回肠腹壁造口术（Bricker术）在膀胱癌根治术尿流改道中的应用

发布时间：2018-05-22 19:28

本文选题：膀胱癌 + 膀胱全切　；参考：《西南医科大学》2017年硕士论文

【摘要】：膀胱癌在我国泌尿系肿瘤发病率占居第一位,欧美仅仅次于前列腺癌,位居第二;对于肌层浸润性膀胱癌、高级别非肌层浸润性膀胱癌等,根治性膀胱切除(新膀胱重建)+双侧盆腔淋巴结清扫+尿流改道术仍然是首选措施,且在临床上已取得一定的疗效,但术后如何取代膀胱的功能及尿流改道的方式目前尚无标准治疗的方案;其中回肠膀胱术(Bricker术)是一种经典的尿流改道方式,具有操作简单、并发症少等优点,随着泌尿外科医师逐渐对其术式的完善,其在临床上的应用价值就更一步体现出来。目的:目前,随着重建原位可控性膀胱的出现,因为其近乎还原正常的泌尿系解剖和功能,而受到患者及泌尿外科医师的重视。回肠膀胱术(Bricker术)有逐渐被替代、忽略的趋势;本研究主要通过对膀胱癌患者行膀胱全切回肠膀胱术(Bricker术)的临床治疗过程分析,来说明Bricker术在膀胱癌手术治疗中仍有重要的临床应用价值。方法:通过回顾性分析2013年1月至2017年1月在我科行膀胱癌膀胱全切回肠膀胱术42例患者临床资料,包括:患者一般情况、临床表现、术前影像学检查、术前膀胱镜检查及术前病理分期。根据不同情况患者术中情况、术后恢复情况、术后近期并发症、有限随访时间段内的远期并发症及造瘘口相关情况;同时结合查阅相关文献,共同分析Bricker术在膀胱癌手术治疗、术后恢复效果及临床应用价值。结果:纳入研究的病例中:其中有18为腹腔镜下行Bricker术,24例为机器人辅助腹腔镜下手术。近期并发症:术中输血0例;术后肠梗阻有5例;术后感染7例;尿瘘1例;术后出血0例;下肢静脉血栓1例;心血管并发症0例;肠瘘0例。远期并发症:肿瘤复发2例;肾脏结石、积水6例;肾功能损害5例;输尿管吻合口狭窄4例;造瘘口皮损10例。值得一提的是:研究病例中有3例病人术前拟行原位膀胱重建术,在术中发现肿瘤侵犯尿道,术中修改手术方式为回肠膀胱术。近期并发症的患者均在院治疗后康复出院,远期并发症的患者经保守治疗有所好转,研究病例大部分病例对术后生活质量满意。结论:回肠膀胱术(Bricker术)在膀胱癌患者可以取得显著的疗效,且具有较高的安全性,术后并发症较少。根据查阅的相关文献,回肠原位膀胱术与Bricker术具有无差异的肿瘤治疗效果,术中、术后的近期并发症并无较大差异。但是Bricker术对于尿道切缘阳性、严重尿道括约肌功能不全及尿道狭窄、肝肾功能不能耐受原位膀胱术等患者来说,是比较唯一的治疗方式;同时原位新膀胱术后上尿路功能并发症要高于回肠膀胱术(Bricker术),包括肾功能的损害、尿路感染、尿路结石的发生概率,原位新膀胱患者术后需要严格的排尿管理,部分病人需要辅助排尿管理行间歇性自行导尿(CIC)或者长期使用尿不湿防止尿液外漏;从而得出以下结论:1)、存在原位新膀胱禁忌症患者,Bricker膀胱术为首选术式;2)、原位新膀胱术在术后早期并发症与Bricker膀胱术并无差异,但是术后远期上尿路功能损害较为严重;所以对于合并慢性疾病,特别是肝肾功能不全的患者,可以首先考虑Bricker膀胱术;3)、对于医从性、经济条件较差的患者来说,Bricker膀胱术优于原位新膀胱术。由此我们认为Bricker术在膀胱癌手术治疗中仍占有不可替代的地位,在临床工作中仍有相当大的应用价值。
[Abstract]:The incidence of bladder cancer is the first in our country, and the second in Europe and America is only inferior to prostate cancer. For invasive bladder cancer and advanced non muscular invasive bladder cancer, radical cystectomy (new bladder reconstruction) + bilateral pelvic lymph node dissection + urinary diversion is still the first choice. There is a certain curative effect, but there is no standard treatment for how to replace the function of bladder and the way of urinary diversion after operation. The ileum cystectomy (Bricker) is a classic way of urinary diversion, which has the advantages of simple operation and less complications. With the improvement of Department of Urology doctors gradually, it should be in clinical practice. At present, with the appearance of the reconstruction of the bladder in situ, it is valued by patients and Department of Urology doctors because of its near reduction of normal urinary anatomy and function. Ileusis (Bricker) has a gradual replacement and a slight trend; this study mainly through bladder cancer patients' bladder. The clinical analysis of cystectomy and cystectomy (Bricker) is an important clinical application of Bricker in the surgical treatment of bladder cancer. Methods: the clinical data of 42 patients with bladder cancer in our department from January 2013 to January 2017 were retrospectively analyzed. Bed performance, preoperative imaging examination, preoperative cystoscopy and preoperative pathological staging. According to different cases, postoperative recovery, postoperative complications, long term complications