Studer U E, Danuser H, Merz V W, Springer J P, Zingg E J
Department of Urology, University of Berne, Switzerland.
J Urol. 1995 Jul;154(1):49-56.
Between April 1985 and April 1993, 100 consecutive men underwent lower urinary tract reconstruction after cystectomy. An ileal low pressure reservoir using the Goodwin cup-patch principle was combined with an afferent ileal tubular segment. The early complication rate was 11%, including 2 postoperative deaths due to septicemia. After a median followup of 27 months (range 3 to 96) 14 patients required surgery for late complications (intestinal obstruction, urethral stricture or tumor recurrence, hernia or ureteral stenosis). A total of 32 patients died of metastatic bladder cancer and 7 died of other causes. The functional capacity of the bladder substitute was increased to the desired 450 to 500 ml. after 3 to 12 months, which was paralleled by improving urinary continence. After 1 year 92% of the patients were continent by day and after 2 years 80% were continent at night. Upper tract surveillance with excretory urography, renal ultrasound and serum creatinine estimation has shown 4 left ureteral strictures but not significant upper tract deterioration or ureteral recurrence. Significant reflux was not observed during video urodynamics unless the reservoir was overfilled. During voiding, by outlet relaxation and straining if necessary, the intra-abdominal pressure increase with straining acted equally on the reservoir and ureters. Therefore, unlike voiding with a normal bladder, no isolated intravesical pressure increase occurred and, thus, there was no reflux from the reservoir. The combination of an ileal low pressure reservoir with an afferent isoperistaltic ileal segment and an open end-to-side ureteroileal anastomosis allows for radical cancer surgery with resection of the ureters where they cross the iliac vessels and minimizes the risk of ureteral stenosis. The unidirectional peristalsis of the ureters and the afferent tubular ileal segment seem to protect the upper urinary tract sufficiently. The surgical technique is straightforward and allows for later conversion to an ileal conduit if necessary. The functional results of the bladder substitute are comparable to other similar reservoir techniques, provided that the patients are carefully selected, well rehabilitated and meticulously followed.
1985年4月至1993年4月期间，100例连续男性患者在膀胱切除术后接受了下尿路重建手术。采用古德温杯状补片原理构建的回肠低压储尿囊与一段传入性回肠管状段相结合。早期并发症发生率为11%，包括2例因败血症导致的术后死亡。中位随访27个月（范围3至96个月）后，14例患者因晚期并发症（肠梗阻、尿道狭窄或肿瘤复发、疝气或输尿管狭窄）需要手术治疗。共有32例患者死于转移性膀胱癌，7例死于其他原因。膀胱替代物的功能容量在3至12个月后增加到理想的450至500毫升，同时尿失禁情况有所改善。1年后，92%的患者白天能保持控尿，2年后，80%的患者夜间能保持控尿。通过排泄性尿路造影、肾脏超声和血清肌酐评估进行的上尿路监测显示有4例左侧输尿管狭窄，但上尿路无明显恶化或输尿管复发。在影像尿动力学检查期间，除非储尿囊过度充盈，否则未观察到明显反流。排尿时，通过出口放松并在必要时用力，用力时腹内压升高对储尿囊和输尿管的作用相同。因此，与正常膀胱排尿不同，储尿囊内压力不会单独升高，从而不会出现储尿囊反流。回肠低压储尿囊与传入性等蠕动回肠段以及开放的端侧输尿管回肠吻合术相结合，能够在输尿管穿过髂血管处进行切除的根治性癌症手术，并将输尿管狭窄的风险降至最低。输尿管和传入性回肠管状段的单向蠕动似乎足以保护上尿路。手术技术简单明了，必要时可在后期转换为回肠导管。如果患者经过精心挑选、良好康复并得到细致随访，膀胱替代物的功能结果与其他类似的储尿囊技术相当。
