改良与传统输尿管皮肤造口术的比较
摘要
背景与目的：
浸润性膀胱癌生物学行为高度恶性,治疗的主要方法是膀胱切除加尿流改道术。根治性手术能有效提高患者生存率、避免局部复发和远处转移,被认为是标准的手术方式。但由于根治性膀胱切除及尿流改道术常给患者带来生活质量的下降及精神上的压力。每一名膀胱癌患者的身体状况、手术耐受性、预期生存及对治疗结果期待的不同,因此有必要探讨适合不同患者需要既达到肿瘤根治又易于被患者接受的膀胱癌根治和尿流改道手术方式。
自1852年Simon报道为1例膀胱外翻患者施行输尿管直肠吻合术以来,尿流改道手术已有100多年历史,根椐不同病情和不同手术医师的经验,研究和设计出各种的手术方法,不同的术式各有其适应范围,也各有其优缺点。
理想的永久性尿流改道应能达到防止术后并发症,保护肾脏功能,使患者能过接近正常的生活。目前使用的各种永久尿流改道方法尚未臻完善,各具优缺点。可概括为下列几类：①尿路造口手术：如输尿管皮肤造口术、永久性膀胱造口术、腹壁尿道术、尿道造口术；②利用一段游离肠管于腹壁造口,作为尿流通道,如回肠膀胱术、结肠膀胱术；③尿粪合流手术：如输尿管乙状结肠造口术、输尿管结肠-结肠直肠吻合术；④尿粪分流手术：如直肠膀胱术、直肠膀胱-结肠腹壁造口术；⑤可控肠膀胱术,分为二类：一类为可控肠膀胱腹壁造口术,如可控回肠膀胱术、可控回盲肠膀胱术；另一类为新膀胱术或正位可控膀胱术,如回肠新膀胱术、去带回盲肠新膀胱术。手术方法的选择需按照病人具体情况,如年龄、身体条件、原发病性质、预期寿命、上尿路及肠管的解剖及功能情况等,既往有无腹部、盆腔手术及放疗史,结合患者的要求和术者的经验,认真加以选择。
输尿管皮肤造口术(Cutaneous Ureterostomy, CU)是输尿管断端和皮肤的永久性或暂时性尿流改道,这是一种简单、安全术式。大体分为两种类型：输尿管攀皮肤造口术和输尿管末端皮肤造口术。Roth在1967年最先报道了使用输尿管皮肤造口术作为尿流改道的一种方法,原本这种方法用于治疗儿童的先天性尿路梗阻,但是后来逐渐扩展到用于治疗成人盆腔恶性肿瘤的姑息性尿流改道。目前将输尿管皮肤造口术作为永久性尿流改道的方法来使用相对较少,但输尿管皮肤造口术仍作为一种有吸引力的永久性尿流改道的方法,尤其适用于晚期膀胱肿瘤。其手术适应症：1、患膀胱或邻近器官的晚期恶性肿瘤,膀胱广泛受累,容量缩小,反复出血,压迫输尿管下段引起肾积水和肾功能不全者；2、儿童患下尿路梗阻或功能性疾患,致上尿路严重积水扩张,尤其是合并感染和尿毒症者；3、患神经原性膀胱功能障碍,伴有膀胱输尿管返流、逆行性肾积水、反复感染及肾功能受损,不能耐受较大手术者。
传统输尿管皮肤造口术简要手术步骤：(1)需施行膀胱全切除或剖腹探查术者,使用下腹正中切口,经腹腔施行手术；单纯作输尿管皮肤造口术者,采用双下腹斜切口,经腹膜外施行手术。(2)腹膜后分离双侧输尿管中下段并将其切断,近端插入F8输尿管支架管达肾盂、固定在输尿管断端,远端用丝线贯穿结扎。(3)在骶岬前方、乙状结肠系膜后方作钝性分离,形成一通道,将一侧输尿管通过此通道拉至对侧。在离对侧输尿管断端约10cm处作输尿管端侧吻合,将支架引流管经吻合口放入对侧输尿管下段,并插至断端之外,将输尿管吻合口前壁缝合,间断缝合吻合口的输尿管外膜。(4)将输尿管造口的一侧的腹部切口延长成S形,两个梯形皮瓣的长度和底宽均为4cm,顶边约为2.5-3.0cm,S形切口的中点相当于髂嵴上缘水平。(5)将腹外斜肌腱膜于相对的腹横肌肌膜创缘缝合数针,其两旁的腱膜、肌肉切口则用丝线缝合,形成一纽扣状通道,让输尿管通过此通道拉出腹壁之外。用3-0可吸收线于适当位置穿过输尿管外膜,并固定于钮孔边缘。(6)3-0可吸收线缝合皮肤创缘,形成包绕输尿管的皮管。用丝线将输尿管末端与皮缘间断缝合,并将引流管固定。
传统的输尿管末端皮肤造口术有以下缺点：(1)腹壁切口多、切口长,创伤大,美容效果差；(2)造口周围皮肤不平坦,易发生漏尿；(3)易发生输尿管末端坏死、狭窄或皮管裂开等合并症；(4)一些病例术后皮管逐渐萎缩、变短、使尿液不易收集,而需长期留置引流管；(5)因需要做皮肤乳头,所需输尿管长度也较长,易增加输尿管张力,导致输尿管血供受限。
基于传统术式以上缺点,有必要对其进行改良,以期达到以下效果：(1)手术方法相对简单；(2)手术时间缩短,对患者全身影响小,对病情较重者风险降低；(3)减少并发症：如减少漏尿、造口周围感染等。(4)降低手术风险,提高病人的生活质量,降低医疗费用等。
本科室对传统输尿管皮肤造口术进行改良,其的简要手术步骤：(1)单侧：取患侧下腹长约12cm手术斜切口,逐层切开腹壁,腹膜外找到患侧输尿管中、下段。根据原发病确定输尿管保留输尿管长度并离断,远断端以丝线缝扎。向上游离输尿管中下段。于患侧中腹部取一圆形切口,直径约0.6cm,戳穿下组织,于腹外斜肌腱膜取一同样大小和形状的切口,并经该切口将输尿管从圆形皮肤口引出体外。间断缝合输尿管壁和腹外斜肌腱膜,以固定输尿管。以可吸收线间断缝合输尿管壁和圆形皮肤切口。纵形切开输尿管0.5cm,将输尿管末端外翻、折叠。右输尿管末端呈乳头状突出皮面0.5cm,从该乳头向输尿管插6F硅胶管,深度约20cm,或插单“J”管,乳头上接一造口袋以搜集尿液。
(2)双侧：取下腹正中切口,起自耻骨联合上缘,长约15cm。逐层切开组织,于腹膜外分别找到双侧输尿管中下段并横断,远断端以4号丝线缝扎,分别于两侧中腹部各取一圆形切口,直径约0.6cm,切除其下皮下组织,于腹外斜肌腱膜取一同样大小和形状的切口,并经该切口戳穿腹内斜肌和腹横肌,分别将双侧输尿管从左右圆形切口引出体外。以4-0可吸收线间断缝合输尿管壁和腹外斜肌腱膜,以固定输尿管。以5-0可吸收线间断缝合输尿管壁和圆形皮肤切口。纵形切开输尿管0.5cm,将输尿管末端外翻、折叠。双侧输尿管末端呈乳头状突出皮面0.5cm。
健康相关生活质量指不同文化和价值体系下,个体受到病情和治疗的影响时,对生活和环境的主观知觉感受,包括对身体症状、社会关系、心理情绪、环境互动等的评价。生命质量作为一个公认的疗效评价指标,能够帮助临床医生、护士站在患者的立场,选择和评价治疗、护理方案,筛选影响患者生命质量的主要因素,有针对性地对患者进行随访和完善健康教育。医学模式已经发生了变化,随着这些变化,在临床工作中,医务工作者不再只关注患者生理的治疗和康复,还要关注患者的生理、心理、社会方面的变化。
生活质量调查是目前国际上对包括肿瘤在内的各种慢性疾病治疗方案筛选和评价的有效方法。所谓健康相关生活质量(HRQOL),是指在疾病、意外损伤及医疗干预影响下,与人的生活条件和事件相关的健康状态和主观满意度。
本研究通过前瞻性研究传统输尿管皮肤造口术与改良术式患者的相关临床资料,应用膀胱癌特异性量表FACT-BL对在我院接受传统输尿管皮肤造口术和改良术两种术式的患者进行问卷调查,比较两种术式术后相关并发症的发生率,总体生活质量和膀胱癌相关方面生活质量的差别,并探讨产生这些差别的原因,为输尿管皮肤造口术式的选择提供健康相关生活质量方面的依据,从而提高患者术后生活质量。
