改良与传统输尿管皮肤造口术的比较
发布时间：2018-07-25 20:35
【摘要】：背景与目的： 浸润性膀胱癌生物学行为高度恶性,治疗的主要方法是膀胱切除加尿流改道术。根治性手术能有效提高患者生存率、避免局部复发和远处转移,被认为是标准的手术方式。但由于根治性膀胱切除及尿流改道术常给患者带来生活质量的下降及精神上的压力。每一名膀胱癌患者的身体状况、手术耐受性、预期生存及对治疗结果期待的不同,因此有必要探讨适合不同患者需要既达到肿瘤根治又易于被患者接受的膀胱癌根治和尿流改道手术方式。 自1852年Simon报道为1例膀胱外翻患者施行输尿管直肠吻合术以来,尿流改道手术已有100多年历史,根椐不同病情和不同手术医师的经验,研究和设计出各种的手术方法,不同的术式各有其适应范围,也各有其优缺点。 理想的永久性尿流改道应能达到防止术后并发症,保护肾脏功能,使患者能过接近正常的生活。目前使用的各种永久尿流改道方法尚未臻完善,各具优缺点。可概括为下列几类：①尿路造口手术：如输尿管皮肤造口术、永久性膀胱造口术、腹壁尿道术、尿道造口术；②利用一段游离肠管于腹壁造口,作为尿流通道,如回肠膀胱术、结肠膀胱术；③尿粪合流手术：如输尿管乙状结肠造口术、输尿管结肠-结肠直肠吻合术；④尿粪分流手术：如直肠膀胱术、直肠膀胱-结肠腹壁造口术；⑤可控肠膀胱术,分为二类：一类为可控肠膀胱腹壁造口术,如可控回肠膀胱术、可控回盲肠膀胱术；另一类为新膀胱术或正位可控膀胱术,如回肠新膀胱术、去带回盲肠新膀胱术。手术方法的选择需按照病人具体情况,如年龄、身体条件、原发病性质、预期寿命、上尿路及肠管的解剖及功能情况等,既往有无腹部、盆腔手术及放疗史,结合患者的要求和术者的经验,认真加以选择。 输尿管皮肤造口术(Cutaneous Ureterostomy, CU)是输尿管断端和皮肤的永久性或暂时性尿流改道,这是一种简单、安全术式。大体分为两种类型：输尿管攀皮肤造口术和输尿管末端皮肤造口术。Roth在1967年最先报道了使用输尿管皮肤造口术作为尿流改道的一种方法,原本这种方法用于治疗儿童的先天性尿路梗阻,但是后来逐渐扩展到用于治疗成人盆腔恶性肿瘤的姑息性尿流改道。目前将输尿管皮肤造口术作为永久性尿流改道的方法来使用相对较少,但输尿管皮肤造口术仍作为一种有吸引力的永久性尿流改道的方法,尤其适用于晚期膀胱肿瘤。其手术适应症：1、患膀胱或邻近器官的晚期恶性肿瘤,膀胱广泛受累,容量缩小,反复出血,压迫输尿管下段引起肾积水和肾功能不全者；2、儿童患下尿路梗阻或功能性疾患,致上尿路严重积水扩张,尤其是合并感染和尿毒症者；3、患神经原性膀胱功能障碍,伴有膀胱输尿管返流、逆行性肾积水、反复感染及肾功能受损,不能耐受较大手术者。 传统输尿管皮肤造口术简要手术步骤：(1)需施行膀胱全切除或剖腹探查术者,使用下腹正中切口,经腹腔施行手术；单纯作输尿管皮肤造口术者,采用双下腹斜切口,经腹膜外施行手术。(2)腹膜后分离双侧输尿管中下段并将其切断,近端插入F8输尿管支架管达肾盂、固定在输尿管断端,远端用丝线贯穿结扎。(3)在骶岬前方、乙状结肠系膜后方作钝性分离,形成一通道,将一侧输尿管通过此通道拉至对侧。在离对侧输尿管断端约10cm处作输尿管端侧吻合,将支架引流管经吻合口放入对侧输尿管下段,并插至断端之外,将输尿管吻合口前壁缝合,间断缝合吻合口的输尿管外膜。(4)将输尿管造口的一侧的腹部切口延长成S形,两个梯形皮瓣的长度和底宽均为4cm,顶边约为2.5-3.0cm,S形切口的中点相当于髂嵴上缘水平。(5)将腹外斜肌腱膜于相对的腹横肌肌膜创缘缝合数针,其两旁的腱膜、肌肉切口则用丝线缝合,形成一纽扣状通道,让输尿管通过此通道拉出腹壁之外。用3-0可吸收线于适当位置穿过输尿管外膜,并固定于钮孔边缘。(6)3-0可吸收线缝合皮肤创缘,形成包绕输尿管的皮管。用丝线将输尿管末端与皮缘间断缝合,并将引流管固定。 传统的输尿管末端皮肤造口术有以下缺点：(1)腹壁切口多、切口长,创伤大,美容效果差；(2)造口周围皮肤不平坦,易发生漏尿；(3)易发生输尿管末端坏死、狭窄或皮管裂开等合并症；(4)一些病例术后皮管逐渐萎缩、变短、使尿液不易收集,而需长期留置引流管；(5)因需要做皮肤乳头,所需输尿管长度也较长,易增加输尿管张力,导致输尿管血供受限。 