【摘要】：目的： 探討回腸膀胱術(shù)、原位回腸新膀胱術(shù)、輸尿管皮膚造口術(shù)等三種不同尿流改道術(shù)式在膀胱癌患者手術(shù)中的應(yīng)用、早期并發(fā)癥及生活質(zhì)量的差異,為膀胱癌患者尿流改道術(shù)式的選擇提供臨床依據(jù)。 方法： 收集2010年1月至2013年6月間在我院接受膀胱癌手術(shù)的186例膀胱癌患者,所有患者在全膀胱切除后行尿流改道術(shù),按尿流改道術(shù)式分為：回腸膀胱術(shù)組(A組,65例),原位新膀胱術(shù)組(B組,58例),輸尿管皮膚造口術(shù)組(C組,63例)。收集并將各組患者的基線資料、術(shù)中失血量、手術(shù)時(shí)間、腸道功能恢復(fù)時(shí)間、住院時(shí)間,記錄術(shù)后早期并發(fā)癥,如傷口感染、肺部感染、腸梗阻、漏尿、尿路感染和圍手術(shù)期死亡人數(shù)及其它并發(fā)癥,采用膀胱癌患者生活質(zhì)量量表(FACT-BL)評估術(shù)后生命質(zhì)量變化,比較三組間各資料差異,探討三種不同尿流改道術(shù)式在老年膀胱癌患者手術(shù)中的應(yīng)用、早期并發(fā)癥及術(shù)后近期生活質(zhì)量的差異。 結(jié)果： 三組間基線資料比較差異無統(tǒng)計(jì)學(xué)意義(P0.05),手術(shù)時(shí)間、術(shù)中出血量、腸道功能恢復(fù)時(shí)間和住院時(shí)間的差異具有統(tǒng)計(jì)學(xué)意義(P0.05)。輸尿管皮膚造口術(shù)組(C組)在術(shù)中出血量、手術(shù)時(shí)間、腸道功能恢復(fù)時(shí)間和住院時(shí)間上優(yōu)于回腸膀胱術(shù)組(A組)及原位新膀胱術(shù)組(B組)(P0.05),回腸膀胱術(shù)組(A組)的手術(shù)時(shí)間、住院時(shí)間優(yōu)于原位新膀胱術(shù)組(B組)(P0.05),A組和B組間的術(shù)中出血、腸道功能恢復(fù)時(shí)間的無統(tǒng)計(jì)學(xué)差異(P0.05)。 三組患者術(shù)后近期(6月)并發(fā)癥如急性腎盂腎炎、急性腸梗阻等其差異具有統(tǒng)計(jì)學(xué)意義(P0.05),C組的急性腎盂腎炎顯著高于A、B兩組(P0.05),而急性腸梗阻顯著低于A、B兩組(P0.05),A、B兩組比較無統(tǒng)計(jì)學(xué)差異(P0.05)。 三組患者術(shù)后遠(yuǎn)期(6月)并發(fā)癥如腎功能損害、代謝性酸中毒具有統(tǒng)計(jì)學(xué)意義(P0.05),C組顯著高于A、B兩組(P0.05),A、B兩組無差異(P0.05)。皮膚造口狹窄、儲尿囊結(jié)石、腫瘤原位復(fù)發(fā)等三組比較無統(tǒng)計(jì)學(xué)差異(P0.05)。 三組患者術(shù)后六個(gè)月后的FACT-BL具有統(tǒng)計(jì)學(xué)差異(P0.05),原位回腸新膀胱術(shù)組(B組)顯著優(yōu)于A、C兩組(P0.05),回腸膀胱術(shù)組(A組)與輸尿管皮膚造口術(shù)組(C組)無統(tǒng)計(jì)學(xué)差異(P0.05)。 結(jié)論： (1)原位回腸新膀胱術(shù)最顯著優(yōu)點(diǎn)是術(shù)后生活質(zhì)量高于回腸膀胱術(shù)及輸尿管皮膚造口術(shù)患者,但該手術(shù)相對復(fù)雜、創(chuàng)傷大、住院時(shí)間長、醫(yī)療費(fèi)用高,回腸膀胱術(shù)次之,但術(shù)后功能恢復(fù)及生活質(zhì)量仍不理想。 (2)輸尿管皮膚造口術(shù)較其它兩種術(shù)式操作簡單、術(shù)后恢復(fù)快,醫(yī)療費(fèi)用少,但輸尿管皮膚造口術(shù)患者術(shù)后生活質(zhì)量差,遠(yuǎn)期并發(fā)癥高于回腸膀胱術(shù)及原位回腸新膀胱術(shù)患者。 (3)三種術(shù)式均可用于膀胱癌患者根治性膀胱切除術(shù)后的尿道改流,臨床上應(yīng)根據(jù)患者腫瘤的性質(zhì)及位置、有無轉(zhuǎn)移、患者的一般情況及個(gè)人意愿等作出個(gè)體化的選擇,以滿足術(shù)后生活質(zhì)量不同期望值及不同病情患者。
[Abstract]:Objective: to explore the application of three different ureteral diversion procedures, including ileal bladder operation, in situ ileal neobladder operation and ureteral dermatostomy, in patients with bladder cancer, and the differences in early complications and quality of life. To provide a clinical basis for the choice of urinary diversion in patients with bladder cancer. Methods: from January 2010 to June 2013, 186 patients with bladder cancer underwent bladder cancer surgery in our hospital. All patients underwent urinary diversion after total cystectomy. The patients were divided into three groups: ileal cystectomy group (group A, 65 cases), orthotopic neocystectomy group (group B, 58 cases) and ureterostomy group (group C, 63 cases). The baseline data, intraoperative blood loss, operative time, intestinal function recovery time, hospitalization time, early postoperative complications such as wound infection, pulmonary infection, intestinal obstruction, leakage of urine were collected and recorded. The quality of life (QOL) of urinary tract infection and perioperative mortality and other complications were evaluated by FACT-BL, and the differences among the three groups were compared. To explore the application of three