and stoma related conditions within limited follow-up period, combined with reference to phase Guan Wenxian, combined analysis of Bricker in bladder cancer surgery, Postoperative recovery and clinical value. Results: among the cases included: 18 were laparoscopic Bricker, 24 cases were assisted by robot assisted laparoscopic surgery, 0 cases of intraoperative blood transfusion, 5 cases of postoperative intestinal obstruction, 7 cases of postoperative infection, 1 cases of urinary fistula, 0 cases of postoperative bleeding, 1 cases of venous thrombosis of the lower extremity, 0 cardiovascular complications 0. 0 cases of intestinal fistula: long term complications: 2 cases of tumor recurrence, renal calculi, 6 cases of water accumulation, 5 cases of renal function damage, 4 cases of ureteral anastomotic stenosis and 10 cases of stoma skin lesions. It is worth mentioning that in the study cases, the urethra reconstruction was made before operation, and the urethra was encroached on the tumor during the operation, and the surgical method was modified in the ileum of the bladder in the operation. The patients with recent complications were discharged after hospital treatment, and the patients with long-term complications were improved by conservative treatment. Most cases were satisfied with the quality of life after the operation. Conclusion: the ileo bladder operation (Bricker) has a significant effect in bladder cancer patients, with high safety and less postoperative complications. In the related literature, ileum in situ cystectomy and Bricker have no difference in tumor treatment, and there is no significant difference in postoperative complications. However, Bricker is the comparison of patients with positive urethral resection margin, severe urethral sphincter dysfunction, urethral stricture, and liver and kidney function intolerance in situ cystectomy. The only way of treatment; at the same time, the complications of upper urinary tract function after in situ cystectomy are higher than that of the ileum (Bricker), including renal impairment, urinary tract infection, urinary calculi, the need for strict urination after the operation of the new bladder in situ, and the need for intermittent spontaneous catheterization (CIC) in some patients. The following conclusions are concluded as follows: 1) the following conclusions are as follows: 1) there is a new contraindication in situ, the first choice for bladder contraindication; 2) there is no difference between the early complications of the orthotopic bladder and the Bricker bladder operation. In particular, patients with liver and kidney insufficiency may first consider Bricker bladder operation; 3) Bricker bladder is superior to in situ new cystectomy for patients with poor health and poor economic conditions. Therefore, we believe that Bricker still occupies an indifferent position in the surgical treatment of bladder cancer and still has considerable application price in clinical work. Value.
【学位授予单位】：西南医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R737.14

【参考文献】