基于传统术式以上缺点,有必要对其进行改良,以期达到以下效果：(1)手术方法相对简单；(2)手术时间缩短,对患者全身影响小,对病情较重者风险降低；(3)减少并发症：如减少漏尿、造口周围感染等。(4)降低手术风险,提高病人的生活质量,降低医疗费用等。 本科室对传统输尿管皮肤造口术进行改良,其的简要手术步骤：(1)单侧：取患侧下腹长约12cm手术斜切口,逐层切开腹壁,腹膜外找到患侧输尿管中、下段。根据原发病确定输尿管保留输尿管长度并离断,远断端以丝线缝扎。向上游离输尿管中下段。于患侧中腹部取一圆形切口,直径约0.6cm,戳穿下组织,于腹外斜肌腱膜取一同样大小和形状的切口,并经该切口将输尿管从圆形皮肤口引出体外。间断缝合输尿管壁和腹外斜肌腱膜,以固定输尿管。以可吸收线间断缝合输尿管壁和圆形皮肤切口。纵形切开输尿管0.5cm,将输尿管末端外翻、折叠。右输尿管末端呈乳头状突出皮面0.5cm,从该乳头向输尿管插6F硅胶管,深度约20cm,或插单“J”管,乳头上接一造口袋以搜集尿液。 (2)双侧：取下腹正中切口,起自耻骨联合上缘,长约15cm。逐层切开组织,于腹膜外分别找到双侧输尿管中下段并横断,远断端以4号丝线缝扎,分别于两侧中腹部各取一圆形切口,直径约0.6cm,切除其下皮下组织,于腹外斜肌腱膜取一同样大小和形状的切口,并经该切口戳穿腹内斜肌和腹横肌,分别将双侧输尿管从左右圆形切口引出体外。以4-0可吸收线间断缝合输尿管壁和腹外斜肌腱膜,以固定输尿管。以5-0可吸收线间断缝合输尿管壁和圆形皮肤切口。纵形切开输尿管0.5cm,将输尿管末端外翻、折叠。双侧输尿管末端呈乳头状突出皮面0.5cm。 健康相关生活质量指不同文化和价值体系下,个体受到病情和治疗的影响时,对生活和环境的主观知觉感受,包括对身体症状、社会关系、心理情绪、环境互动等的评价。生命质量作为一个公认的疗效评价指标,能够帮助临床医生、护士站在患者的立场,选择和评价治疗、护理方案,筛选影响患者生命质量的主要因素,有针对性地对患者进行随访和完善健康教育。医学模式已经发生了变化,随着这些变化,在临床工作中,医务工作者不再只关注患者生理的治疗和康复,还要关注患者的生理、心理、社会方面的变化。 生活质量调查是目前国际上对包括肿瘤在内的各种慢性疾病治疗方案筛选和评价的有效方法。所谓健康相关生活质量(HRQOL),是指在疾病、意外损伤及医疗干预影响下,与人的生活条件和事件相关的健康状态和主观满意度。 本研究通过前瞻性研究传统输尿管皮肤造口术与改良术式患者的相关临床资料,应用膀胱癌特异性量表FACT-BL对在我院接受传统输尿管皮肤造口术和改良术两种术式的患者进行问卷调查,比较两种术式术后相关并发症的发生率,总体生活质量和膀胱癌相关方面生活质量的差别,并探讨产生这些差别的原因,为输尿管皮肤造口术式的选择提供健康相关生活质量方面的依据,从而提高患者术后生活质量。 方法：选取2006年12月至2013年02月在广州市第一人民医院泌尿外科住院的患者。病人的入选标准：1、因各种原因需行输尿管皮肤造口术者：(1).膀胱或邻近器官的晚期恶性肿瘤、膀胱广泛受累,容量缩小,反复出血,压迫输尿管下段引起肾功能衰竭的患者；(2).患神经性膀胱功能障碍,伴有膀胱输尿管返流、上行性肾积水、反复感染及肾功能受损,不能耐受较大手术的患者。2、患者无精神疾病,能正确理解问卷内容并独立完成问卷的填写；3、患者签署知情同意书。 将手术组分为传统手术组和改良手术组。其中19例行传统输尿管皮肤造口术,22例行改良输尿管皮肤造口术。病人的分组标准：从临床实际出发,病人的分组不可能做到随机分组。我们的研究根据主刀医生来进行分组,其中以谢克基教授为主刀的治疗组施行改良手术；以其他熟练掌握输尿管皮肤造口术的医生为主刀的治疗组施行传统术式。 筛选出符合入选标准的病例41例,其中19例行传统输尿管皮肤造口术,22例行改良手术。收集患者手术资料,包括手术时间,术中出血量,术后住院时间,术后并发症等资料并进行统计分析。