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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后好转。所有患者术后2年内复查各项肾功能和尿常规指标均在正常范围内,静脉肾盂造影检查均未见明显输尿管反流。结论腹膜外代膀胱技术相对简单、并发症少、术后恢复快、疗效满意,值得临床推广应用。
Objective To investigate the clinical value of extraperitoneal bladder replacement in radical total resection of bladder cancer. Methods A total of 105 cases of bladder cancer patients, 87 males and 18 females, the median age was 67 years. Thirty-nine patients (all male) underwent radical gastrectomy + lymph node dissection + urinary diversion. Sixty patients underwent Bricker’s surgery. The radical resection of bladder cancer + urinary tract diversion technology improvements, the scope of cystectomy and lymph node dissection with the traditional surgical procedures. Construction of extraperitoneal bladder steps: ① select the extraperitoneal approach; ② non-top wall of the tumor completely retain the peritoneum in the nude area, the top wall of the tumor is complete removal of the peritoneum in the nude area; ③ in the premise of guaranteeing behalf of the bladder blood supply to the mesenteric root part Free to increase the degree of free on behalf of the bladder; ④ close the mesentery to prevent the formation of internal hernia; ⑤ in accordance with the order from the bottom to close the peritoneum, and the peritoneal and bladder substitution of the mesentery for intermittent suture, the generation of the bladder placed extraperitoneal. The postoperative complications were followed up with the Clavien Severity Grading System, with a focus on assessing gastrointestinal complications and complications. Results All patients underwent surgery successfully. Surgery time 4.0 ~ 7.5h, the median operation time was 5.8h; intraoperative blood loss of 100 ~ 1 400mL, the median blood loss was 350mL; intraoperative need of blood transfusion in 12 cases. Postoperative exhaust time 1.0 ~ 8.5d, the median exhaust time of 2d. Perioperative small intestinal obstruction occurred in 13 cases (12.4%), after fasting, acid and aprotinia and other treatment improved; pelvic fluid with infection in 4 cases, fully recovered after a good recovery. Postoperative hospital stay 8 ~ 28d, median postoperative hospital stay 13d. Within 1 month after operation, 29 cases of Clavien grade 1, 17 cases of grade 2, 1 case of grade 3 and 1 case of grade 5 (large area pulmonary infarction occurred after operation). The incidence of grade 1 and grade 2 complications of Clavien was 43.8% (46/105). At 3 months after ileal bladder surgery, the rate of urine control during the day was 92.3% (36/39) and nighttime control was 87.2% (34/39). The B-ultrasound showed that the residual urine volume was 10-75mL , The median residual urine volume was 32mL. Three months after the ileal bladder surgery, the patient’s mastopia had a good blood supply and had no ulcer and infection in the stoma skin. Six months after operation, 11 patients developed mild dilation of the upper urinary tract with lumbar acid. After anti-infection and retrograde dilation under bladder soft- ware, ten patients were improved after single J tube treatment, and one patient failed to undergo ureteral ileal urinary bladder And then consistent with postoperative improvement. All patients were reviewed within 2 years after the renal function and urinalysis were within the normal range, intravenous pyelography showed no obvious ureteral reflux. Conclusion Extraperitoneal replacement of bladder is relatively simple, less complications, quick recovery, satisfactory efficacy, which is worthy of clinical application.