经肠系膜浆膜下隧道输尿管吻合技术在原位新膀胱术中的应用

Application of the transmesenteric serosal tunnel ureteral anastomosis technique in neobladder

目的:探讨经肠系膜浆膜下隧道输尿管吻合技术在乙状结肠新膀胱手术中的临床应用。方法:纳入2016年1月—2020年1月昆明医科大学第二附属医院收治的46例膀胱癌患者,采用标准根治性膀胱切除术和乙状结肠原位尿流改道。取25 cm乙状结肠制作储尿囊,在储尿囊两侧肠系膜缘戳孔,将输尿管经肠系膜浆膜下拖入膀胱约1.5 cm,用4-0可吸收线作4~6针间断缝合固定于膀胱黏膜。修整输尿管末端,在输尿管内留置6~8 F支架管,剖开输尿管末端上缘,将剖开的输尿管向下方展开形成扇形,用4-0可吸收线在扇形顶端将输尿管与储尿囊后壁黏膜2针缝合。结果:手术时间200~300 min,术中失血量300~725 mL,平均住院时间(22.6±6.1)d,无围手术期死亡病例。术后随访4~59个月,平均34个月。在3个月后的长期随访中,有3例患者出现单侧肾积水,经输尿管镜检查发现输尿管-新膀胱吻合口狭窄。无输尿管反流病例。日间控尿率为81.1%,夜间控尿率为55.9%。4例患者残余尿测定超过50 mL。最大新膀胱容量平均为(410±60)mL。结论:经肠系膜浆膜下隧道输尿管吻合技术简单、可靠,可实现抗反流作用的同时保证较低的输尿管狭窄发生率。

Objective To explore the clinical application of the transmesenteric serosal tunnel ureteral anastomosis technique in sigmoid neobladder.Methods This study included 46 patients who underwent standard radical cystectomy and in situ urinary diversion through the sigmoid colon from Jan.2016 to Jan.2020 at Second Affiliated Hospital of Kunming Medical University.A 25 cm segment of the sigmoid colon was used to create a urinary reservoir.Punctures were made at the mesenteric edges of both sides of the reservoir,and the ureters were dragged through the subserosal layer of the mesentery into the bladder for about 1.5 cm,then fixed to the bladder mucosa using 4-0 absorbable sutures with 4 to 6 interrupted stitches.The ureteral ends were trimmed,and a 6 to 8F stent was placed inside the ureter.The upper edge of the ureteral end was incised,and the incised ureter was unfolded downwards to form a fan shape,which was then sutured to the posterior wall mucosa of the reservoir at the apex of the fan shape with two stitches using 4-0 absorbable sutures.Results The operation time was 200-300 min,with a blood loss of 300-725 mL.The average hospital stay was(22.6±6.1)days,with no intraoperative or perioperative deaths.The follow-up period ranged from 4 to 59 months,averaging 34 months.During the 3-month postoperative long-term follow-up,3 patients developed unilateral hydronephrosis,and ureteral-neobladder anastomotic stricture was discovered through ureteroscopy.There were no cases of ureteral reflux.The daytime continence rate was 81.1%,and the nighttime continence rate was 55.9%.Four patients had residual urine volume exceeding 50 mL.The maximum neobladder capacity was(410±60)mL.Conclusion The transmesenteric serosal tunnel ureteral anastomosis technique is simple and reliable,achieving antireflux effects while ensuring a low incidence of ureteral stricture.