Patil Mukul B, Hannoun Donald, Reyblat Polina, Boyd Stuart D
Center for Genitourinary Prosthetics and Reconstruction, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Center for Genitourinary Prosthetics and Reconstruction, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
J Urol. 2015 May;193(5):1649-54. doi: 10.1016/j.juro.2014.11.102. Epub 2014 Dec 19.
Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis.
We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined.
No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion.
Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion.
顽固性后尿道狭窄是一种具有挑战性的疾病。当合并膀胱功能丧失时，皮肤造口尿流改道是最常见的手术选择。我们提出一种全下尿路重建的新技术，结合挽救性膀胱切除术、回肠新膀胱形成术和尿道拖入术，作为膀胱功能丧失和顽固性后尿道狭窄患者的原位替代方案。
我们对8例行挽救性膀胱切除术、原位回肠新膀胱形成术和尿道拖入术的患者进行了回顾性研究。人工尿道括约肌分阶段置入。6例患者接受了包括放疗在内的前列腺癌治疗，1例在机器人根治性前列腺切除术后发生尿道断裂，1例在摩托车事故中发生膀胱破裂和尿道牵拉伤。对患者的人口统计学、手术变量和术后结果进行了检查。
挽救性膀胱切除术、原位新膀胱形成术和尿道拖入术后未观察到高级别并发症。在分阶段置入人工尿道括约肌后，平均需要2次（范围0至4次）翻修手术才能实现社会控尿。所有患者在中位随访58个月时均保持了功能性膀胱储尿、尿道通畅和社会控尿。没有患者出现与原位新膀胱形成相关的并发症，包括输尿管回肠吻合口狭窄或肾盂肾炎，也没有患者需要皮肤造口尿流改道。
膀胱切除术、回肠新膀胱形成术和尿道拖入术的全下尿路重建为顽固性后尿道狭窄和膀胱功能丧失的患者提供了一种原位替代方案。虽然需要分阶段置入人工尿道括约肌，但这种方法可以提供功能性膀胱储尿、持久的尿道通畅并避免皮肤造口尿流改道。