签署知情同意书,征得患者同意后收集其基本资料,包括患者姓名、性别、年龄、手术日期、手术方式、疾病类型、病理类型、肿瘤分期、分级以及患者家庭地址、联系电话、E-mai1等内容,应用膀胱癌特异性量表FACT-BL进行调查,定期邀患者来我院门诊复查,同时现场完成问卷,或通过邮寄附带回信邮资和信封,或E-mail发送电子调查表以或电话询问方式完成调查对两种术式患者术后并发症及术后1个月、3个月、6个月、9个月、12个月等不同时间点的生活质量进行多次问卷调查,从而动态观察两种术式患者手术后的生活质量变化情况,并对不同时间点两种术式方式患者生活质量进行比较。 计量资料用均数±标准差(x±s)表示,比较采用独立样本的t检验(Independent Samples T Test)或者秩和检验(Mann-Whitney Test)进行分析；组间率的比较采用χ2检验,,以P=0.05作为检验水准。应用SPSS13.0软件对数据进行统计分析。 结果：传统手术组：男16例,女3例,年龄67.9±5.4岁；膀胱多发尿路上皮癌7例、膀胱浸润性尿路上皮癌4例,膀胱鳞癌1例,膀胱癌术后复发7例；≥T3期8例；其中单侧输尿管皮肤造口9例,双侧10例。改良手术组：男17例,女5例,年龄平均67.8±5.9岁；膀胱多发尿路上皮癌6例,膀胱癌术后复发5例,膀胱浸润性尿路上皮癌4例,膀胱尿路上皮癌合并肾盂癌2例,膀胱鳞癌2例,直肠癌侵犯膀胱1例,膀胱平滑肌肉瘤合并前列腺癌1例,膀胱癌阴道转移1例；≥T3期10例；其中单侧输尿管皮肤造口8例,双侧14例。(1)两组患者性别、年龄、性别比例、≥T3期、单数／双侧造口比例方面无统计学差异(P0.05)；(2)、手术并发症：造口感染传统手术组高于改良手术组(P=0.036),乳头萎缩、末端坏死、外口狭窄两组之间无差异(P0.05)；(3)、两组患者术后1个月、3个月、6个月、9个月、12个月时的HRQOL评分均呈逐渐升高趋势,术后1个月、3个月、6个月、9个月时两组患者HRQOL评分接近,差别无统计学意义(P0.05)。术后12个月时,患者改良组HRQOL评分高于传统手术组患者,P=0.000.05,两组间差别有统计学意义。两组患者在生理状况、社会、家庭状况、情感状况及FACT-G等方面HRQOL评分接近,差别无统计学意义(P0.05),而改良组患者在FWB、BSS得分和FACT-BL总得分方面高于传统组患者,差别有统计学意义(P0.05)。 结论：改良输尿管皮肤造口术在术后造口皮肤感染、术后12个月时HRQOL方面优于传统手术方式。因此,在患者身体状况允许的情况下,选择输尿管皮肤造口方式时应优先考虑行改良输尿管皮肤造口手术,以减少手术并发症和提高患者术后生活质量。
[Abstract]:Background and purpose:
The biological behavior of invasive bladder cancer is highly malignant. The main treatment is cystectomy and urinary diversion. Radical surgery can effectively improve the survival rate of the patients, avoid local recurrence and distant metastasis. However, radical cystectomy and urinary diversion often bring the quality of life to the patients. The physical condition of each bladder cancer patient, surgical tolerance, expectation of survival and the expectation of treatment are different, so it is necessary to explore the way of radical resection of bladder cancer and urinary diversion that are suitable for different patients.
