腹膜外逆行切除前列腺膀胱的根治性膀胱切除术165例报告

Retrograde extraperitoneal approach of resection of prostate and bladder to radical cystectomy： 165 cases report

目的 探讨腹膜外逆行切除前列腺膀胱的根治性膀胱切除术的安全性和有效性.方法 2010年5月至2014年5月,行腹膜外逆行切除前列腺膀胱的根治性膀胱切除术165例.年龄33 ～ 85岁,平均71岁.Ta～T1期87例,T2期65例,T3 ～T4期13例.尿流改道术式：原位新膀胱Studer术50例,回肠膀胱Bricker术73例,输尿管皮肤造口术42例.全身麻醉,患者取臀部抬高过伸的仰卧位或截石位.取脐下正中切口,切开皮肤至膀胱腹膜外,牵开腹壁显露前列腺及膀胱外结构,行盆腔髂血管淋巴结清扫,遇膀胱动脉予以结扎.切开盆筋膜、游离前列腺侧面,缝扎阴茎背深静脉,切开前列腺尖部外包膜,游离前列腺尿道部,切断尿道.于前列腺尖部处提起腔内留置的导尿管,游离切开尿道直肠肌,游离前列腺底部及侧部,精囊处切开狄氏筋膜,分离膀胱侧韧带,LigaSure血管闭合系统切割游离并止血,逐渐将前列腺膀胱从直肠前腹膜游离,锐性游离腹膜上膀胱.如怀疑腹膜浸润,切除区域腹膜. 结果 本组术中出血量30～160 ml,平均100 ml;手术时间45～ 120 min,平均80 min.术后病理报告尿路上皮癌157例,膀胱腺癌5例,鳞状细胞癌1例,前列腺癌侵犯膀胱2例;淋巴结转移16例,未见切缘阳性者.随访3～32个月,中位随访时间13个月,未见腹膜转移者.结论 腹膜外逆行切除前列腺膀胱的根治性膀胱切除术依赖前列腺膀胱区精细解剖,是一种安全有效、创伤小的术式,尤其适用于行原位新膀胱术的患者.

Objective To describe the security and validity of retrograde extraperitoneal approach of resection of prostate and bladder to radical cystectomy.Methods From May 2010 to May 2014,total 165 cases,aged 33-85 years,were treated with retrograde extraperitoneal radical cystectomy.There were 87 cases of Ta-T1,65 cases of T2,and 13 cases of T3-T4 ; Urinary diversion：50 cases of Studer orthotopic neobladder,73 cases of Bricker operation,42 cases of ureterocutaneostomy.General anesthesia and hip elevation hyperextension were taken,the skin and fascial layers were incised from pubic symphysis to subumbilical incision,extraperitoneal bladder wall and prostate bladder structure were visualized.Pelvic iliac artery lymphadenectomy was performed,followed with bladder artery ligated and incision of pelvic fascia.Both sides of the prostate were dissociated,dorsal vein complex was sutured,prostatic urethra was dissociated and cut off.The indwelling urethral catheter of the apex of the prostate was raised,rectourethral muscle was dissociated and cut off,the bottom and sides of the prostate were dissociated,Denonvillier fascia at the seminal vesicle was incised,the lateral ligament of bladder was separated.LigaSure system was used to cut hemostasis and gradually seperete the prostate and bladder from rectal peritoneum.Regional peritoneum was excised if peritoneal invasion was suspected.Results The amount of operative bleeding was 30-160 ml,average 100 ml; operation time was 45-120 min,average 80 min.Postoperative pathologic results：157 cases of urothelial carcinoma,5 cases of adenocarcinoma of bladder,1 cases of squamous cell carcinoma,and 2 cases of prostate carcinoma invading the bladder; lymph node metastasis was found in 16 cases.The period of follow-up was 3-32 months （median,13 months）.No peritoneal metastasiswas found.Conclusions Radical retrograde extraperitoneal cystectomy is based on a finer knowledge of anatomy and requires accurate dissection.It is safe,effective,and minimally invasive,especially in the neobladder.