方法：选取2006年12月至2013年02月在广州市第一人民医院泌尿外科住院的患者。病人的入选标准：1、因各种原因需行输尿管皮肤造口术者：(1).膀胱或邻近器官的晚期恶性肿瘤、膀胱广泛受累,容量缩小,反复出血,压迫输尿管下段引起肾功能衰竭的患者；(2).患神经性膀胱功能障碍,伴有膀胱输尿管返流、上行性肾积水、反复感染及肾功能受损,不能耐受较大手术的患者。2、患者无精神疾病,能正确理解问卷内容并独立完成问卷的填写；3、患者签署知情同意书。
将手术组分为传统手术组和改良手术组。其中19例行传统输尿管皮肤造口术,22例行改良输尿管皮肤造口术。病人的分组标准：从临床实际出发,病人的分组不可能做到随机分组。我们的研究根据主刀医生来进行分组,其中以谢克基教授为主刀的治疗组施行改良手术；以其他熟练掌握输尿管皮肤造口术的医生为主刀的治疗组施行传统术式。
筛选出符合入选标准的病例41例,其中19例行传统输尿管皮肤造口术,22例行改良手术。收集患者手术资料,包括手术时间,术中出血量,术后住院时间,术后并发症等资料并进行统计分析。签署知情同意书,征得患者同意后收集其基本资料,包括患者姓名、性别、年龄、手术日期、手术方式、疾病类型、病理类型、肿瘤分期、分级以及患者家庭地址、联系电话、E-mai1等内容,应用膀胱癌特异性量表FACT-BL进行调查,定期邀患者来我院门诊复查,同时现场完成问卷,或通过邮寄附带回信邮资和信封,或E-mail发送电子调查表以或电话询问方式完成调查对两种术式患者术后并发症及术后1个月、3个月、6个月、9个月、12个月等不同时间点的生活质量进行多次问卷调查,从而动态观察两种术式患者手术后的生活质量变化情况,并对不同时间点两种术式方式患者生活质量进行比较。
计量资料用均数±标准差(x±s)表示,比较采用独立样本的t检验(Independent Samples T Test)或者秩和检验(Mann-Whitney Test)进行分析；组间率的比较采用χ2检验,,以P=0.05作为检验水准。应用SPSS13.0软件对数据进行统计分析。
结果：传统手术组：男16例,女3例,年龄67.9±5.4岁；膀胱多发尿路上皮癌7例、膀胱浸润性尿路上皮癌4例,膀胱鳞癌1例,膀胱癌术后复发7例；≥T3期8例；其中单侧输尿管皮肤造口9例,双侧10例。改良手术组：男17例,女5例,年龄平均67.8±5.9岁；膀胱多发尿路上皮癌6例,膀胱癌术后复发5例,膀胱浸润性尿路上皮癌4例,膀胱尿路上皮癌合并肾盂癌2例,膀胱鳞癌2例,直肠癌侵犯膀胱1例,膀胱平滑肌肉瘤合并前列腺癌1例,膀胱癌阴道转移1例；≥T3期10例；其中单侧输尿管皮肤造口8例,双侧14例。(1)两组患者性别、年龄、性别比例、≥T3期、单数／双侧造口比例方面无统计学差异(P>0.05)；(2)、手术并发症：造口感染传统手术组高于改良手术组(P=0.036),乳头萎缩、末端坏死、外口狭窄两组之间无差异(P>0.05)；(3)、两组患者术后1个月、3个月、6个月、9个月、12个月时的HRQOL评分均呈逐渐升高趋势,术后1个月、3个月、6个月、9个月时两组患者HRQOL评分接近,差别无统计学意义(P>0.05)。术后12个月时,患者改良组HRQOL评分高于传统手术组患者,P=0.00<0.05,两组间差别有统计学意义。两组患者在生理状况、社会、家庭状况、情感状况及FACT-G等方面HRQOL评分接近,差别无统计学意义(P>0.05),而改良组患者在FWB、BSS得分和FACT-BL总得分方面高于传统组患者,差别有统计学意义(P<0.05)。
结论：改良输尿管皮肤造口术在术后造口皮肤感染、术后12个月时HRQOL方面优于传统手术方式。因此,在患者身体状况允许的情况下,选择输尿管皮肤造口方式时应优先考虑行改良输尿管皮肤造口手术,以减少手术并发症和提高患者术后生活质量。
Background and Objectives:
As we know, invasive bladder cancer is highly malignant biological behavior; the main method of treatment is radical excision of bladder and pelvic lymph node cleaning and urinary diversion technique. Radical surgery can effectively improve the patients'survival rate, avoid local recurrence and distant metastasis, it is considered a standard surgical procedure. But as a result of total resection of the bladder and urinary diversion surgery often brings to the patients with a drop in the quality of life and mental pressure, patients make it difficult to accept this way of operation. Each physical condition of patients with bladder cancer, surgery tolerance, expected to survive, and look forward to the result of the treatment is different, so it is necessary to explore suitable for different patients need to cancer effect a radical cure and easily accepted by patients with bladder cancer effect a radical cure and urinary diversion operation method.
Since1852, Simon reported1patient with bladder diversion of ureteral rectal anatomizes, urinary diversion surgery has100years of history, whether the different illness and surgery doctor's experience, research and design a variety of surgical methods, different operative methods have their adaptation range, also have their advantages and disadvantages.