Since Simon reported 1 cases of ureterorectal anastomosis in patients with vesical valgus in 1852, urinary diversion has a history of more than 100 years. According to the experience of different conditions and different surgeons, various surgical methods have been studied and designed. Different surgical methods have their own adaptability and their advantages and disadvantages.
The ideal permanent urinary diversion should be able to prevent postoperative complications, protect the renal function and make patients close to normal life. The various permanent urinary diversion methods currently used have not been perfected and have their own advantages and disadvantages. Surgery, abdominal wall urethra, urethra orostomy; (2) using a segment of free bowel in the abdominal wall orostomy as a channel of urinary flow, such as ileocecal bladder, colon bladder operation, and urinary fecal confluence operation: ureterostomy, ureterocolonic and rectal anastomosis; (4) fecal shunt: rectal bladder, rectum bladder to colon Abdominal orostomy; 5. Controlled enterostomy is divided into two categories: one type of controlled intestinal bladder abdominal orostomy, such as controlled ileocecal bladder, controlled ileocecal cystectomy; the other is new cystectomy or orthotopic bladder operation, such as ileocecal cystectomy, and cecum new bladder operation. The choice of surgical methods should be based on the patient's specific conditions, such as Age, physical condition, primary nature, life expectancy, anatomy and function of the upper urinary tract and bowel, history of abdominal, pelvic surgery and radiotherapy, combined with the patient's requirements and the experience of the surgeon, to choose carefully.
Ureterostomy (Cutaneous Ureterostomy, CU) is a permanent or temporary urinary diversion of the ureteral broken end and skin. This is a simple, safe operation. It is divided into two types: ureterostomy and ureterostomy at the end of ureter. In 1967, ureterostomy was first reported by ureterostomy. A method of urinary diversion, which was used to treat congenital urinary tract obstruction in children, was later extended to the palliative urinary diversion for treatment of adult pelvic malignancies. Ureterostomy is currently used as a permanent urinary diversion, but ureterostomy is relatively less. Still used as an attractive permanent urinary diversion, especially for advanced bladder tumor. Its surgical indications are: 1, advanced malignant tumors of the bladder or adjacent organs, extensive bladder involvement, reduced capacity, repeated bleeding, and oppression of the lower ureteral segment of the kidney and renal insufficiency; 2, children suffering from urinary obstruction or Functional disorders, causing severe water dilatation in the upper urinary tract, especially in patients with infection and uremia, and 3, suffer from neurogenic bladder dysfunction, cystureteral reflux, retrograde hydronephrosis, recurrent infection and impaired renal function, which can not be tolerated by the larger surgeons.
The simple procedure of the traditional ureterostomy: (1) a total cystectomy or exploratory laparotomy should be performed, with a median incision in the lower abdomen and a abdominal operation; a simple ureterostomy, a double lower abdominal incision and extraperitoneal surgery. (2) the posterior subperitoneum and the lower middle ureteral segment are separated and cut off. The F8 ureteral stent was inserted into the renal pelvis at the end of the ureter, and the distal end of the ureter was ligated through the thread. (3) a blunt separation was made in front of the sacral promontory and the posterior sigmoid mesenteric membrane, forming a channel to pull the ureter through the channel to the opposite side. The ureter was anastomosed to the end of the ureter from the contralateral ureter to the end of the ureter, and the stent drainage tube was kissed. The anterior wall of the ureter was inserted into the inferior ureter and inserted into the broken end, sutured the anterior wall of the ureter anastomosis and sutured the ureteral outer membrane of the anastomotic mouth intermittently. (4) the abdominal incision on one side of the ureterostomy was extended into S shape, the length and bottom width of the two trapezoid flaps were both 2.5-3.0cm, and the middle point of the S shaped incision was equivalent to the superior margin of the iliac crest. Level. (5) to stitch the aponeurosis of the abdominis muscle to the relative musculus musculus musculus. The aponeurosis on both sides of the aponeurosis and the incision of the muscles are sutured with silk thread to form a button shaped channel, which allows the ureter to pull out the abdominal wall through this channel. The 3-0 absorbable line passes through the outer membrane of the urinary duct and is fixed to the edge of the buttonhole. (6) 3-0 absorbs the seam. Combined with skin wound, the skin tube was wrapped around ureter. The distal ureter and the skin margin were sutured by silk thread, and the drainage tube was fixed.
