腹腔镜与开放性膀胱全切原位回肠代膀胱术的疗效比较

Radical cystectomy with orthotopic ileal neobladder:comparison of laparoscopy vs open surgery

目的比较腹腔镜与开放性手术施行膀胱全切除-原位回肠新膀胱手术的临床疗效.方法对1994年6月至2004年9月施行的膀胱全切除-原位回肠新膀胱术81例患者进行随访,根据手术方法不同分为腹腔镜手术组(A组,33例)和开放性手术组(B组,48例);对两种术式的手术方法、手术时间、术中出血量、术后疗效及并发症进行比较分析.结果平均手术时间:A组为390min,B组为330 min.术中平均出血量:A组460 ml,B组1200 ml.术后肠道功能恢复时间:A组3～4d,B组4～5 d,两组手术组织切缘均无肿瘤.盆腔淋巴结清扫阳性率:A组18.2%(6例),B组18.8%(9例).尿控功能:术后3～6个月A组的日间尿控率为93.9%,夜间尿控率为87.9%,B组分别为90.5%和85.7%.新膀胱尿动力学检查结果:A组的最大尿流率为(18.4±6.1)mL/s,B组为(15.7±5.5)ml/s;新膀胱容量、膀胱内压、剩余尿量两组差异无统计学意义.IVU检查及新膀胱造影检查:两组病例均可见输尿管轻度扩张但无明显输尿管梗阻及返流,新膀胱形态大小接近正常膀胱,排空完全.尿道膀胱镜见尿道吻合口通畅,新膀胱内可见输尿管小乳头并有喷尿.术后并发症:A组总并发症发生率为18.2%,其中尿瘘2例,盆腔感染1例,肠梗阻2例,新膀胱阴道瘘1例;B组总并发症发生率31.3%,其中尿瘘4例,切口感染5例,肺部感染2例,盆腔感染2例,肠梗阻1例,尿道狭窄1例.两组均未发生直肠损伤,肠瘘及内疝等严重并发症,无围手术期死亡.结论腹腔镜下行膀胱全切除-原位回肠新膀胱术比开放性手术出血少,肠道功能恢复快,并发症少,术后尿控率高,但手术时间较长.在新膀胱容量、内压、剩余尿量、上尿路功能及肿瘤根治切除方面与开放性手术效果相当.

Objective To compare the therapeutic effect of laparoscopic radical cystectomy with orthotopic ileal neobladder (LRC-INB) vs open radical cystectomy (ORC-INB). Methods A total of 81 patients were evaluated including 33 undergoing LRC-INB (group A) and 48,ORC-INB (group B) from June 1994 to September 2004 at our institution.The parameters for analysis included operative time,surgical method,blood loss,therapeutic effect,complications and hospital stay.Statistics included t-test and chi-square analysis (P<0.05 was considered statistically significant). Results There was no significant difference in factors of patients at baseline between the 2 groups.The mean operative time was 390 min in group A vs.330 min in group B.The mean intraoperative blood loss was 460 ml in group A vs.1200 ml in group B.The mean recovery time of intestinal function was 3-4 d in group A.vs 4-5 d in group B.The positive rates of pelvic lymphadenectomy was 18.2% (6 cases) in group A and 18.8% (9) in group B.Three to 6 months after surgery,the patients of group A had 93.9% of daytime continence and 87.9% of nocturnal continence,while group B had 90.5% and 85.7%,respectively.The Qmax of the 2 groups were (18.4±6.1)ml/s vs.(15.7±5.5)ml/s with no significant difference of volume,pressure and residual urine volume (RUV) of neobladder.The IVU and retrograde contrast examination of neobladder showed that all the patients’ ureters had mild expansion without obstruction and reflux.The neobladder’s form and size were close to normal bladder without residual urine.The stoma of urethra and neobladder was patent and urine blew off from the papillae of ureter under the cystoscope.The complication rate of group A was 18.2%,with 2 cases of urine leakage,1 of pelvic cavity infection,2 of intestinal obstruction and 1 of vesicovaginal fistula.By contrast,the complication rate of group B was 31.3%,with 4 cases of urine leakage,5 of incision infection,2 of pulmonary infection,2 of pelvic cavity infection,1 of intestinal obstruction and 1 of urethrostenosis.Both groups had no rectal injury,intestinal fistula,entocele and other serious complications or perioperative death. Conclusions LRC-INB is of less blood loss,shorter intestinal recovery time,less complications,and better urine control,but longer operative time than ORC-INB.There is no significant difference in volume,pressure and RUV of neobladder,upper urinary tract function and tumor radical resection between the two approaches.