The ideal permanent urinary diversion should be able to achieve to prevent postoperative complications, protect kidney function, to enable patients to live close to normal. Currently in use of various kinds of permanent urinary diversion method has yet to become perfect, each has its advantages and disadvantages. Can be summarized as the following categories:(1).Urinary colostomy surgery such as ureter skin colostomy, permanent cystostomy, abdominal wall, urethra, urethra colostomy surgery;(2) Using a free loops in the abdominal wall colostomy, as urine flow, such as the ileum bladder, colon, bladder surgery;(3) Urine stool confluence surgery:such as ureter sigmoid colostomy, ureteral colic colorectal anastomosis;(4) Urine stool bypass surgery, such as a colon rectal bladder, rectum bladder abdominal wall colostomy surgery;(5) Controllable irritable bladder, divided into two categories:category for controllable irritable bladder abdominal surgery, such as controllable ileum bladder surgery, control back to the cecum bladder surgery; Another kind is a new bladder or is a controllable bladder, such as the ileum new, go back to the cecum new bladder to the bladder. The choice of surgical method according to the patient and the circumstances, such as age, health condition, the properties of the primary disease, life expectancy, urinary and bowel loops on anatomy and function, etc., always have any history of abdominal and pelvic surgery and radiation therapy, combined with the requirements of the patients and the experience of the performer, carefully select.
Cutaneous Ureterostomy (CU) is permanent or temporary ureteral end and skin urinary diversion; this is a simple and safe operation. The patiense were divided into two types:the ureteral climbing skin colostomy and ureteral end colostomy. Roth was first reported in1967, the use of ureteral skin colostomy surgery as a way of urinary diversion, originally this method used in the treatment of children congenital urinary obstruction, but later expanded to used in the treatment of adult pelvic malignant tumor palliative urinary diversion. Will now ureteral skin as a permanent colostomy surgery urinary diersion relatively few ways to use, but ureteral skin incision surgery is still attractive as a permanent urinary diersion method, especially suitable for advanced bladder tumor. The surgical indications:1. Bladder or adjacent organs of advanced malignant tumor, extensive involvement, the bladder capacity, repeated bleeding, oppression ureter under paragraph causes of uremia;2, children with urinary tract obstruction or functional disorders, urinary tract in severe circuitry expansion, especially the co-infection and uremia.3. Neutrogena bladder dysfunction, accompanied by bladder ureter reflux, upward kidney sweeper, repeated infection, and kidney function is damaged, can't tolerate larger operation.
