、肠梗阻等并发症及切口愈合情况。结果:观察组手术均获成功,无中转开腹。观察组与对照组腹腔镜阶段手术时间[(172.3±25.5)min vs.(172.1±27.4)min]、出血量[(194.5±100.5)mL vs.(207.6±107.8)mL]、淋巴结清扫数量[(11.6±2.9)枚vs.(11.8±2.7)枚]差异无统计学意义,观察组与对照组术后肠功能恢复时间[(2.2±0.4)d vs.(3.4±0.6)d,P<0.05]、肠梗阻例数(0 vs.7,P<0.01)、切口愈合不良(1 vs.9,P<0.01)差异有统计学意义。结论:经腹膜外入路腹腔镜根治性膀胱切除+回肠膀胱术是安全、可靠的,利用膀胱位于腹膜外及腹膜天然屏障的特点,改良手术入路将回肠袢、输尿管吻合口完全置于腹膜外,可减少肠梗阻的发生,术后肠功能恢复快,切口感染率低,值得临床推广应用。

Objective:To investigate the feasibility and safety of extraperitoneal laparoscopic radical cystectomy(ELRC)with intracorporeal ileal conduit urinary diversion(Bricker surgery).Methods:From Mar.2020 to Dec.2023,a total of 42 male patients,aged between 60 and 84 years old,who underwent ELRC and were diagnosed with muscle invasive bladder cancer,were included in the study as observation group.The average age was(69.2±4.9)years.The median incision was approximately extended to 5 cm in order to extract the specimen.Bricker surgery was performed after specimen extraction,the loop of the ileum was completely i solated from the abdominal cavity.In addition,38 patients who underwent transabdominal laparoscopic radical cystectomy and Bricker surgery by the same surgeon team from Mar.2020 to Dec.2023 were considered as the control group.And the two groups were compared in terms of operation time,blood loss,number of lymph nodes dissection,postoperative intestinal function recovery time,intestinal o bstruction and incision healing.Results:All 42 patients in the observation group were successfully operated,and no cases were converted to laparotomy.In observation group and control group,there were no significant differences in operative time of laparoscopic stage[(172.3±25.5)min vs.(172.1±27.4)min],blood loss[(194.5±100.5)mL vs.(207.6±107.8)mL],number of lymph node harvested[(11.6±2.9)vs.(11.8±2.7)],there were statistically significant differences in postoperative intestinal function recovery time[(2.2±0.4)d vs.(3.4±0.6)d,P<0.05],incidence of postoperative intestinal obstruction(0 vs.7,P<0.01)and incision u ndesirable healing(1 vs.9,P<0.01).Conclusions:ELRC with Bricker operation is safe and reliable,and takes advantage of the extraperitoneal location of the bladder and the natural barrier provided by the peritoneum,this improved surgical approach completely positions the ileal loop and ureteral anastomosis outside the peritoneum,resulting in a significant reduction in intestinal obstruction and incisional infection rate,and quick r ecovery of postoperative intestinal function.This procedure is worthy of clinical promotion and application.