女性膀胱癌腹腔镜根治性切除原位回肠新膀胱术术式改进

Modified methods for laparoscopic radical cystectomy with orthotopic ileal neobladder in women patients with bladder carcinoma

目的探讨并改进腹腔镜女性膀胱癌根治性切除-原位回肠新膀胱术的手术方法,随访观察其治疗效果。方法2003年2月至2008年9月,为19例女性膀胱癌患者施行了腹腔镜膀胱全切除-原位回肠新膀胱术,其中13例同时行子宫、卵巢及附件切除,6例行保留子宫、卵巢附件。主要手术步骤为:①行标准盆腔淋巴结清扫,②行膀胱全切除同时切除或不切除内生殖器,③在下腹正中线上作4～5cm切口,取出标本,并构建"M"形去管回肠储尿囊,④输尿管末端形成半乳头,"插入式"种植于储尿囊;⑤储尿囊回纳腹腔,在腹腔镜下作储尿囊与尿道吻合。术后记录围手术期情况,并对患者进行定期随访,了解患者的生活质量、排尿情况,并检测患者的残余尿量、新膀胱压力等。结果手术时间(340.5±43.1)min,术中出血(353.9±71.3)ml。术后随访2～69个月,半年内均能自主排尿,1例日间偶有尿失禁,2例夜间尿失禁,3例排尿困难。膀胱容量(333.6±45.4)ml,残余尿量0～210(41.2±18.1)ml。术后半年至1年,行静脉尿路造影,除1例单侧肾积液外,其余双肾显影良好,未见肾盂输尿管扩张。膀胱尿道造影,可见膀胱位于盆腔,其形状大小位置于正常膀胱相似,未见膀胱输尿管反流。术后输尿管新膀胱吻合口梗阻1例,新膀胱阴道瘘1例,肿瘤远处转移2例于随访期间死亡。结论腹腔镜女性膀胱全切除-原位回肠新膀胱术,技术上可行,可根据患者情况采用保留或切除内生殖器的手术方法,术中出血较少,创伤较小,术后大部分患者能自主排尿,但尿失禁及排尿困难发生率略高于男性,术后中远期新膀胱功能及肿瘤根治效果还需进一步临床观察。

Objective To present our initial experience and results of the laparoscopic radical cystectomy （LRC） with orthotopic ileal neobladder in women patients with bladder carcinoma. Methods From February 2003 to September 2008, we performed laparoscopic radical eystectomy with orthotopic ileal neobladder in 19 women patients with bladder carcinoma （13 patients undergoing hysterectomy and ovariectomy, 6 patients having internal genitals preserved）. The major procedures included standard pelvic lymphadenectomy, radical cystectomy with genital resection or genital preservation, extrcorporeal construction of ＂M＂ shaped ileal neobladder and the anastomosis of ureter-neobladder through a 4 - 5 cm midline subumbilical skin incision, and laparoscopic urethra-pouch anastomosis. After the surgery, all the patients were followed up. The perioperative data, urodynamic analysis, the residual urine volume, and the recurrence of tumor were recorded. Results The operation time and the blood loss were （340.5±43.1） min and （353.9±71.3） ml, respectively. A follow-up for 2 to 69 months showed mictnrition in all patients in half a year, but occasional daytime urinary incontinence in l case, nighttime incontinence in 2 cases, and voiding difficulties in 3 cases 1 year later. The volume of neobladder was （333.6±45.4） ml and the residual urine volume was （41.2±18.1 ） ml （0 to 210 ml） , respectively. The neobladder was in the pelvic with the shape, size, and location similar to the original one in cystourethrography. Postoperative complications included urethra-pouch anastomose stenosis in 1 case and pouch-vaginal fistula in 1 case. Bone metastasis was found in 2 cases during the follow-up. Conclusion Laparoscopic radical cystectomy with orthotopic ileal neobladder in women patients is a technically feasible surgery which can cure patients with reservation or removal of internal genitals, and has the advantages of less blood loss and less trauma. Most female patients are able to urinate. However, urinary incontinence and voiding difficulties rate are slightly higher than those found in male patients. Long term follow-up is needed to evaluate the new bladder function and tumor control.