Traditional ureteral skin colostomy operation steps:(1) briefly to total excision of the bladder or laparotomy performer, use a ventral midline incision, after abdominal surgery;Simple ureteral skin colostomy performer, adopts double ventral oblique incision, surgery via the peritoneum.(2) retroperitoneal separation bilateral ureteral middle segment and its cut, proximal insertion F8ureteral stent tube of the renal pelvis, fixed to the end of ureter and distal through ligation with a thread of silk.(3) In the sacral promontory, front and rear of the sigmoid colon is a film blunt separation, forming a channel, one side will pull through this channel to the contralateral ureter. In about10cm from the contralateral ureter end for ureteral end side anastomosis, to pass through the anastomotic stent drainage tube into the contralateral ureter under section, and insert to the end, the anterior wall of ureteral anastomosis suture, interrupted suture anastomosis of the outer membrane of the ureters.(4)ureteral colostomy on one side of the abdominal incision extending into S shape, both the length and width of trapezoid flap is4cm, top side is about2.53.0cm, the halfway point of the s-shaped incision is equivalent to the superior border of the iliac crest level.(5)and the external oblique relative transverse abdominal muscle, muscle tendon membrane in the membrane and the edge number of suture needle, its the aponeurosis, muscle on both sides of the incision suture with a thread of silk, forming a channel button shape, let ureteral pull through this channel outside the abdominal wall. With line3in proper positions across the outer membrane of ureter and edge and fixed buttonhole.(6) Line1suture skin edge, form the hose of the ureter. The ends of ureter and interrupted suture the skin with a thread of silk, and the drainage tube fixed.
Traditional ureteral end colostomy skin incision has the following drawbacks:(1)Incision length, trauma, cosmetic effect is poor;(2)Fistula surrounding skin is not flat, prone to leakage;(3)It is easy happening ureteral end complications such as necrosis, narrow or hose burst;(4)Some cases postoperative hoses are gradually atrophic, become shorter, make it difficult to collect, and a long-term indwelling drainage tube;(5)For the need to do the dermal papilla, the ureteral length is longer, easy to increase the tension of ureter, lead to ureteral blood supply is limited.
Based on the traditional operation above shortcomings, it is necessary to carry out the improvement, in order to achieve the following results:(1) the surgical method is relatively simple;(2) shorten the operation time, small influence on the patients with systemic, reduce the risk of illness;(3) reduce the complications, such as reducing leakage, incision infection, etc. Through the improvement of operation, reduce the operation risk, improve the patient's quality of life, reduce the medical cost, etc.
Modified ureteral skin briefly operation steps of:(1) on single sides signal:take a side lower abdomen is about12cm long oblique incision surgery, layered cut tissue, peritoneal found outside of ureteral middle and lower segment. According to primary disease of ureteral retained ureter length and broken, far end with silk thread sewing. Free up ureteral middle section. On one side of the abdomen in a circular incision0.6cm in diameter, puncture under the organization, to the external oblique tendon membrane in a same size and shape of the incision, and the incision will ureter from the circular mouth skin in vitro. Interrupted suture ureteral wall and the external oblique tendon membrane, with a fixed ureter. In an absorption line interrupted suture ureteral wall and circular, skin incision. Longitudinal incision ureteral0.5cm, the ends of ureteral valgus and fold. Right end of the ureter is prominent papillary leather0.5cm,6f silicone tube from the nipple to the ureter, about20cm depth, or the " J" tube, nipples pocket to collect urine after another.(2) on both sides:take a ventral midline incision, from the superior border of pubic symphysis, about15cm long. Layered cut organization, extraperitoneal respectively to find the bilateral ureteral middle segments and transaction, far end in4thread sewing, a circular from each respectively in on both sides of the abdominal incision, ca.0.6cm in diameter, excision of subcutaneous tissue underneath, and on the external oblique tendon membrane in a same size and shape of the incision, and the puncture the internal oblique muscle and transverse abdominal incision, respectively bilateral ureter from the circular incision around in vitro. At a4-0line can be absorbed and the external oblique tendon suture ureteral wall film, with a fixed ureter.5-0absorbable thread interrupted suture ureteral wall and circular, skin incision. Longitudinal incision ureteral0.5cm, the ends of ureteral vague, fold. Bilateral ureteral end in papillary highlight the leather face is0.5cm.
Health related quality of life refers to the different cultures and value systems; the individual is affected by the illness and treatment, the subjective feeling of life and the environment, including the physical symptoms, social relationship and interaction between the psychological moods, environment evaluation. Medical mode has changed, as these changes, in clinical work; medical workers not only focus on physical therapy and rehabilitation, but also focus on the patient's physical, psychological and social changes.
This study by prospective studies traditional ureteral skin colostomy surgery is associated with improved patients' clinical data, the application of bladder cancer specificity scale FACT-BL to our hospital to accept traditional ureteral skin for and improvement of two kinds of surgical patients, the questionnaire survey to compare two kinds of surgical operation time, intraoperative blood loss, postoperative hospital stay, the incidence of postoperative complications related to the overall quality of life and bladder cancer related aspects of the difference of quality of life, and to explore the reasons of these differences, for the selection of ureteral skin incision surgery the basis of health related quality of life, thus improve the patients quality of life after surgery.
Methods:
Between December2006and February2013, in department of Urology,***Hospital, the improvement of the late malignant tumor of the bladder or adjacent organs, extensive involvement, the bladder capacity, repeated bleeding, under the oppression ureter section of the cause of renal failure patients;2from neuropathic bladder dysfunction, accompanied by bladder ureter reflux, upward kidney sweeper, repeated infection, and kidney function is damaged, can't tolerate larger surgery patients.
The patient's inclusion criteria:(1) For various reasons ureteral skin colostomy performer;(2) Patients without a mental illness, can correctly understand the content of the questionnaire and fill in the questionnaire independently;(3) The patients signed informed consent.
