肠代膀胱术中回肠反套入抗输尿管返流方法的临床研究

Clinical study of the intussuscepted ileum as antireflux procedure in orthotopic ileal neobladder

目的评价肠代膀胱术中回肠反套入的抗输尿管返流作用.方法患者5例,男4例,女1例.年龄48～67岁,平均61岁.均为浸润性移行细胞癌,行膀胱全切、回肠正位膀胱术.距回盲部屈氏韧带15 cm处切取回肠30 cm,近端回肠反套入4cm,回肠段远端肠管对系膜缘纵形剖开,U形缝合;套入肠管与对应肠片均切除1 cm宽之黏膜,相应浆肌层可吸收线固定4针,对应黏膜缘缝合,防止套入肠管滑脱;双侧输尿管远端剖开6 cm,侧侧吻合后经套入肠管引入,吻合口与套入肠管口间断缝合;U形肠管对折成储尿囊,与尿道吻合.术后定期行血生化、双肾B超、排泄性膀胱造影和尿动力学检查.结果5例患者随访10～33个月.排尿次数白天3～5次,夜间0～3次;日间控尿100%,夜间控尿80%;尿动力学检查:最大尿流率9.5～31.5 ml/s,膀胱容量350～710 ml,平均433 ml;剩余尿50～305 ml;最大膀胱排尿压23～52 cm H2O;膀胱出口无梗阻.B超检查双肾无积水.膀胱造影未见输尿管返流.结论回肠正位膀胱术中回肠反套入方法有良好的抗输尿管返流作用.

Objective To assess the functional results of the intussuscepted ileum as antireflux procedure in orthotopic ileal neobladder. Methods Five patients （4 males and 1 female;mean age,61 years; age range,48-67 years） with invasive transitional cell carcinoma underwent total cystectomy and orthotopic ileal neohladder with antireflux technique using the intussuscepted ileum. The surgical procedures were as follows. Four-cm proximal ileum was intussuscepted into the reservoir constructed from a detubularized ,30 cm segment which was isolated from the distal ileum and arranged in a U-shaped configuration. The intussuscepted ileum was sutured to the reservoir wall after stripping the mucosa of the reservoir in a trapezoidal zone opposite to the similarly stripped mucosa of the intussuscepted ileum,to avoid dessusception. After the distal ureters of 6 cm long was incised, united laterally and pulled through the intussuscepted segment of ileum, the combined distal ureter was sutured to the labial edge of intussuscepted segment. Postoperatively, blood biochemistry, B-ultrasound, cystography and urodynamic examinations were conducted periodically. Results During the follow-up for 10 to 33 months,good daytime and nocturnal continence was reported by 100% and 80% of the patients. Voiding times were 3 to 5 during the day and 0 to 3 at night, respectively. Urodynamic studies revealed that the Qmax ranged from 9.5 to 31.5ml/s and the capacity of neobladder ranged from 350 to 710 ml （mean,433 ml）. The residual urine was 50 to 305 ml. The maximal voiding pressure was 23 to 52cm H2O. There was no evidence of bladder outlet obstruction and hydronephrosis in the patients. Voiding cystourethrograms revealed no reflux in them. Conclusions The intussuscepted ileum has an effective antireflux mechanism for an orthotopic ileal neobladder.