改良全膀胱切除和原位新膀胱术重建下尿路功能

Reconstruction of lower urinary tract using modified neobladder after total cystectomy for invasive bladder cancer

背景与目的:全膀胱切除原位新膀胱术是治疗浸润性膀胱癌最有效的手段。但由于手术繁杂、时间长、出血和并发症较多,以及相当一部分患者控尿不佳等缺点,我们对全膀胱切除和原位新膀胱术进行了反复改良,获得了比较满意的效果,本文报告我们的经验。方法:采用改良的全膀胱切除和原位新膀胱术治疗119例临床诊断为浸润性膀胱癌的患者。男性109例,女性10例。年龄33～78岁,平均55岁。统计手术时间、术中出血和输血量,对新膀胱功能、并发症、肿瘤控制和生存情况进行随访分析。结果:对全膀胱切除和原位新膀胱术一共进行了八处改良。从2000年1月至2007年2月用改良术治疗119例,无围手术期死亡。手术时间150～330min,平均245min。输血39例(32.8%)。术后病理分期浅表性膀胱癌(T1N0M0)9例,浸润性110例(其中T2N0M0102例、T3aN0M03例、T3aN1M02例、T3bN1M02例,、T4N1M01例)。随访6～72个月,平均45个月,108例生存,10例因肿瘤死亡,1例非肿瘤原因死亡。术后白天控尿良好113例(95%),夜间控尿良好97例(81.5%)。主要并发症有切口裂开5例,二次缝合后治愈;输尿管新膀胱吻合口漏1例,经再次手术作输尿管再植治愈;肠梗阻3例需住院处理。输尿管末端粘连引起肾积水8例,经内镜下切断粘连后积水消退。无肠瘘和新膀胱尿道吻合口瘘或狭窄,无膀胱输尿管返流。结论:全膀胱切除后采用改良原位新膀胱术重建下尿路功能,手术时间短、出血少和并发症少,新膀胱控尿和排尿满意,是目前全膀胱切除后最理想的下尿路重建方式。

Background and purpose： Total cystectomy and neobladder are one of the most effective treatments for invasive bladder cancer. But the procedure is complicated and time consuming, it could cause massive blood loss and complications. Some patients even develop urinary incontinence after the procedure. This study is to improve the procedure and investigate the efficacy of modified operation. Methods： 119 patients （ male 109, female 10） with invasive bladder cancer had been treated with modified total cystectomy and neobladder. The mean age of the patients was 55 （range 33-78） years. The operative time, blood loss and blood transfusion during the operation was documented. The outcome including neobladder function, complications, tumor control and patients＇ survival, were analyzed retrospectively. Results： The procedure of total eysteetomy and neobladder has been modified in 8 steps. From January 2000 to February 2007 119 patients with bladder cancer underwent modified eysteetomy and neobladder. There was no surgical mortality. Operative time was 150-330 min （mean 245 min） ; blood transfusion was required in 39 （32.8%） cases. 9 of them had pathologically T1NOM0, and invasive tumor in 110 eases（T2NoM0 in 102 cases, T3aNoM0 in 3 cases, T3aNl M0 in 2 cases, T3bNl M0 in 2 cases and T4NIM0 in 1 cases）. So far, 108 patients still survive disease-free; ten patients died of tumor metastasis and 1 case died of non-tumor cause. 113 （95%） patients were continent during daytime and 97（8l. 5%） patients were continent at night. Complications including wound dehiscence in 5 cases, urine leakage at ureter anastomosis in 1 case and eonglutination of ureter orifices in 8 cases, were corrected surgically without sequelae. Conclusions： Modified total eysteetomy and neobladder was an ideal method for treating invasive bladder cancer because of its excellent clinical outcome of tumor control, high quality of life, good urinary continence and few severe complications.