膀胱全切除-原位W形回肠新膀胱术后尿流动力学的临床研究

The clinical study on urodynamics after total cystectomy and orthotopic ileal neobladder

目的:分析膀胱全切除-原位W形回肠新膀胱术后的尿流动力学结果,探讨引起异常尿动力学的原因,提出相应的预防和治疗措施,为进一步改进下尿路重建手术提供依据。方法:总结分析我院2005年11月至2011年12月期间行膀胱全切除-原位W形回肠新膀胱术的13例患者术后上、下尿路尿流动力学的结果。结果:最大自由尿流率、腹压、残余尿量和最大尿道压与正常功能膀胱比较差异有显著性(P<0.05),最大膀胱容量、充盈期膀胱压、膀胱顺应性和最大尿流率时膀胱压与正常膀胱比较差异无显著性(P>0.05);有1例患者出现输尿管新膀胱吻合口狭窄并急性肾功能衰竭,2例患者术后双肾输尿管轻度肾积水。结论:膀胱全切除-原位W形回肠新膀胱术基本解决了下尿路重建问题,但存在输尿管梗阻、肾积水、控尿不完全和新膀胱排空不良等问题,可以通过术中输尿管、尿道的外翻吻合、新膀胱的最低位与尿道吻合、蹲位(增加腹压和松弛盆底肌肉)排尿、术后加强盆底肌功能锻炼及定时排尿正确的训练等得以解决。

Objective To analyze the changes of urodynamics after total cystectomy and orthotopic ileal neobladder and its reasons, and to explore the evidence for further improvement of reconstruction operation on lower urinary. Methods The clinical data of upper and lower urinary urodynamics of 13 patients receiving total cystectomy and W-shaped orthotopic ileal neobladder from November 2005 to December 2011 in our hospital were analyzed. Results The maximum free uroflow rate, the abdominal pressure, the residual urine volume, and the maximal urethral pressure of the 13 patients were obviously different from those of normal controls （P 〈 0.05）, while there were no significant differences of the maximum bladder capacity, the filling bladder pressure, the bladder compliance, and the bladder pressure at maximum flow rate （P 〉 0.05）. Anastomotic stenosis of the ureter-neobladder and acute renal failure occurred in l case and 2 patients suffered mild hydronephrosis in both sides of kidney and ureter after the operation. Conclusions The issue of reconstruction of lower urinary is basically dealt with by total cystectomy and W-shaped orthotopic ileal neobladder. However, there are a series of problems such as ureteral obstruction, hydronephrosis, imperfect urine control, and abnormal neobladder emptying, which can be solved by the methods of everting anastomosis of the ureter-urethra during operation, anastomosis of the lowest part of neobladder to urethra, squatting during urination （to increase the abdominal pressure and to relax pelvis floor muscles）, keeping the training of pelvis floor muscles and building up the habit of urination at predetermined time after operation.