The traditional ureterostomy has the following shortcomings: (1) the abdominal wall incision is many, the incision is long, the trauma is big, the beauty effect is poor; (2) the skin around the orostomy is not flat, and the leakage urine is easy to occur; (3) the complications of the ureteral end necrosis, the stenosis or the skin tube cracking are easy to occur. (4) some cases have gradually atrophied and shortened after operation, making urine difficult to receive. (5) because of the need to make skin nipples, the length of ureters needed is longer, and the ureteral tension is easy to increase, resulting in limited blood supply to ureters.
Based on the shortcomings of traditional surgical methods, it is necessary to improve it in order to achieve the following results: (1) the operation method is relatively simple; (2) the time of operation is shortened, the effect of the patient is small, the risk of the serious disease is reduced; (3) reduce the complications, such as reducing the leakage of urine, the infection around the stoma, and so on. (4) reduce the risk of operation and improve the patient's life. Quality, reduce medical expenses and so on.
The improvement of traditional ureterostomy was made in the undergraduate room: (1) unilateral: unilateral ureteral incision in the lower abdomen of the affected side, incision of the abdominal wall by layer by layer, out of the peritoneum and the lower part of the ureter outside the peritoneum. The ureteral retention and ureteral length of the ureter were determined according to the original disease. The distal end of the ureter was ligation with silk thread. Up to the upper end of the ureter, the ureter was sutured with 12cm. The middle and lower middle section of the tube. A circular incision was taken in the middle abdomen of the affected side. The diameter of the incision was about 0.6cm. The incision in the aponeurosis of the abdominal tendinous aponeurosis was taken and the ureter was extracted from the round skin through the incision. The ureter was sutured intermittently to fix the ureter. The ureter was sutured intermittently with the absorbable line. Wall and round skin incision. Longitudinal incision of ureteral 0.5cm, ureteral end to turn out, fold. The end of the right ureter is papillary protrusion 0.5cm, from the nipple to the ureter 6F silicone tube, depth about 20cm, or insert a single "J" tube, nipple on a pocket to collect urine.
(2) bilateral: Taking the middle incision of the lower abdomen, starting from the upper edge of the pubis, opening the tissue by 15cm. layer by layer, finding the middle and lower middle segment of the bilateral ureters and transection separately from the peritoneum. The distal end is ligation of the 4 silk thread, each of the two sides of the middle abdomen is taken a circular incision, the diameter is about 0.6cm, the subcutaneous tissue is removed, and the aponeurosis of the abdominal oblique muscle is equally big. Small and shape incisions were cut through the incision in the abdominal and abdominal transverse muscles, and the bilateral ureters were extracted from the left and right circular incisions. The ureteral wall and the aponeurosis were sutured intermittently by 4-0 absorbable lines to fix the ureter. The ureteral wall and the round skin incision were sutured intermittently with 5-0 absorbable lines. Ureterotomy was made in the longitudinal incision of the ureter 0.5cm The end of the ureter is everted and folded. Papillary protrusion at the ends of the ureter 0.5cm..
Health related quality of life refers to the subjective perception of life and environment, including physical symptoms, social relations, psychological emotions, and environmental interaction when the individual is affected by the condition and treatment of different cultures and values. The quality of life as a recognized therapeutic evaluation index can help clinicians and nursing station. In the position of the patient, the choice and evaluation of the treatment, the nursing plan, the screening of the main factors affecting the quality of life of the patient, the follow-up of the patients and the improvement of health education. The medical model has changed. With these changes, in clinical work, the medical workers are not only concerned with the treatment and rehabilitation of the patients' physiology, but also in the clinical work. Pay attention to the physiological, psychological and social changes of the patients.
The quality of life survey is an effective method for screening and evaluating various chronic diseases, including cancer, and the so-called health related quality of life (HRQOL) refers to the health status and subjective satisfaction of people's living conditions and events under the influence of disease, accidental injury and medical intervention.
The present study conducted a prospective study of the related clinical data of traditional ureterostomy and improved surgical patients, using a bladder cancer specific scale FACT-BL to conduct a questionnaire survey of two patients receiving traditional ureterostomy and modification in our hospital and compared the incidence of postoperative complications of the two surgical procedures. Quality of life and the quality of life related to bladder cancer, and explore the causes of these differences, provide the basis of health related quality of life for the choice of ureterostomy, so as to improve the quality of life after the operation of the patients.
