腹腔镜根治性膀胱切除术加原位T型回肠新膀胱重建的临床观察

Pilot study of laparoscopic radical cystectomy and construction of orthotopic T pouch ileal neobladder

目的 总结13例腹腔镜根治性膀胱切除、标准淋巴结清扫加T型原位回肠新膀胱重建的经验，评价此术式肿瘤学结果与功能性结果。方法2005年8月至2009年7月，对首都医科大学附属北京朝阳医院13例肌层浸润性膀胱肿瘤患者实施腹腔镜根治性膀胱切除加下腹壁小切口行原位T型回肠新膀胱重建术，对手术时间、淋巴结数量、围手术期并发症、出血量、输血量、生存率、上尿路形态与功能、控尿情况进行分析。结果平均手术时间为6（5～8）h，平均出血量为480（100～800）ml，平均输血量133（0～400）ml，平均清扫淋巴结数16（8—22）个，无围手术期死亡，围手术期并发症发生率为15．4％（2／13）。术后3周行膀胱造影检查，未发现明显造影剂外溢及反流。患者日间完全控尿率达84．6％（11／13）；夜间完全控尿率为46．1％（6／13），夜间仅需要1块尿垫者占30．8％（4／13）。上尿路检查提示，23．1％（3／13）术后45d内出现双侧肾盂及输尿管的轻度暂时陛扩张，但肾功能保持正常。随访24（16～63）个月，7．7％（1／13）于术后55个月死于急性心肌梗死，92．3％（12／13）无复发生存。结论腹腔镜根治性膀胱切除、标准淋巴结清扫加下腹壁小切口行T型原位回肠新膀胱重建术取得了满意的肿瘤学与功能性结果；T型原位新膀胱输入袢的抗反流效果令人满意，能够充分保护上尿路形态与功能。

Objective To summarize the preliminary experiences of 13 cases of laparoscopic radical eystectomy and construction of orthotopic T pouch ileal neobladder and evaluate the oncological and functional outcomes of this procedure. Methods From August 2005 through July 2009, 13 patients underwent radical cystectomy and standard lymphadenectomy followed by construction of orthotopic T pouch ileal neobladder via mini-laparostomy for muscular invasive bladder cancer. The data were analyzed according to procedure time, blood loss volume, transfusion volume, number of dissected lymph nodes, perioperative complications, morphology and function of upper urinary tract and status of urinary continence. Results The mean operating duration was 6 （ 5 - 8 ） hours, estimated volume of blood loss 480 （ 100 - 800） ml, transfusion volume 133 （0 -400） ml and the number of dissected lymph nodes 16 （8 -22）. There was no peri-operative mortality. The peri-operative complications were found in 15.4% （ 2/13 ） and included urine leak at neobladder-urethra junction managed by drainage （ n =1 ） and urine leak at ureter- neobladder junction repaired （n = 1 ）. The complete daytime continence rate was 84. 6% （ 11/13）, complete nocturnal continence rate 46. 1% （6/13） and 〈 1 pad in 30. 8% （4/13）. No reflux into afferent limb of neobladder was observed by cystography. Temporary dilation of upper urinary tract was observed in 23.1% （3/13） at Day 45 post-operation and later it disappeared spontaneously. Serum creatinine remained in a normal range in all patients. Within a follow-up of 24 （ 16 - 63 ） months, 7.7% （ 1/13 ） died of myocardial infarction at Month 55 post-operation. And 92. 3% （ 12/13 ） survived without a local relapse or a distal metastasis. Conclusion Within an intermediate follow-up period, the oncological and functional outcomes are encouraging after laparoscopic radical cystectomy and construction of orthotopic T pouch ileal neobladder via miniaparostomy upper urinary tract.