Treatment team can be divided into traditional surgery group and modified surgical group.19patients carried traditional ureteral skin incision after operation,22patients carried modified ureteral skin incision after operation. Patient group standards:from the clinical practice, patient group may not be randomized. Our research the patience were divied into two groups according to the surgeon, which is given priority to with the professor Xie in the treatment group improved surgery; in other skilled ureteral skin doctors to give priority to operate in the treatment group of conventional surgery.
This research will be traditional ureteral colostomy skin and improve skin patients of ureter as the research object, a total of53cases,41cases of completed follow-up, including12cases lost follow-up,6died of postoperative tumor recurrence and metastasis,2cases died of other diseases, due to various reasons failed to complete the follow-up in4patients. Meets the criteria for the cases of41patients,19underwent traditional ureteral skin colostomy,22modified routine surgery. To record into the group of patients with surgery information collected, including the operation time, intraoperative blood loss, postoperative hospital stay, postoperative complications, such as data and statistical analysis. Obtained the consent of the patient to collect the basic information, including name, gender, age, date of surgery, patients with operation method, the types of disease, patients with pathological type, tumor stage, grade and family address, phone number, E-mail and other content, investigate the application of bladder cancer specificity scale FACT-BL, regularly invited to patients to our hospital outpatient care, on-site to complete the questionnaire at the same time, or by mail with return postage and envelope, or E-mail to send electronic questionnaires or calls to complete the survey the postoperative complications in patients with two kinds of operative methods and postoperative1month,3months,6months,9months,12months many times the quality of life of different time points, such as questionnaire survey, and dynamic observation of two kinds of operation, the change of the quality of life of patients after surgery, patients with two operation ways and the different time points compared the quality of life.
Measurement data use (x±s), rate between groups compares use the x2, between groups of mean more use independent sample t-test (Independent Samples t test), compares the two sample rank and inspection (the Mann-Whitney Test) is analyzed, with P=0.05as the inspection level. The statistic analysis was completed by SPSS13.0.
Results:
1. Two groups of patients with gender, age, the number of men, tumor pathological staging no statistical difference (P>0.05);2. Two groups of patients with postoperative1month,3months,6months,9months,12months of HRQOL scores all showed a trend of increasing gradually, after1month,3months,6months,9months HRQOL scores close to two groups of patients, no statistically significant difference (P>0.05).12months postoperatively, the patient improved group HRQOL scores higher than that of patients with traditional surgery group, the difference was statistically significant (P<0.05).Two groups of patients in physiology, society, family situation, emotional state and FACT-G HRQOL scores close, no statistically significant difference (P>0.05), and improved group patients in the field of functional status, the BSS scores and FACT-BL in total score higher than the traditional group of patients, the difference was statistically significant (P<0.05).
