腹腔镜下侵袭性膀胱癌盆腔淋巴结清扫的应用解剖及手术技巧

The clinical anatomy and operation skill of laparoscopic pelvic lymphadenectomy for invasive bladder cancer

目的 总结腹腔镜下侵袭性膀胱癌盆腔淋巴结清扫的应用解剖及手术技巧和经验.方法 回顾性分析2008年6月至201 1年7月行腹腔镜下膀胱癌根治性切除和盆腔淋巴结清扫术43例患者的资料.男29例,女14例.年龄40～ 77岁,平均（58.9±10.0）岁.其中复发肿瘤19例;多发肿瘤11例;单发肿瘤位于三角区9例,右侧壁8例,左侧壁6例,底部7例,顶部2例.肿瘤大小1.0～7.5 cm,平均（3.0±1.4）cm.术前分期T2期28例,T3期10例,T4期5例.活检病理提示低级别尿路上皮癌20例,高级别尿路上皮癌22例,原位癌1例.结果 腹腔镜下盆腔淋巴结清扫术可按3个解剖界面分离：外侧面沿腰大肌表面的生殖股神经,远端至髂外动脉出盆腔处;内侧面以膀胱外侧闭锁的脐动脉,即呈圆索样的脐内侧韧带开始,向近端延续至髂内动脉分支——脐动脉及膀胱上动脉;前底面为内侧面与外侧面向前汇合至耻骨,沿着骨盆壁至盆底筋膜.43例手术均顺利,完成全部手术时间180～510 min,平均（320±88） min.术中失血量50～1 500 ml,平均（342±291） ml,输血12例,输血量200～1 000 ml,平均（567±187） ml.手术切缘均为阴性.平均每例清扫淋巴结数5.6个,淋巴结阳性率为7.0％（3/43）.术后病理提示低级别尿路上皮乳头状癌12例,高级别尿路上皮乳头状癌9例,高级别浸润性尿路上皮癌22例.本组无围手术期死亡者,出现并发症4例.术后36例获随访,平均随访时间（15.4±9.5）个月,死亡1例,发生并发症8例,肿瘤无复发生存率为94.4％（34/36）.结论 遵循开放手术原则及3个解剖界面,腹腔镜下侵袭性膀胱癌盆腔淋巴结清扫技术上是安全有效的,临床治疗效果满意,具有创伤小、术野清晰、失血少及手术时间短等优点.

Objective To summarize the anatomy,operation skill and experience of laparoscopic pelvic lymphadenectomy for the treatment of invasive bladder cancer.Methods From June 2008 to July 2011,43 patients including 29 males and 14 females; aged 40-77 years-old with 58.9±10.0 on average,who underwent laparoscopic radical cystectomy and pelvic lymphadenectomy were analyzed retrospectively.Among those patients,tumor recurrence 19 cases; there were 11 cases of multiple tumors,and the others were single tumor,including 9 cases on triangle,8 cases on right wall,6 cases on left wall,7 cases on bottom,2 cases on dome.The size of the tumors is between 1.0～7.5 cm with （3.0±1.4） cm on average.Preoperative staging showed 28 cases of T2,10 cases of T3 and 5 cases of T4.Biopsy pathological examination showed 22 cases of high-grade papillary urothelial carcinoma,20 cases of low-grade papillary urothelial carcinoma,and 1 case of carcinoma in situ.Results Laparoscopic pelvic lymphadenectomy can be performed through three different interfaces.Lateral surface follows the genitocrural nerve at the surface of psoas major muscle,and the far end is at the plain of the external iliac artery emerging out the pelvic cavity.Medial surface begins with the cleidoic umbilical artery,or circular cord-shape medial umbilical ligament in the lateral side of the bladder,extending to upper bladder artery which is the branch of the internal illiac artery.Anterior basal surface is pubic bone converged by the medial surface and the lateral surface,along with the pelvic wall to the pelvic bottom fascia.The operation time was 180-510 min with （320±88） min on average.The EBL was 50-1 500 ml with （342±291） ml on average,and 12 cases need blood transfusion with volume of 200-1 000 ml and （567±187） ml on average.All cutting edges were negative and average 5.6 lymph nodes were removed during the operation with lymph node positive rate of 7.0％ （3/43）.Postoperative pathological examination showed 12 cases of low-grade papillary urothelial carcinoma,9 cases of high-grade papillary urothelial carcinoma,and 22 case of invasive urothelial carcinoma.There was no death during the perioperatire period,but 4 patients had postoperative complications.Thirty-six patients were followed up with average of （15.4±9.5） months.One patient died and 8 patients developed complications during the follow-up period,and the relapse free survival rate was 94.4％ （34/36）.Conclusions Following the principles of open surgery and the 3 anatomical surface,laparoscopic pelvic lymphadenectomy for the treatment of invasive bladder cancer is technically safe and effective,and the clinical effectiveness was satisfied,with the advantages of minimal invasiveness,clear surgical field,less blood loss,and shorten operation time.