Methods: patients who were hospitalized in the Department of Urology of Guangzhou No.1 People's Hospital from December 2006 to 2013 were selected for admission criteria: 1, for various reasons, ureterostomy was required for various reasons: (1). Late malignant tumors of the bladder or adjacent organs, extensive bladder involvement, reduced capacity, repeated bleeding, and compression of the lower ureter to cause the kidney. Patients with functional failure (2). Neurogenic bladder dysfunction, accompanied by vesical ureteral reflux, ascending hydronephrosis, repeated infection and impaired renal function, unable to tolerate large surgical patients.2, patients without mental illness, can correctly understand the content of the questionnaire and complete the questionnaire independently; and 3, patients sign informed consent.
The operation group was divided into the traditional operation group and the modified operation group. 19 cases were treated with traditional ureterostomy and 22 cases of modified ureterostomy. The group standard of the patients: from the clinical practice, the group of patients could not be randomly divided into groups. Our study was divided into groups according to the doctor, Professor Xie Keji. Modified operation was performed in the treatment group of the main knife, and the traditional operation was performed in the treatment group with other doctors who were skilled in the treatment of ureterostomy.
41 cases were selected, including 19 cases of traditional ureterostomy and 22 cases of improved operation. The data were collected, including operation time, intraoperative bleeding, postoperative hospitalization time, postoperative complications and so on. Including patient name, sex, age, operation date, operation mode, type of disease, pathological type, tumor staging, classification, family address, telephone, E-mai1 and other contents, use bladder cancer specific scale FACT-BL to investigate, invite patients to visit our hospital regularly, complete the questionnaire at the same time, or send a return letter by mail, or send a return letter by mail. Postage and envelope, or E-mail send electronic questionnaire, or telephone inquiry to complete the investigation on the postoperative complications of two surgical patients and the quality of life at 1 months, 3 months, 6 months, 9 months, 12 months and so on, so as to dynamically observe the changes of the quality of life after the operation of the two surgical patients. The quality of life was compared between two surgical methods at different time points.
The measurement data were expressed by mean + standard deviation (x + s), and the independent sample t test was used (Independent S).
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R737.14
本文编号：2145008
[Abstract]:Background and purpose:
The biological behavior of invasive bladder cancer is highly malignant. The main treatment is cystectomy and urinary diversion. Radical surgery can effectively improve the survival rate of the patients, avoid local recurrence and distant metastasis. However, radical cystectomy and urinary diversion often bring the quality of life to the patients. The physical condition of each bladder cancer patient, surgical tolerance, expectation of survival and the expectation of treatment are different, so it is necessary to explore the way of radical resection of bladder cancer and urinary diversion that are suitable for different patients.
Since Simon reported 1 cases of ureterorectal anastomosis in patients with vesical valgus in 1852, urinary diversion has a history of more than 100 years. According to the experience of different conditions and different surgeons, various surgical methods have been studied and designed. Different surgical methods have their own adaptability and their advantages and disadvantages.
The ideal permanent urinary diversion should be able to prevent postoperative complications, protect the renal function and make patients close to normal life. The various permanent urinary diversion methods currently used have not been perfected and have their own advantages and disadvantages. Surgery, abdominal wall urethra, urethra orostomy; (2) using a segment of free bowel in the abdominal wall orostomy as a channel of urinary flow, such as ileocecal bladder, colon bladder operation, and urinary fecal confluence operation: ureterostomy, ureterocolonic and rectal anastomosis; (4) fecal shunt: rectal bladder, rectum bladder to colon Abdominal orostomy; 5. Controlled enterostomy is divided into two categories: one type of controlled intestinal bladder abdominal orostomy, such as controlled ileocecal bladder, controlled ileocecal cystectomy; the other is new cystectomy or orthotopic bladder operation, such as ileocecal cystectomy, and cecum new bladder operation. The choice of surgical methods should be based on the patient's specific conditions, such as Age, physical condition, primary nature, life expectancy, anatomy and function of the upper urinary tract and bowel, history of abdominal, pelvic surgery and radiotherapy, combined with the patient's requirements and the experience of the surgeon, to choose carefully.
