构建腹膜外代膀胱在膀胱癌根治性全切除术中的应用  

Application of extra-peritoneal pouch in radical cystectomy and urinary diversion

作　　者：张振声[1] 李惠珍[1] 许传亮[1] 杨波[1] 曾蜀雄[1] 赵俊杰[1] 徐伟东[1] 韦荣超[1] 宋瑞祥[1] 王辉清[1] 侯建国[1] 高旭[1] 孙颖浩[1] 

机构地区：[1]上海长海医院泌尿外科,上海200433

出　　处：《上海医学》2013年第7期577-580,I0001,共5页Shanghai Medical Journal

摘　　要：目的探讨腹膜外代膀胱在膀胱癌根治性全切除术中的临床应用价值。方法共105例膀胱癌患者,男87例,女18例,中位年龄为67岁。均行膀胱癌根治性全切除＋淋巴结清扫＋尿流改道术,其中行原位回肠膀胱术39例（均为男性）,行回肠膀胱术（Bricker术）66例。对膀胱癌根治性全切除＋尿流改道术进行技术改进,膀胱切除和淋巴结清扫范围同传统术式。构建腹膜外膀胱步骤：①选择腹膜外入路;②非顶壁肿瘤完全保留裸区腹膜,顶壁肿瘤则完整切除裸区腹膜;③在保证代膀胱血供的前提下尽可能向肠系膜根部分游离以增加代膀胱的游离度;④闭合肠系膜防止内疝形成;⑤按照由下至上的顺序关闭腹膜,并将腹膜与代膀胱的肠系膜作间断缝合,将代膀胱置于腹膜外。采用Clavien严重程度分级系统随访术后并发症发生情况,重点评估胃肠道相关并发症和感染并发症。结果所有患者手术均获成功。手术时间4.0~7.5h,中位手术时间为5.8h;术中出血量100~1 400mL,中位术中出血量为350mL;术中需输血12例。术后排气时间1.0~8.5d,中位排气时间为2d。围术期发生不全性小肠梗阻13例（12.4%）,经禁食、制酸和抑酶等处理后好转;盆腔积液伴感染4例,经充分引流后恢复良好。术后住院时间8~28d,中位术后住院时间13d。术后1个月内,Clavien 1级29例,2级17例,3级1例,5级1例（患者术后出现大面积肺梗死灶）;Clavien 1级＋2级并发症发生率为43.8%（46/105）。原位回肠膀胱术后3个月,患者白天控制尿液率为92.3%（36/39）,夜间控制尿液率为87.2%（34/39）;B超检查示,残余尿量10~75mL,中位残余尿量为32mL。回肠膀胱术后3个月,患者造口乳头血运良好,造口皮肤无溃疡和感染。术后6个月,11例患者发生上尿路轻度扩张伴腰酸,经抗感染和膀胱软镜下逆行扩张、留置单J管治疗后,10例好转,1例失败者再行输尿管回肠膀胱再吻合术Objective To investigate the value of extra-peritoneal pouch in radical cystectomy and urinary diversion.Methods Technical refinements on radical cystectomy and urinary diversion were applied in 105patients with bladder cancer;they included extraperitoneal approach,retaining the peritoneum,suturing the peritoneum,and keeping the peritoneal cavity closed,to make the pouch in the extraperitoneal cavity.Of the 105 patients,there were 87males and 18females with a mean age of 67years.Orthotopic ileal neobladder was done in 39cases（all male）,and the remaining 66patients underwent ileal neobladder（Bricker procedure）.Clavien grading system was used to evaluate the severity of postoperative complications during follow-up.Gastrointestinal complications and infection complications were the focuses.Results The procedure was successfully performed in all patients.The median operative time was 5.8h（range,4.0-7.5h）,and median blood loss was 350mL （range,100-1 400mL）.Blood was transfused in 12cases during surgery.Bowel function recovered from 1.0d to 8.5dpostoperatively,with a median of 2d.Perioperative incomplete small bowel obstruction occurred in 13 patients（12.4%）,which was cured by conservative treatment（fasting,restraining acid and enzyme）.Pelvic reservior with infection happened in 4patients,who recovered after drainage.Postoperative hospital stay lasted for 8-28d,with a median of 13d.Complications within 1month after surgery were classified according to Clavien system,and there were 29cases in ClavienⅠ,17cases in ClavienⅡ,1case in ClavienⅢand 1case in Clavien V who died due to pulmonary infarction.Urinary control was achieved in 92.3%（36/39）patients on the daytime and in 87.2%（34/39）patients in the night 3months after orthotopic ileal neobladder.Residual volume of urine was 10-75mL with a median of 32mL by B ultrasound examination.No ulcer or infection occurred in the skin of stoma 3months after Bricker operation.Upper urinary tract dilatation and mild flank pain happened in 11cases

关 键 词：膀胱癌 尿流改道 腹膜外 

分 类 号：R737.14[医药卫生—肿瘤]