Lane Brian R, Finelli Antonio, Moinzadeh Alireza, Sharp David S, Ukimura Osamu, Kaouk Jihad H, Gill Inderbir S
Section of Laparoscopic and Minimally Invasive Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
Urology. 2006 Oct;68(4):778-83. doi: 10.1016/j.urology.2006.05.027.
To report the technique and early outcomes of nerve-sparing laparoscopic radical cystectomy with continent orthotopic ileal neobladder in selected male and female patients with bladder cancer.
Since 2000, 52 patients have undergone laparoscopic radical cystectomy at our institution, with nerve-sparing laparoscopic radical cystectomy performed in 5 patients. In the nerve-sparing technique, transection of the lateral vascular pedicle and the posterior dissection proceeds closer to the bladder, at some distance from the rectum. Hem-o-lock clips were used for hemostasis, avoiding the need for any energy source near the neurovascular bundle (NVB). In the male, the identification and complete release of the NVB before division of the urethra minimizes damage to the NVB along the prostatic apex. In the female, preservation of the uterus, fallopian tubes, ovaries, and vagina, maintenance of the endopelvic fascia, and minimal mobilization distal to the urethra facilitates nerve sparing.
The median operative time was 10 hours, blood loss was 400 mL, and the length of stay was 5 days. No patient required blood transfusion, and one had a postoperative complication. All patients were free of recurrence at a median follow-up of 30 months. At 12 months, nocturnal and daytime continence was preserved in 100% and 75% of patients, respectively. Sexual function was preserved in the female patient and 2 of the 4 male patients.
With careful attention to the anatomic location of the NVBs and a precise operative technique, nerve-sparing laparoscopic radical cystectomy can be performed in appropriately selected male and female patients with organ-confined bladder cancer.
报告在选定的男性和女性膀胱癌患者中，采用保留神经的腹腔镜根治性膀胱切除术并同期行可控性回肠原位新膀胱术的技术及早期疗效。
自2000年以来，我院有52例患者接受了腹腔镜根治性膀胱切除术，其中5例患者接受了保留神经的腹腔镜根治性膀胱切除术。在保留神经技术中，外侧血管蒂的横断及后方的分离操作更靠近膀胱，距直肠有一定距离。使用Hem-o-lock夹止血，避免在神经血管束（NVB）附近使用任何能量源。在男性患者中，在离断尿道前识别并完全游离NVB可最大程度减少沿前列腺尖部对NVB的损伤。在女性患者中，保留子宫、输卵管、卵巢和阴道，维持盆腔内筋膜，并尽量减少尿道远端的游离，有助于保留神经。
中位手术时间为10小时，失血量为400 mL，住院时间为5天。无患者需要输血，1例患者有术后并发症。所有患者在中位随访30个月时均无复发。在12个月时，100%的患者夜间控尿良好，75%的患者白天控尿良好。女性患者及4例男性患者中的2例性功能得以保留。
通过仔细关注NVB的解剖位置并采用精确的手术技术，在适当选择的局限于器官的男性和女性膀胱癌患者中可以实施保留神经的腹腔镜根治性膀胱切除术。