Ureterostomy (Cutaneous Ureterostomy, CU) is a permanent or temporary urinary diversion of the ureteral broken end and skin. This is a simple, safe operation. It is divided into two types: ureterostomy and ureterostomy at the end of ureter. In 1967, ureterostomy was first reported by ureterostomy. A method of urinary diversion, which was used to treat congenital urinary tract obstruction in children, was later extended to the palliative urinary diversion for treatment of adult pelvic malignancies. Ureterostomy is currently used as a permanent urinary diversion, but ureterostomy is relatively less. Still used as an attractive permanent urinary diversion, especially for advanced bladder tumor. Its surgical indications are: 1, advanced malignant tumors of the bladder or adjacent organs, extensive bladder involvement, reduced capacity, repeated bleeding, and oppression of the lower ureteral segment of the kidney and renal insufficiency; 2, children suffering from urinary obstruction or Functional disorders, causing severe water dilatation in the upper urinary tract, especially in patients with infection and uremia, and 3, suffer from neurogenic bladder dysfunction, cystureteral reflux, retrograde hydronephrosis, recurrent infection and impaired renal function, which can not be tolerated by the larger surgeons.
The simple procedure of the traditional ureterostomy: (1) a total cystectomy or exploratory laparotomy should be performed, with a median incision in the lower abdomen and a abdominal operation; a simple ureterostomy, a double lower abdominal incision and extraperitoneal surgery. (2) the posterior subperitoneum and the lower middle ureteral segment are separated and cut off. The F8 ureteral stent was inserted into the renal pelvis at the end of the ureter, and the distal end of the ureter was ligated through the thread. (3) a blunt separation was made in front of the sacral promontory and the posterior sigmoid mesenteric membrane, forming a channel to pull the ureter through the channel to the opposite side. The ureter was anastomosed to the end of the ureter from the contralateral ureter to the end of the ureter, and the stent drainage tube was kissed. The anterior wall of the ureter was inserted into the inferior ureter and inserted into the broken end, sutured the anterior wall of the ureter anastomosis and sutured the ureteral outer membrane of the anastomotic mouth intermittently. (4) the abdominal incision on one side of the ureterostomy was extended into S shape, the length and bottom width of the two trapezoid flaps were both 2.5-3.0cm, and the middle point of the S shaped incision was equivalent to the superior margin of the iliac crest. Level. (5) to stitch the aponeurosis of the abdominis muscle to the relative musculus musculus musculus. The aponeurosis on both sides of the aponeurosis and the incision of the muscles are sutured with silk thread to form a button shaped channel, which allows the ureter to pull out the abdominal wall through this channel. The 3-0 absorbable line passes through the outer membrane of the urinary duct and is fixed to the edge of the buttonhole. (6) 3-0 absorbs the seam. Combined with skin wound, the skin tube was wrapped around ureter. The distal ureter and the skin margin were sutured by silk thread, and the drainage tube was fixed.
The traditional ureterostomy has the following shortcomings: (1) the abdominal wall incision is many, the incision is long, the trauma is big, the beauty effect is poor; (2) the skin around the orostomy is not flat, and the leakage urine is easy to occur; (3) the complications of the ureteral end necrosis, the stenosis or the skin tube cracking are easy to occur. (4) some cases have gradually atrophied and shortened after operation, making urine difficult to receive. (5) because of the need to make skin nipples, the length of ureters needed is longer, and the ureteral tension is easy to increase, resulting in limited blood supply to ureters.
Based on the shortcomings of traditional surgical methods, it is necessary to improve it in order to achieve the following results: (1) the operation method is relatively simple; (2) the time of operation is shortened, the effect of the patient is small, the risk of the serious disease is reduced; (3) reduce the complications, such as reducing the leakage of urine, the infection around the stoma, and so on. (4) reduce the risk of operation and improve the patient's life. Quality, reduce medical expenses and so on.
The improvement of traditional ureterostomy was made in the undergraduate room: (1) unilateral: unilateral ureteral incision in the lower abdomen of the affected side, incision of the abdominal wall by layer by layer, out of the peritoneum and the lower part of the ureter outside the peritoneum. The ureteral retention and ureteral length of the ureter were determined according to the original disease. The distal end of the ureter was ligation with silk thread. Up to the upper end of the ureter, the ureter was sutured with 12cm. The middle and lower middle section of the tube. A circular incision was taken in the middle abdomen of the affected side. The diameter of the incision was about 0.6cm. The incision in the aponeurosis of the abdominal tendinous aponeurosis was taken and the ureter was extracted from the round skin through the incision. The ureter was sutured intermittently to fix the ureter. The ureter was sutured intermittently with the absorbable line. Wall and round skin incision. Longitudinal incision of ureteral 0.5cm, ureteral end to turn out, fold. The end of the right ureter is papillary protrusion 0.5cm, from the nipple to the ureter 6F silicone tube, depth about 20cm, or insert a single "J" tube, nipple on a pocket to collect urine.
