程序化腹腔镜下根治性膀胱切除术120例经验总结

Programmed laparoscopic radical cystectomy for bladder cancer:clinical experience summary of 120 cases

目的:总结程序化腹腔镜下根治性膀胱切除术(LRC)临床应用效果,进一步优化手术步骤,介绍手术技巧,帮助同行降低学习难度,加快此术式推广。方法:回顾性分析2012年6月～2016年7月我院120例接受程序化LRC的膀胱癌患者临床及随访资料,重点介绍手术方法及技巧。其中男99例,女21例,平均年龄(65.5±10.2)岁;BMI为(23.8±2.5)kg/m^2;Charlson合并症指数(CCI)评分(2.5±0.7)分。所有患者均经病理学确诊为膀胱癌。记录并分析患者围手术期资料、术后病理、术后并发症及随访结果等。结果:120例手术均顺利完成,无中转开放,膀胱切除时间为(90.2±23.1)min;行标准淋巴结清扫(sPLND)78例,时间为(44.2±15.6)min,清扫淋巴结数为(11.7±5.2)个;行扩大淋巴结清扫(ePLND)36例,时间为(71.8±17.1)min,清扫淋巴结数为(23.2±6.8)个。淋巴结密度为7.9%(138/1 747),阳性患者24例(21.1%)。出血量为(160.0±142.9)ml。40例患者行原位回肠新膀胱术(完全腹腔镜25例,小切口辅助15例),回肠通道术60例(完全腹腔镜36例,小切口辅助24例),20例患者行输尿管皮肤造口,其中大网膜包裹6例。女性患者保留生殖器官13例,整块切除8例。术后病理显示115例为尿路上皮癌,2例鳞癌,2例腺癌,1例肉瘤;T分期≥T2期的患者84例(70.0%);低级别6例(5.0%),高级别109例(90.8%)。术后早期并发症均为Ⅰ～Ⅱ级,主要为发热、疼痛,给予对症处理后好转。120例患者中,共14例患者失访,中位随访时间48个月,无明显肾积水及肾功能受损。结论:程序化LRC可以有效简化手术步骤,降低手术难度,缩短学习曲线,减少不必要的操作和损伤,降低出血量和围术期并发症发生率,最终促进患者早期康复,值得进一步推广和应用。

Objective：To summarize the clinical application effect of programmed laparoscopic radical cystectomy,further optimize the surgical procedures,introduce operating technique,and to help urologists to reduce the learning difficulty and speed up the promotion of this technique.Method：From June 2012 to July 2016,programmed laparoscopic radical cystectomy（LRC）was performed in 120 patients diagnosed with bladder cancer in our center,and the relevant clinical and follow-up data were retrospectively reviewed.Surgical methods and techniques are mainly emphasized.Ninety-nine patients were male and 21 were female,the mean age was（65.5±10.2）years old.BMI was（23.8±2.5）kg/m^2.The Charlson comorbidity index（CCI）score was（2.5±0.7）.All the patients were diagnosed as bladder cancer by preoperative pathological results and their perioperative data,postoperative pathological results,postoperative complications and follow-up outcomes were recorded and analyzed.Result：All the 120 operations were successfully performed without conversion to open surgery.The time for cystectomy was（90.2±23.1）min.Standard lymph node dissection（sPLND）was performed in 78 patients and the mean（11.7±5.2）lymph nodes were dissected.The time for sPLND was（44.2±15.6）min.Extended lymph node dissection（ePLND）was performed in 36 patients and the mean（23.2±6.8）lymph nodes were dissected.The time for ePLND was（71.8±17.1）min.The lymph node density was 7.9%（138/1 747）and 24 cases（21.1%）had positive ones.The estimated blood loss was（160.0±142.9）ml.There were 40 cases receiving orthotopic ileal neobladder（intracorporeal for 25 cases and extracorporeal for 15 cases）,60 cases receiving ileal conduit（intracorporeal for 36 cases and extracorporeal for 24 cases）and 20 cases receiving cutaneous ureterostomy respectively.For female patients,13 cases had their reproductive organs preserved and 8 cases bad their bladder resected with reproductive organs.Postoperative pathological results showed urothelial carcinoma in 115 patients,squamous cell carcinoma in 2 patients,adenocarcinoma in 2 patients and sarcoma in one patient.There were 84 cases with T stage greater than or equal to T2（70.0%）,6 cases of low grade（5.0%）and 109 cases of high grade（90.8%）.All the early postoperative complications were grade Ⅰ-Ⅱ mainly manifested as fever and pain and could get better with symptomatic treatment.During the 120 patients,14 were lost to follow-up and the median follow-up time was 48 months without obvious hydronephrosis or impaired renal function.Conclusion：Programmed laparoscopic radical cystectomy can effectively simplify the surgical procedures,lower the surgery difficulty,shorten the learning curve,reduce unnecessary operation and injury as well as blood loss,decrease the incidence of perioperative complications,and finally promote the early rehabilitation of patients,which is worthy of further promotion and application.