Flohr P, Hefty R, Paiss T, Hautmann R
Department of Urology, Faculty of Medicine, University of Ulm, Germany.
World J Urol. 1996;14(1):22-6. doi: 10.1007/BF01836340.
From April 1986 through May 1995, 306 men with primary urothelial carcinoma underwent radical cystoprostatectomy and orthotopic bladder substitution via the ileal neobladder. Altogether, 7.5% of the patients suffered general early complications, including thrombosis, embolism, wound infection, and pneumonia. Specific early complications directly related to formation of the neobladder and requiring surgery included ileus (4%), abscess drainage (2%), and leakage of the ileal anastomosis (0.5%). The early reoperation rate was 6.5%. Early complications that required temporary percutaneous drainage were lymphocele formation (3%) or ureteral obstruction (6%). In all, 9% of our patients required prolonged catheter drainage for leakage of the ileouretheral anastomosis. Late complications requiring reoperation were ileus (2%), abscess drainage (1%), neobladder fistula to the colon (1.5%), ureteral reimplantation because of obstruction (3.6%), and nephrectomy for hydronephrosis (1%). A transurethral incision of the ileouretheral anastomosis was necessary in 7% of cases. Continence was separately addressed by sending each patient and his home physician a detailed questionnaire: Using our criteria (no diapers, no awakenings) the night and day continence rate increased from 67% at 6 months, to 72% at 1 year to 85% at 2 years, finally reacting 90% after 4 years. In part II of this presentation we address the question as to whether the option of orthotopic bladder replacement has any impact on the patient's and physician's decision toward earlier cystectomy. We compared our ileal neobladder cohort with a group of 137 patients that had been operated on during the same time span by the same group of surgeons. There was no negative selection with regard of the tumor stage of our patients. However, as compared with the conduit group, the neobladder cohort had a significantly improved survival rate. This phenomenon is explainable by the significantly lower number of previous transurethral resections of the bladder (TUR-Bs) performed in the neobladder group. The time span between primary diagnosis and cystectomy was 10 months in the neobladder group as compared with 18 months in the conduit patients. These data reinforce our belief that orthotopic bladder replacement using the ileal neobladder yields an extraordinary functional result that can be accomplished with a high degree of patient satisfaction and minimal complication. The availability of orthotopic bladder replacement does indeed stimulate the physicians and patients decision toward earlier cystectomy.
从1986年4月至1995年5月，306例原发性尿路上皮癌男性患者接受了根治性膀胱前列腺切除术，并通过回肠新膀胱进行原位膀胱替代。总体而言，7.5%的患者出现了一般早期并发症，包括血栓形成、栓塞、伤口感染和肺炎。与新膀胱形成直接相关且需要手术的特定早期并发症包括肠梗阻（4%）、脓肿引流（2%）和回肠吻合口漏（0.5%）。早期再次手术率为6.5%。需要临时经皮引流的早期并发症是淋巴囊肿形成（3%）或输尿管梗阻（6%）。总之，9%的患者因回肠输尿管吻合口漏需要延长导管引流。需要再次手术的晚期并发症有肠梗阻（2%）、脓肿引流（1%）、新膀胱结肠瘘（1.5%）、因梗阻行输尿管再植（3.6%）以及因肾积水行肾切除术（1%）。7%的病例需要经尿道切开回肠输尿管吻合口。通过向每位患者及其家庭医生发送详细问卷来单独评估控尿情况：按照我们的标准（不用尿布、无夜间觉醒），白天和夜间控尿率从6个月时的67%，提高到1年时的72%，2年时的85%，最终在4年后达到90%。在本报告的第二部分，我们探讨原位膀胱替代选项是否对患者和医生关于早期膀胱切除术的决策有任何影响这一问题。我们将回肠新膀胱组与同期由同一组外科医生手术的137例患者组成的一组进行了比较。在患者的肿瘤分期方面没有负面选择。然而，与导管组相比，新膀胱组的生存率有显著提高。这种现象可以通过新膀胱组之前进行的经尿道膀胱肿瘤切除术（TUR-B）数量明显较少来解释。新膀胱组从初次诊断到膀胱切除术的时间跨度为10个月，而导管组患者为18个月。这些数据强化了我们的信念，即使用回肠新膀胱进行原位膀胱替代能产生非凡的功能效果，可实现高度的患者满意度且并发症极少。原位膀胱替代的可用性确实促使医生和患者做出早期膀胱切除术的决策。