(2) bilateral: Taking the middle incision of the lower abdomen, starting from the upper edge of the pubis, opening the tissue by 15cm. layer by layer, finding the middle and lower middle segment of the bilateral ureters and transection separately from the peritoneum. The distal end is ligation of the 4 silk thread, each of the two sides of the middle abdomen is taken a circular incision, the diameter is about 0.6cm, the subcutaneous tissue is removed, and the aponeurosis of the abdominal oblique muscle is equally big. Small and shape incisions were cut through the incision in the abdominal and abdominal transverse muscles, and the bilateral ureters were extracted from the left and right circular incisions. The ureteral wall and the aponeurosis were sutured intermittently by 4-0 absorbable lines to fix the ureter. The ureteral wall and the round skin incision were sutured intermittently with 5-0 absorbable lines. Ureterotomy was made in the longitudinal incision of the ureter 0.5cm The end of the ureter is everted and folded. Papillary protrusion at the ends of the ureter 0.5cm..
Health related quality of life refers to the subjective perception of life and environment, including physical symptoms, social relations, psychological emotions, and environmental interaction when the individual is affected by the condition and treatment of different cultures and values. The quality of life as a recognized therapeutic evaluation index can help clinicians and nursing station. In the position of the patient, the choice and evaluation of the treatment, the nursing plan, the screening of the main factors affecting the quality of life of the patient, the follow-up of the patients and the improvement of health education. The medical model has changed. With these changes, in clinical work, the medical workers are not only concerned with the treatment and rehabilitation of the patients' physiology, but also in the clinical work. Pay attention to the physiological, psychological and social changes of the patients.
The quality of life survey is an effective method for screening and evaluating various chronic diseases, including cancer, and the so-called health related quality of life (HRQOL) refers to the health status and subjective satisfaction of people's living conditions and events under the influence of disease, accidental injury and medical intervention.
The present study conducted a prospective study of the related clinical data of traditional ureterostomy and improved surgical patients, using a bladder cancer specific scale FACT-BL to conduct a questionnaire survey of two patients receiving traditional ureterostomy and modification in our hospital and compared the incidence of postoperative complications of the two surgical procedures. Quality of life and the quality of life related to bladder cancer, and explore the causes of these differences, provide the basis of health related quality of life for the choice of ureterostomy, so as to improve the quality of life after the operation of the patients.
Methods: patients who were hospitalized in the Department of Urology of Guangzhou No.1 People's Hospital from December 2006 to 2013 were selected for admission criteria: 1, for various reasons, ureterostomy was required for various reasons: (1). Late malignant tumors of the bladder or adjacent organs, extensive bladder involvement, reduced capacity, repeated bleeding, and compression of the lower ureter to cause the kidney. Patients with functional failure (2). Neurogenic bladder dysfunction, accompanied by vesical ureteral reflux, ascending hydronephrosis, repeated infection and impaired renal function, unable to tolerate large surgical patients.2, patients without mental illness, can correctly understand the content of the questionnaire and complete the questionnaire independently; and 3, patients sign informed consent.
The operation group was divided into the traditional operation group and the modified operation group. 19 cases were treated with traditional ureterostomy and 22 cases of modified ureterostomy. The group standard of the patients: from the clinical practice, the group of patients could not be randomly divided into groups. Our study was divided into groups according to the doctor, Professor Xie Keji. Modified operation was performed in the treatment group of the main knife, and the traditional operation was performed in the treatment group with other doctors who were skilled in the treatment of ureterostomy.
41 cases were selected, including 19 cases of traditional ureterostomy and 22 cases of improved operation. The data were collected, including operation time, intraoperative bleeding, postoperative hospitalization time, postoperative complications and so on. Including patient name, sex, age, operation date, operation mode, type of disease, pathological type, tumor staging, classification, family address, telephone, E-mai1 and other contents, use bladder cancer specific scale FACT-BL to investigate, invite patients to visit our hospital regularly, complete the questionnaire at the same time, or send a return letter by mail, or send a return letter by mail. Postage and envelope, or E-mail send electronic questionnaire, or telephone inquiry to complete the investigation on the postoperative complications of two surgical patients and the quality of life at 1 months, 3 months, 6 months, 9 months, 12 months and so on, so as to dynamically observe the changes of the quality of life after the operation of the two surgical patients. The quality of life was compared between two surgical methods at different time points.
The measurement data were expressed by mean + standard deviation (x + s), and the independent sample t test was used (Independent S).
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R737.14
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