腹腔镜下根治性膀胱切除Studer回肠新膀胱术

Laparoscopic radical cystectomy with Studer orthotopic ileal neobladder

目的介绍腹腔镜下根治性膀胱切除Studer回肠新膀胱术的方法。方法膀胱癌患者8例，均为男性，年龄51～69岁，平均57岁。浸润性膀胱癌7例，腺癌1例。临床分期：T27例，T31例。经腹取5个穿刺点，腹腔镜下清扫双侧闭孔、髂内及髂外淋巴结；游离膀胱腹侧，剪开双侧盆筋膜，缝扎阴茎背静脉复合体；游离输精管和精囊，剪开狄氏筋膜，分离前列腺与直肠间隙；分离前列腺尖部尿道，切断尿道，将切下的膀胱和前列腺装入标本袋。下腹正中切口6～8cm，取出标本，于该切口外距回盲部20cm处截取45cm回肠，取远端40cm段对折，纵行切开对系膜缘肠壁，交叉折叠缝制新膀胱，将双侧输尿管吻合于新膀胱近端未剖开的5cm肠管上。新膀胱颈部与保留尿道断端间断缝合。结果8例手术顺利，手术时间6～8h，平均7．2h；出血量200800ml，平均420ml；无中转开放手术者。术后病理分期pTz6例、pT。1例、pTzNzM。1例，切缘均为阴性。术后发生右侧输尿管套叠1例，经输尿管镜下还纳松解。8例随访3～12个月，生活质量良好。结论腹腔镜下根治性膀胱切除术切口小、出血少，技术可行，Stueder原位膀胱技术简单、输入袢长、术后功能好。

Objective To discuss the technique of laparoscopic radical cystectomy with Studer orthotopic ileal neobladder. Methods Eight men with bladder cancer who were indicated for radical surgery underwent laparoscopic cystectomy with Studer orthotopic ileal neobladder. The ages were between 51 and 69 with the mean age was 57 years. Seven cases were transitional cell carcinoma and 1 case was adenocarcinoma. A 5-port approach was employed. The first step was the bilateral pevic lymphadenectomiy including obturator lymph nodes, internal and external lilac lymph nodes. Then ventral surface of the bladder was mobilized and the bilateral endopelvic fascia was incised. Next step included the stich of dorsal vein complex and dissection of both the vas deferens and seminal vesicles. Denonvillier＇s fascia was incised to develop the plane between the rectum and the prostate. The urethra located in the prostatic apex was divided and transected thereby completely separating the specimen. Then the specimen was placed in a packet. Finally, a 6-8 cm lower median abdominal incision was performed, through which the specimen was extracted. Construction of the Studer pouch： A portion of terminal ileum about 45cm long was isolated approximately 20cm proximal to the ileocecal valve. The ends of the isolated ileal segment were closed to restore the bowel continuity. The distal 40 cm segment of ileum was placed in a U shape and opened along the antimesenteric border. The two medial borders were then oversewn and the bottom was folded over to form a neobladder. The ureters were anastomosed to the nonincised 5 cm portion of ileum. Finally, the neobladder was put into the abdominal cavity and the anastomosis between the neck of the neohladder and the end of the remaining uretheral was performed with interrupted suture. Results All the procedures were successful. The time of the operation was 6- 8 h with the mean estimated blood loss 420（200-800）mt. Complication included i case of right ureteral indigitation in neobladder. The postoperative histopathology revealed 7 cases of pT2 and 1 cases of pTa. No positive margin was found. The follow-up （3- 12 months） showed no recurrence. Conclusions The technique of laparoscopic radical cystectomy is feasible with the advantages of smaller incision and less blood loss. Studer orthotopic ileal neobladder has the ad vantages of simple skill, antireflux, better postoperative urination.