Conclusion:
Modified cutaneous ureterostomy in operation time, intraoperative blood loss, postoperative hospital stay, postoperative incision after12months of skin infections, HRQOL aspects when way is better than traditional surgeries. Therefore, under the condition of the patients' physical condition allows, choosing ureteral skin incision approach line priority should be given to improvement of ureteral skin incision surgery, in order to improve the patients quality of life after surgery.
浸润性膀胱癌生物学行为高度恶性,治疗的主要方法是膀胱切除加尿流改道术。根治性手术能有效提高患者生存率、避免局部复发和远处转移,被认为是标准的手术方式。但由于根治性膀胱切除及尿流改道术常给患者带来生活质量的下降及精神上的压力。每一名膀胱癌患者的身体状况、手术耐受性、预期生存及对治疗结果期待的不同,因此有必要探讨适合不同患者需要既达到肿瘤根治又易于被患者接受的膀胱癌根治和尿流改道手术方式。
自1852年Simon报道为1例膀胱外翻患者施行输尿管直肠吻合术以来,尿流改道手术已有100多年历史,根椐不同病情和不同手术医师的经验,研究和设计出各种的手术方法,不同的术式各有其适应范围,也各有其优缺点。
理想的永久性尿流改道应能达到防止术后并发症,保护肾脏功能,使患者能过接近正常的生活。目前使用的各种永久尿流改道方法尚未臻完善,各具优缺点。可概括为下列几类：①尿路造口手术：如输尿管皮肤造口术、永久性膀胱造口术、腹壁尿道术、尿道造口术；②利用一段游离肠管于腹壁造口,作为尿流通道,如回肠膀胱术、结肠膀胱术；③尿粪合流手术：如输尿管乙状结肠造口术、输尿管结肠-结肠直肠吻合术；④尿粪分流手术：如直肠膀胱术、直肠膀胱-结肠腹壁造口术；⑤可控肠膀胱术,分为二类：一类为可控肠膀胱腹壁造口术,如可控回肠膀胱术、可控回盲肠膀胱术；另一类为新膀胱术或正位可控膀胱术,如回肠新膀胱术、去带回盲肠新膀胱术。手术方法的选择需按照病人具体情况,如年龄、身体条件、原发病性质、预期寿命、上尿路及肠管的解剖及功能情况等,既往有无腹部、盆腔手术及放疗史,结合患者的要求和术者的经验,认真加以选择。
输尿管皮肤造口术(Cutaneous Ureterostomy, CU)是输尿管断端和皮肤的永久性或暂时性尿流改道,这是一种简单、安全术式。大体分为两种类型：输尿管攀皮肤造口术和输尿管末端皮肤造口术。Roth在1967年最先报道了使用输尿管皮肤造口术作为尿流改道的一种方法,原本这种方法用于治疗儿童的先天性尿路梗阻,但是后来逐渐扩展到用于治疗成人盆腔恶性肿瘤的姑息性尿流改道。目前将输尿管皮肤造口术作为永久性尿流改道的方法来使用相对较少,但输尿管皮肤造口术仍作为一种有吸引力的永久性尿流改道的方法,尤其适用于晚期膀胱肿瘤。其手术适应症：1、患膀胱或邻近器官的晚期恶性肿瘤,膀胱广泛受累,容量缩小,反复出血,压迫输尿管下段引起肾积水和肾功能不全者；2、儿童患下尿路梗阻或功能性疾患,致上尿路严重积水扩张,尤其是合并感染和尿毒症者；3、患神经原性膀胱功能障碍,伴有膀胱输尿管返流、逆行性肾积水、反复感染及肾功能受损,不能耐受较大手术者。
传统输尿管皮肤造口术简要手术步骤：(1)需施行膀胱全切除或剖腹探查术者,使用下腹正中切口,经腹腔施行手术；单纯作输尿管皮肤造口术者,采用双下腹斜切口,经腹膜外施行手术。(2)腹膜后分离双侧输尿管中下段并将其切断,近端插入F8输尿管支架管达肾盂、固定在输尿管断端,远端用丝线贯穿结扎。(3)在骶岬前方、乙状结肠系膜后方作钝性分离,形成一通道,将一侧输尿管通过此通道拉至对侧。在离对侧输尿管断端约10cm处作输尿管端侧吻合,将支架引流管经吻合口放入对侧输尿管下段,并插至断端之外,将输尿管吻合口前壁缝合,间断缝合吻合口的输尿管外膜。(4)将输尿管造口的一侧的腹部切口延长成S形,两个梯形皮瓣的长度和底宽均为4cm,顶边约为2.5-3.0cm,S形切口的中点相当于髂嵴上缘水平。(5)将腹外斜肌腱膜于相对的腹横肌肌膜创缘缝合数针,其两旁的腱膜、肌肉切口则用丝线缝合,形成一纽扣状通道,让输尿管通过此通道拉出腹壁之外。用3-0可吸收线于适当位置穿过输尿管外膜,并固定于钮孔边缘。(6)3-0可吸收线缝合皮肤创缘,形成包绕输尿管的皮管。用丝线将输尿管末端与皮缘间断缝合,并将引流管固定。
传统的输尿管末端皮肤造口术有以下缺点：(1)腹壁切口多、切口长,创伤大,美容效果差；(2)造口周围皮肤不平坦,易发生漏尿；(3)易发生输尿管末端坏死、狭窄或皮管裂开等合并症；(4)一些病例术后皮管逐渐萎缩、变短、使尿液不易收集,而需长期留置引流管；(5)因需要做皮肤乳头,所需输尿管长度也较长,易增加输尿管张力,导致输尿管血供受限。
基于传统术式以上缺点,有必要对其进行改良,以期达到以下效果：(1)手术方法相对简单；(2)手术时间缩短,对患者全身影响小,对病情较重者风险降低；(3)减少并发症：如减少漏尿、造口周围感染等。(4)降低手术风险,提高病人的生活质量,降低医疗费用等。
本科室对传统输尿管皮肤造口术进行改良,其的简要手术步骤：(1)单侧：取患侧下腹长约12cm手术斜切口,逐层切开腹壁,腹膜外找到患侧输尿管中、下段。根据原发病确定输尿管保留输尿管长度并离断,远断端以丝线缝扎。向上游离输尿管中下段。于患侧中腹部取一圆形切口,直径约0.6cm,戳穿下组织,于腹外斜肌腱膜取一同样大小和形状的切口,并经该切口将输尿管从圆形皮肤口引出体外。间断缝合输尿管壁和腹外斜肌腱膜,以固定输尿管。以可吸收线间断缝合输尿管壁和圆形皮肤切口。纵形切开输尿管0.5cm,将输尿管末端外翻、折叠。右输尿管末端呈乳头状突出皮面0.5cm,从该乳头向输尿管插6F硅胶管,深度约20cm,或插单“J”管,乳头上接一造口袋以搜集尿液。
(2)双侧：取下腹正中切口,起自耻骨联合上缘,长约15cm。逐层切开组织,于腹膜外分别找到双侧输尿管中下段并横断,远断端以4号丝线缝扎,分别于两侧中腹部各取一圆形切口,直径约0.6cm,切除其下皮下组织,于腹外斜肌腱膜取一同样大小和形状的切口,并经该切口戳穿腹内斜肌和腹横肌,分别将双侧输尿管从左右圆形切口引出体外。以4-0可吸收线间断缝合输尿管壁和腹外斜肌腱膜,以固定输尿管。以5-0可吸收线间断缝合输尿管壁和圆形皮肤切口。纵形切开输尿管0.5cm,将输尿管末端外翻、折叠。双侧输尿管末端呈乳头状突出皮面0.5cm。
