University of Ulm, Germany.
Eur Urol. 2013 Jan;63(1):67-80. doi: 10.1016/j.eururo.2012.08.050. Epub 2012 Aug 31.
A summary of the 2nd International Consultation on Bladder Cancer recommendations on the reconstructive options after radical cystectomy (RC), their outcomes, and their complications.
To review the literature regarding indications, surgical details, postoperative care, complications, functional outcomes, as well as quality-of-life measures of patients with different forms of urinary diversion (UD).
An English-language literature review of data published between 1970 and 2012 on patients with UD following RC for bladder cancer was undertaken. No randomized controlled studies comparing conduit diversion with neobladder or continent cutaneous diversion have been performed. Consequently, almost all studies used in this report are of level 3 evidence. Therefore, the recommendations given here are grade C only, meaning expert opinion delivered without a formal analysis.
Indications and patient selection criteria have significantly changed over the past 2 decades. Renal function impairment is primarily caused by obstruction. Complications such as stone formation, urine outflow, and obstruction at any level must be recognized early and treated. In patients with orthotopic bladder substitution, daytime and nocturnal continence is achieved in 85-90% and 60-80%, respectively. Continence is inferior in elderly patients with orthotopic reconstruction. Urinary retention remains significant in female patients, ranging from 7% to 50%.
RC and subsequent UD have been assessed as the most difficult surgical procedure in urology. Significant disparity on how the surgical complications were reported makes it impossible to compare postoperative morbidity results. Complications rates overall following RC and UD are significant, and when strict reporting criteria are incorporated, they are much higher than previously published. Fortunately, most complications are minor (Clavien grade 1 or 2). Complications can occur up to 20 yr after surgery, emphasizing the need for lifelong monitoring. Evidence suggests an association between surgical volume and outcome in RC; the challenge of optimum care for elderly patients with comorbidities is best mastered at high-volume hospitals by high-volume surgeons. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results.
本文总结了第二次膀胱癌根治性切除术（RC）后重建选择、结果和并发症的国际咨询会议建议。
综述不同尿路改道术式（UD）患者的适应证、手术细节、术后护理、并发症、功能结局以及生活质量评估的相关文献。
对 1970 年至 2012 年间发表的膀胱癌 RC 后行 UD 患者的英文文献进行了回顾。目前还没有比较导管分流术与新膀胱或可控性皮管尿流改道术的随机对照研究。因此，本报告中几乎所有的研究都属于 3 级证据。因此，这里给出的建议仅为 C 级，即专家意见，没有经过正式分析。
过去 20 年来，适应证和患者选择标准发生了显著变化。肾功能损害主要由梗阻引起。结石形成、尿液流出和任何水平的梗阻等并发症必须早期识别并及时治疗。在接受原位膀胱替代术的患者中，日间和夜间的控尿率分别达到 85-90%和 60-80%。对于接受原位重建的老年患者，控尿效果较差。女性患者的尿潴留仍较严重，比例为 7%至 50%。
RC 及随后的 UD 被评估为泌尿科最具挑战性的手术。由于报告手术并发症的方式存在显著差异，因此无法比较术后发病率结果。RC 和 UD 后总的并发症发生率较高，当纳入严格的报告标准时，其发生率远高于先前的报道。幸运的是，大多数并发症为轻度（Clavien 1 或 2 级）。并发症可在手术后 20 年内发生，强调需要终身监测。有证据表明 RC 中手术量与结局之间存在关联；患有合并症的老年患者最佳护理的挑战最好由高容量医院的高容量外科医生来掌握。术前患者信息、患者选择、手术技术和仔细的术后随访是实现良好长期效果的基石。
