完全腹腔镜下膀胱癌根治性全切除+尿流改道术(附69例报告)

Laparoscopic radical cystectomy with urinary diversion:a report of 69 cases

目的探讨完全腹腔镜下膀胱癌根治性全切除＋尿流改道术的临床可行性,并总结手术技巧。方法对69例膀胱癌患者行完全腹腔镜下膀胱癌根治性全切除＋尿流改道术（包括回肠膀胱术和原位回肠新膀胱术）,其中行完全腹腔镜下膀胱癌根治性全切除＋回肠膀胱术22例,行完全腹腔镜下膀胱癌根治性全切除＋原位回肠新膀胱术47例。结果 69例患者的手术均获成功。完全腹腔镜下膀胱癌根治性全切除＋回肠膀胱术组的手术时间为（240±28）min,术中出血量为（380±120）mL,术后肠功能恢复时间为（2.5±1.2）d,术后住院时间为（7.7±0.9）d,术后无肠瘘、尿瘘等并发症发生。完全腹腔镜下膀胱癌根治性全切除＋原位回肠新膀胱术组的手术时间为（333±32）min,术中出血量为（680±200）mL,术后肠功能恢复时间为（3.6±1.1）d,术后住院时间为（24.0±3.2）d;术后1例患者发生回肠吻合口瘘,遂行开放吻合口修补术。所有患者经术后病理学检查证实均为膀胱尿路上皮癌,病理分级Ⅰ级10例、Ⅱ级29例、Ⅲ级30例,淋巴结清扫数目为（17.0±6.3）枚,淋巴结阳性率为7.2%（5/69）。术后随访3~24个月,平均随访时间为（14.7±5.3）个月,无1例患者发生肿瘤复发或转移。结论完全腹腔镜下膀胱癌根治性全切除＋尿流改道术可减少手术创伤,术中解剖结构显露较满意,有利于患者术后恢复;但手术难度较大,须熟练掌握各种腹腔镜操作技术后方可进一步开展。

Objective To investigate the feasibility of radical cystectomy combined with urinary diversion under laparoscope and summarize the surgical techniques.Methods A total of 69patients with bladder cancer underwent laparoscopic radical cystectomy with urinary diversion.Of them,22received ileal conduit and 47 received ileal orthotopic neobladder.Results All procedures were successfully performed.The operative time was（240±28）min in ileal conduit group and（333±32）min in ileal orthotopic neobladder group;the blood loss was（380±120）mL and（680±200）mL;the recovery time of bowel function was（2.5±1.2）d and（3.6± 1.1）d;and the postoperative hospital stay was（7.7±0.9）d and（24±3.2）d,respectively.No severe complication occurred in the ileal conduit group.One patient in the ileal orthotopic neobladder group suffered from intestinal fistula and underwent open neoplasty.Postoperative pathologic results confirmed that all patients had bladder transitional cell carcinoma.There were 10cases in gradeⅠ,29cases in gradeⅡ and 30cases in grade Ⅲ.The number of lymph nodes dissected was 17±6.3during surgery.Positive nodes were detected in 5cases,and the positive rate was 7.2%.The average duration was（14.7±5.3）months（range,3to 24months）.No recurrence or metastasis was found.Conclusion Laparoscopic radical cystectomy with urinary diversion can reduce surgical trauma,expose anatomical structure more clearly and is helpful for postoperative recovery.Due to the difficulty of surgical procedures,the surgeon must master laparoscopic technique.