健康相关生活质量指不同文化和价值体系下,个体受到病情和治疗的影响时,对生活和环境的主观知觉感受,包括对身体症状、社会关系、心理情绪、环境互动等的评价。生命质量作为一个公认的疗效评价指标,能够帮助临床医生、护士站在患者的立场,选择和评价治疗、护理方案,筛选影响患者生命质量的主要因素,有针对性地对患者进行随访和完善健康教育。医学模式已经发生了变化,随着这些变化,在临床工作中,医务工作者不再只关注患者生理的治疗和康复,还要关注患者的生理、心理、社会方面的变化。
生活质量调查是目前国际上对包括肿瘤在内的各种慢性疾病治疗方案筛选和评价的有效方法。所谓健康相关生活质量(HRQOL),是指在疾病、意外损伤及医疗干预影响下,与人的生活条件和事件相关的健康状态和主观满意度。
本研究通过前瞻性研究传统输尿管皮肤造口术与改良术式患者的相关临床资料,应用膀胱癌特异性量表FACT-BL对在我院接受传统输尿管皮肤造口术和改良术两种术式的患者进行问卷调查,比较两种术式术后相关并发症的发生率,总体生活质量和膀胱癌相关方面生活质量的差别,并探讨产生这些差别的原因,为输尿管皮肤造口术式的选择提供健康相关生活质量方面的依据,从而提高患者术后生活质量。
方法：选取2006年12月至2013年02月在广州市第一人民医院泌尿外科住院的患者。病人的入选标准：1、因各种原因需行输尿管皮肤造口术者：(1).膀胱或邻近器官的晚期恶性肿瘤、膀胱广泛受累,容量缩小,反复出血,压迫输尿管下段引起肾功能衰竭的患者；(2).患神经性膀胱功能障碍,伴有膀胱输尿管返流、上行性肾积水、反复感染及肾功能受损,不能耐受较大手术的患者。2、患者无精神疾病,能正确理解问卷内容并独立完成问卷的填写；3、患者签署知情同意书。
将手术组分为传统手术组和改良手术组。其中19例行传统输尿管皮肤造口术,22例行改良输尿管皮肤造口术。病人的分组标准：从临床实际出发,病人的分组不可能做到随机分组。我们的研究根据主刀医生来进行分组,其中以谢克基教授为主刀的治疗组施行改良手术；以其他熟练掌握输尿管皮肤造口术的医生为主刀的治疗组施行传统术式。
筛选出符合入选标准的病例41例,其中19例行传统输尿管皮肤造口术,22例行改良手术。收集患者手术资料,包括手术时间,术中出血量,术后住院时间,术后并发症等资料并进行统计分析。签署知情同意书,征得患者同意后收集其基本资料,包括患者姓名、性别、年龄、手术日期、手术方式、疾病类型、病理类型、肿瘤分期、分级以及患者家庭地址、联系电话、E-mai1等内容,应用膀胱癌特异性量表FACT-BL进行调查,定期邀患者来我院门诊复查,同时现场完成问卷,或通过邮寄附带回信邮资和信封,或E-mail发送电子调查表以或电话询问方式完成调查对两种术式患者术后并发症及术后1个月、3个月、6个月、9个月、12个月等不同时间点的生活质量进行多次问卷调查,从而动态观察两种术式患者手术后的生活质量变化情况,并对不同时间点两种术式方式患者生活质量进行比较。
计量资料用均数±标准差(x±s)表示,比较采用独立样本的t检验(Independent Samples T Test)或者秩和检验(Mann-Whitney Test)进行分析；组间率的比较采用χ2检验,,以P=0.05作为检验水准。应用SPSS13.0软件对数据进行统计分析。
结果：传统手术组：男16例,女3例,年龄67.9±5.4岁；膀胱多发尿路上皮癌7例、膀胱浸润性尿路上皮癌4例,膀胱鳞癌1例,膀胱癌术后复发7例；≥T3期8例；其中单侧输尿管皮肤造口9例,双侧10例。改良手术组：男17例,女5例,年龄平均67.8±5.9岁；膀胱多发尿路上皮癌6例,膀胱癌术后复发5例,膀胱浸润性尿路上皮癌4例,膀胱尿路上皮癌合并肾盂癌2例,膀胱鳞癌2例,直肠癌侵犯膀胱1例,膀胱平滑肌肉瘤合并前列腺癌1例,膀胱癌阴道转移1例；≥T3期10例；其中单侧输尿管皮肤造口8例,双侧14例。(1)两组患者性别、年龄、性别比例、≥T3期、单数／双侧造口比例方面无统计学差异(P>0.05)；(2)、手术并发症：造口感染传统手术组高于改良手术组(P=0.036),乳头萎缩、末端坏死、外口狭窄两组之间无差异(P>0.05)；(3)、两组患者术后1个月、3个月、6个月、9个月、12个月时的HRQOL评分均呈逐渐升高趋势,术后1个月、3个月、6个月、9个月时两组患者HRQOL评分接近,差别无统计学意义(P>0.05)。术后12个月时,患者改良组HRQOL评分高于传统手术组患者,P=0.00<0.05,两组间差别有统计学意义。两组患者在生理状况、社会、家庭状况、情感状况及FACT-G等方面HRQOL评分接近,差别无统计学意义(P>0.05),而改良组患者在FWB、BSS得分和FACT-BL总得分方面高于传统组患者,差别有统计学意义(P<0.05)。
结论：改良输尿管皮肤造口术在术后造口皮肤感染、术后12个月时HRQOL方面优于传统手术方式。因此,在患者身体状况允许的情况下,选择输尿管皮肤造口方式时应优先考虑行改良输尿管皮肤造口手术,以减少手术并发症和提高患者术后生活质量。
Background and Objectives:
As we know, invasive bladder cancer is highly malignant biological behavior; the main method of treatment is radical excision of bladder and pelvic lymph node cleaning and urinary diversion technique. Radical surgery can effectively improve the patients'survival rate, avoid local recurrence and distant metastasis, it is considered a standard surgical procedure. But as a result of total resection of the bladder and urinary diversion surgery often brings to the patients with a drop in the quality of life and mental pressure, patients make it difficult to accept this way of operation. Each physical condition of patients with bladder cancer, surgery tolerance, expected to survive, and look forward to the result of the treatment is different, so it is necessary to explore suitable for different patients need to cancer effect a radical cure and easily accepted by patients with bladder cancer effect a radical cure and urinary diversion operation method.
