吲哚菁绿荧光腹腔镜在根治性膀胱切除术中的应用

Application of fluorescence laparoscopy combined with indocyanine green in radical cystectomy

目的探讨吲哚菁绿荧光腹腔镜在根治性膀胱切除+盆腔淋巴结清扫术中的应用价值及初步经验。方法回顾性分析2018年5月至2019年8月湖州市第一人民医院采用荧光腹腔镜系统行根治性膀胱切除+盆腔淋巴结清扫术的8例肌层浸润性膀胱癌患者的临床资料。男6例,女2例;年龄58~71岁,平均65.8岁。术前病理诊断均为尿路上皮癌,病理分期T2a期2例,T2b期4例,T3a期2例。患者术前经硬性膀胱镜使用18G膀胱镜注射针在膀胱肿瘤及其周围的膀胱黏膜下层和浅层逼尿肌注射荧光造影剂吲哚菁绿2 ml(浓度2.5 g/L),后利用PINPOINT内窥镜荧光摄像系统实时进行手术,每5分钟对近红外荧光下的手术区域进行一次系统性检查,观察和记录吲哚菁绿结合荧光腹腔镜对膀胱肿瘤区域及盆腔淋巴结的定位及识别。结果本组8例手术均顺利完成。在肿瘤标记方面,膀胱镜下注射吲哚菁绿后,8例中7例在荧光腹腔镜下识别肿瘤区域。8例中6例淋巴结显影,其中3例淋巴结阳性病例均有荧光显影。通过静脉注射吲哚菁绿观察代膀胱及输尿管末端血运均良好。手术时间190~310 min,平均235 min;出血量150~380 ml,平均180 ml;术后住院时间10~22 d,平均14.5 d。术后病理分期T2a期2例,T2b期3例,T3a期3例;清扫淋巴结数量8~14枚,平均10枚。术后随访4~12个月,平均5.5个月,无使用吲哚菁绿相关的并发症。结论吲哚菁绿荧光腹腔镜在根治性膀胱切除术中可对膀胱肿瘤区域及盆腔淋巴结进行准确定位及识别,可减少切缘阳性及不必要的扩大淋巴结清扫,促进患者术后恢复。

Objective To explore the application value and initial clinical experience of fluorescence-enhanced laparoscopy combined with indocyanine green in radical cystectomy with pelvic lymphadenectomy.Methods A retrospective analysis was performed on the clinical data of a total of 8 patients admitted from May 2018 to August 2019 who underwent laparoscopic radical cystectomy with pelvic lymphadenectomy for muscle-invasive bladder cancer using the fluorescent laparoscopy system.There were 6 males and 2 females;aged 58 to 71 years,with an average of 65.8 years.The preoperative pathology was urothelial carcinoma,with 2 cases in T2a stage,4 cases in T2b stage,and 2 cases in T3a stage.The patient was injected a total of 2 ml of 2.5 mg/ml of indocyanine green through a rigid cystoscope using a 18 gauge cystoscope injection needle before surgery.The PINPOINT endoscopic fluorescence camera system performed surgery in real-time.A systematic examination of the surgical area under near-infrared fluorescence was performed every 5 minutes.Observation and recording of indocyanine green combined with fluorescence laparoscopy to mark the bladder tumor area and identify the sentinel drainage.Results Eight cases were successfully completed under the fluorescence laparoscopic system.In terms of tumor markers,cystoscopy with indocyanine green allowed 7 of the 8 patients to successfully identify the tumor area under fluorescent laparoscopy.Six of the 8 patients with sentinel lymph nodes identified by indocyanine green lymphangiography were also successful,of which 3 were positive for lymph nodes.At the same time,intravenous indocyanine green was used to observe that the blood supply to the bladder and the end of the ureter was good.The operation time was 190-310 minutes,with an average of 235 minutes;the bleeding volume was 150-380 ml,with an average of 180 ml;the postoperative hospital stay was 10-22 days,with an average of 14.5 days.Postoperative pathological staging 2 cases in T2a stage,3 cases in T2b stage,3 cases in T3a stage,with total number of lymph nodes 8-14,average 10.The 8 cases were followed-up for 4-12 months,average 5.5 months,without indocyanine green related complications.Conclusions Indocyanine green fluorescent laparoscopy can accurately locate and identify the bladder tumor area and pelvic lymph nodes during radical cystectomy,which can reduce positive margins and unnecessary enlarged lymph node dissection.