本文選題：膀胱癌 + 膀胱全切��； 參考：《西南醫(yī)科大學》2017年碩士論文

【摘要】：膀胱癌在我國泌尿系腫瘤發(fā)病率占居第一位,歐美僅僅次于前列腺癌,位居第二;對于肌層浸潤性膀胱癌、高級別非肌層浸潤性膀胱癌等,根治性膀胱切除(新膀胱重建)+雙側盆腔淋巴結清掃+尿流改道術仍然是首選措施,且在臨床上已取得一定的療效,但術后如何取代膀胱的功能及尿流改道的方式目前尚無標準治療的方案;其中回腸膀胱術(Bricker術)是一種經(jīng)典的尿流改道方式,具有操作簡單、并發(fā)癥少等優(yōu)點,隨著泌尿外科醫(yī)師逐漸對其術式的完善,其在臨床上的應用價值就更一步體現(xiàn)出來。目的:目前,隨著重建原位可控性膀胱的出現(xiàn),因為其近乎還原正常的泌尿系解剖和功能,而受到患者及泌尿外科醫(yī)師的重視�；啬c膀胱術(Bricker術)有逐漸被替代、忽略的趨勢;本研究主要通過對膀胱癌患者行膀胱全切回腸膀胱術(Bricker術)的臨床治療過程分析,來說明Bricker術在膀胱癌手術治療中仍有重要的臨床應用價值。方法:通過回顧性分析2013年1月至2017年1月在我科行膀胱癌膀胱全切回腸膀胱術42例患者臨床資料,包括:患者一般情況、臨床表現(xiàn)、術前影像學檢查、術前膀胱鏡檢查及術前病理分期。根據(jù)不同情況患者術中情況、術后恢復情況、術后近期并發(fā)癥、有限隨訪時間段內(nèi)的遠期并發(fā)癥及造瘺口相關情況;同時結合查閱相關文獻,共同分析Bricker術在膀胱癌手術治療、術后恢復效果及臨床應用價值。結果:納入研究的病例中:其中有18為腹腔鏡下行Bricker術,24例為機器人輔助腹腔鏡下手術。近期并發(fā)癥:術中輸血0例;術后腸梗阻有5例;術后感染7例;尿瘺1例;術后出血0例;下肢靜脈血栓1例;心血管并發(fā)癥0例;腸瘺0例。遠期并發(fā)癥:腫瘤復發(fā)2例;腎臟結石、積水6例;腎功能損害5例;輸尿管吻合口狹窄4例;造瘺口皮損10例。值得一提的是:研究病例中有3例病人術前擬行原位膀胱重建術,在術中發(fā)現(xiàn)腫瘤侵犯尿道,術中修改手術方式為回腸膀胱術。近期并發(fā)癥的患者均在院治療后康復出院,遠期并發(fā)癥的患者經(jīng)保守治療有所好轉(zhuǎn),研究病例大部分病例對術后生活質(zhì)量滿意。結論:回腸膀胱術(Bricker術)在膀胱癌患者可以取得顯著的療效,且具有較高的安全性,術后并發(fā)癥較少。根據(jù)查閱的相關文獻,回腸原位膀胱術與Bricker術具有無差異的腫瘤治療效果,術中、術后的近期并發(fā)癥并無較大差異。但是Bricker術對于尿道切緣陽性、嚴重尿道括約肌功能不全及尿道狹窄、肝腎功能不能耐受原位膀胱術等患者來說,是比較唯一的治療方式;同時原位新膀胱術后上尿路功能并發(fā)癥要高于回腸膀胱術(Bricker術),包括腎功能的損害、尿路感染、尿路結石的發(fā)生概率,原位新膀胱患者術后需要嚴格的排尿管理,部分病人需要輔助排尿管理行間歇性自行導尿(CIC)或者長期使用尿不濕防止尿液外漏;從而得出以下結論:1)、存在原位新膀胱禁忌癥患者,Bricker膀胱術為首選術式;2)、原位新膀胱術在術后早期并發(fā)癥與Bricker膀胱術并無差異,但是術后遠期上尿路功能損害較為嚴重;所以對于合并慢性疾病,特別是肝腎功能不全的患者,可以首先考慮Bricker膀胱術;3)、對于醫(yī)從性、經(jīng)濟條件較差的患者來說,Bricker膀胱術優(yōu)于原位新膀胱術。由此我們認為Bricker術在膀胱癌手術治療中仍占有不可替代的地位,在臨床工作中仍有相當大的應用價值。
[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.
【學位授予單位】：西南醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R737.14

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