different urinary diversion methods in the elderly patients with bladder cancer, the early complications and the difference of postoperative quality of life. Results: there was no significant difference in baseline data among the three groups (P0.05). The time of operation, the amount of intraoperative bleeding, the time of recovery of intestinal function and the time of hospitalization were statistically significant (P0.05). The operative time of ureteral dermatostomy group (group C) was better than that of ileal cystectomy group (group A) and in situ neocystectomy group (group B) (P0.05) and ileal cystectomy group (group A). The hospitalization time was better than that in the in situ neobladder group (P0.05). There was no significant difference in the recovery time of intestinal function between), A group and B group (P0.05). The immediate postoperative complications in the three groups were acute pyelonephritis, The difference of acute intestinal obstruction was statistically significant (P0.05). The acute pyelonephritis in), C group was significantly higher than that in), C group (P0.05), while acute intestinal obstruction was significantly lower than that in Ameb group (P0.05), and there was no significant difference between the two groups (P0.05). The complications such as renal function damage and metabolic acidosis were significantly higher in), C group than in Agna B group (P0.05), but there was no significant difference between the two groups (P0.05). There was no significant difference among the three groups (P0.05). Six months after operation, the FACT-BL of the three groups was statistically different (P0.05), the in situ ileal neobladder operation group (group B) was significantly better than that of the control group (P0.05), while the ileal cystectomy group (group A) and ureterostomy group (group C) had no statistical difference (P0.05). Conclusion: (1) the most significant advantage of in situ ileal neobladder surgery is that the quality of life after operation is higher than that in patients with ileal cystectomy and ureteral dermatostomy, but the operation is relatively complex, with large trauma, long hospital stay and high medical cost. Ileal cystectomy was the second, but the functional recovery and quality of life were still not satisfactory. (2) the ureteral dermatostomy was easier to operate than the other two methods, the postoperative recovery was faster, and the cost of medical treatment was less. However, the quality of life of patients with ureteral dermatostomy was poor, and the long-term complications were higher than those of patients with ileal cystectomy and in situ ileal neobladder surgery. (3) all three methods could be used for urethral revascularization after radical cystectomy in patients with bladder cancer. The individual choice should be made according to the nature and location of the tumor, the metastasis, the general situation and the personal will of the patients, so as to meet the different expectations of postoperative quality of life and patients with different conditions.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R737.14

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