电切镜联合腹腔镜在膀胱副神经节瘤治疗中的初步应用经验

Preliminary application experience of resectoscope combined with laparoscopy in the treatment of paraganglioma of urinary bladder

目的探讨电切镜联合腹腔镜在膀胱副神经节瘤手术治疗中的可行性及安全性。方法回顾性分析2014年11月至2018年8月收治的7例膀胱副神经节瘤患者的病例资料。男5例，女2例。年龄22-37岁，平均31．1岁。体重指数18．3-25．5kg／m^2，平均22．3kg／m^2。7例均主诉排尿后头晕、心悸。基础收缩压97-124mmHg（1mmHg=0．133kPa），平均111．8mmHg；排尿前后收缩压波动28-91mmHg，平均64．9mmHg。CT及膀胱镜检查提示膀胱肿瘤，肿瘤直径2．1-3．5cm，平均2．7em^2术前血浆去甲。肾上腺素330-997pg／ml，平均706．3pg／ml（参考值0-600pg／m1）；血浆多巴胺44-145pg／ml，平均101．1pg,／ml（参考值0-100pg／m1）；24h尿香草扁桃酸10．3-16．1mg／24h，平均13．4mg／24h（参考值0-12mg／24h）。结合病史考虑为膀胱副神经节瘤可能性大。7例术前均予盐酸酚苄明控制血压及扩张血管，术前连续3d扩容。全麻下行电切镜联合腹腔镜膀胱部分切除＋经腹入路膀胱缝合术。患者取头低足高截石位，经腹入路制备气腹。同时经尿道置入电切镜，距肿瘤边缘1cm左右离断膀胱黏膜，并电切离断膀胱壁全层，以见到腹膜外脂肪为准。在腹腔镜下能够清晰地观察到切缘，采用超声刀辅助切除盆底腹膜、腹膜外脂肪及肿瘤，标本放置膀胱内，使用可吸收线或倒刺线缝合关闭膀胱，标本经电切镜取出。结果本组7例手术均顺利完成，无中转开放病例。手术时间65-100min，平均85．3min。术中出血量10-50ml，平均27．9ml。术中收缩压波动范围6-15mmHg，平均8．7mmHg。术后24h停止膀胱冲洗，术后1周拔除尿管，未发生明显并发症。术后住院时间3-5d，平均3．7d。4例术后4h疼痛评分2-5分，平均3．8分；术后24h复评为1-4分，平均2．3分。术后随访2-15个月，平均7．9个月，7例症状均消失，监测排尿前后收缩压无明显波动，未见肿瘤复发。结论对于膀胱底壁或前壁的副神经节瘤，电切镜联合腹腔镜可以精确切除肿瘤，减少术中血压波动，减小手术创伤，是安全、有效的微创手术方法。

Objective To analyze the feasibility and safety in application of resectoscope combined with laparoscopy in the operation treatment of paraganglioma of urinary bladder. Methods 7 cases patients with paragauglioma of urinary bladder treated in our hospital from November 2014 to August 2018 were analyzed retrospectively. There were 5 males and 2 females, average age of 31. 1 years （22 - 37 years ） , average body mass index was 22.3 kg/m^2 （ 18.3 - 22.5 kg/m^2 ）. All the 7 cases patients complained of dizziness and palpitation after urination, average basal systolic blood pressure was 111.8 mmHg （ 97 - 124 mmHg） , the average fluctuation of systolic blood pressure before and after urination was 64.9 mmHg（ 28 -91 mmHg） ,the CT and cystoscopy prompt bladder tumor, the average diameter was 2.7 cm （2.1 - 3.5 cm）. The average of plasma norepinephrine was 706.3 pg/ml（330 -997 pg/ml） ;the average of plasma dopamine was 101. 1 pg/ml （ 44 - 145 pg/ml ） ; the average of 24h urinary vanilmandelic acid was 13.4 mg/24h （ 10.3 - 16.1 mg/24h）. All the patients has controlled the blood pressure and dilate the blood vessels with phenoxybenzamine hydrochloride, accepted the operation of resectoscope combined with laparoscopy partial cystectomy and bladder sutura per abdomen after ample dilatancy. The patients had lithotomy position with trendelenburg, preparation of gas peritoneal cavity by transabdominal, inside the resectoscope by transurethral at the same time, mutilated bladder mucosa beside l cm at the edge of the tumor, and cut full thickness bladder wall, take the extraperitional fat as the standard procedure ;we could see the cutting edge clear at this time by laparoscopy, cnt off the pelvic peritoneum, extraperitional fat and the tumor. The sample placed in bladder,close the bladder with absorbable or barbed wires, take out the sample by resectoscope. Results All the 7 cases patients operation was successfully completed, no cases has been transfered to open. The average time of operation is 85.3 min（65 -100 rain） , the average amount of bleeding is 27.9 ml（ 10 -50 nil）. The average fluctuation of systolic blood pressure is 8.7 mmHg（6 - 15 mmHg）. Bladder washout was stopped 24h after operation, catheter was removed 1 weeks after operation. There is no obvious complications occurred. The average hospital stay is 3.7 days （ 3 - 5 days）. The average pain score of d cases 4h after operation is 3.8 （ 2 - 5 ）, reevaluation 24h after operation is 2.3 （ 1 - 4 ）. The average follow-up time is 7.9 months（2- 15 months）. All the 7 cases patients clinical symptoms disappeared, there is no fluctuation of systolic blood pressure before and after urination, there is no recurrence of the tumor. Conclusions To the paraganglioma of urinary bladder in fundus of bladder or anterior wall of bladder, we can accurate resection tumor by resectoscope combined with laparoscopy, reduce blood pressure fluctuations, reduce the surgical trauma and the distress of patients. It is a safety and effective minimally invasive surgery.