Since1852, Simon reported1patient with bladder diversion of ureteral rectal anatomizes, urinary diversion surgery has100years of history, whether the different illness and surgery doctor's experience, research and design a variety of surgical methods, different operative methods have their adaptation range, also have their advantages and disadvantages.
The ideal permanent urinary diversion should be able to achieve to prevent postoperative complications, protect kidney function, to enable patients to live close to normal. Currently in use of various kinds of permanent urinary diversion method has yet to become perfect, each has its advantages and disadvantages. Can be summarized as the following categories:(1).Urinary colostomy surgery such as ureter skin colostomy, permanent cystostomy, abdominal wall, urethra, urethra colostomy surgery;(2) Using a free loops in the abdominal wall colostomy, as urine flow, such as the ileum bladder, colon, bladder surgery;(3) Urine stool confluence surgery:such as ureter sigmoid colostomy, ureteral colic colorectal anastomosis;(4) Urine stool bypass surgery, such as a colon rectal bladder, rectum bladder abdominal wall colostomy surgery;(5) Controllable irritable bladder, divided into two categories:category for controllable irritable bladder abdominal surgery, such as controllable ileum bladder surgery, control back to the cecum bladder surgery; Another kind is a new bladder or is a controllable bladder, such as the ileum new, go back to the cecum new bladder to the bladder. The choice of surgical method according to the patient and the circumstances, such as age, health condition, the properties of the primary disease, life expectancy, urinary and bowel loops on anatomy and function, etc., always have any history of abdominal and pelvic surgery and radiation therapy, combined with the requirements of the patients and the experience of the performer, carefully select.
Cutaneous Ureterostomy (CU) is permanent or temporary ureteral end and skin urinary diversion; this is a simple and safe operation. The patiense were divided into two types:the ureteral climbing skin colostomy and ureteral end colostomy. Roth was first reported in1967, the use of ureteral skin colostomy surgery as a way of urinary diversion, originally this method used in the treatment of children congenital urinary obstruction, but later expanded to used in the treatment of adult pelvic malignant tumor palliative urinary diversion. Will now ureteral skin as a permanent colostomy surgery urinary diersion relatively few ways to use, but ureteral skin incision surgery is still attractive as a permanent urinary diersion method, especially suitable for advanced bladder tumor. The surgical indications:1. Bladder or adjacent organs of advanced malignant tumor, extensive involvement, the bladder capacity, repeated bleeding, oppression ureter under paragraph causes of uremia;2, children with urinary tract obstruction or functional disorders, urinary tract in severe circuitry expansion, especially the co-infection and uremia.3. Neutrogena bladder dysfunction, accompanied by bladder ureter reflux, upward kidney sweeper, repeated infection, and kidney function is damaged, can't tolerate larger operation.
Traditional ureteral skin colostomy operation steps:(1) briefly to total excision of the bladder or laparotomy performer, use a ventral midline incision, after abdominal surgery;Simple ureteral skin colostomy performer, adopts double ventral oblique incision, surgery via the peritoneum.(2) retroperitoneal separation bilateral ureteral middle segment and its cut, proximal insertion F8ureteral stent tube of the renal pelvis, fixed to the end of ureter and distal through ligation with a thread of silk.(3) In the sacral promontory, front and rear of the sigmoid colon is a film blunt separation, forming a channel, one side will pull through this channel to the contralateral ureter. In about10cm from the contralateral ureter end for ureteral end side anastomosis, to pass through the anastomotic stent drainage tube into the contralateral ureter under section, and insert to the end, the anterior wall of ureteral anastomosis suture, interrupted suture anastomosis of the outer membrane of the ureters.(4)ureteral colostomy on one side of the abdominal incision extending into S shape, both the length and width of trapezoid flap is4cm, top side is about2.53.0cm, the halfway point of the s-shaped incision is equivalent to the superior border of the iliac crest level.(5)and the external oblique relative transverse abdominal muscle, muscle tendon membrane in the membrane and the edge number of suture needle, its the aponeurosis, muscle on both sides of the incision suture with a thread of silk, forming a channel button shape, let ureteral pull through this channel outside the abdominal wall. With line3in proper positions across the outer membrane of ureter and edge and fixed buttonhole.(6) Line1suture skin edge, form the hose of the ureter. The ends of ureter and interrupted suture the skin with a thread of silk, and the drainage tube fixed.
Traditional ureteral end colostomy skin incision has the following drawbacks:(1)Incision length, trauma, cosmetic effect is poor;(2)Fistula surrounding skin is not flat, prone to leakage;(3)It is easy happening ureteral end complications such as necrosis, narrow or hose burst;(4)Some cases postoperative hoses are gradually atrophic, become shorter, make it difficult to collect, and a long-term indwelling drainage tube;(5)For the need to do the dermal papilla, the ureteral length is longer, easy to increase the tension of ureter, lead to ureteral blood supply is limited.
Based on the traditional operation above shortcomings, it is necessary to carry out the improvement, in order to achieve the following results:(1) the surgical method is relatively simple;(2) shorten the operation time, small influence on the patients with systemic, reduce the risk of illness;(3) reduce the complications, such as reducing leakage, incision infection, etc. Through the improvement of operation, reduce the operation risk, improve the patient's quality of life, reduce the medical cost, etc.
Modified ureteral skin briefly operation steps of:(1) on single sides signal:take a side lower abdomen is about12cm long oblique incision surgery, layered cut tissue, peritoneal found outside of ureteral middle and lower segment. According to primary disease of ureteral retained ureter length and broken, far end with silk thread sewing. Free up ureteral middle section. On one side of the abdomen in a circular incision0.6cm in diameter, puncture under the organization, to the external oblique tendon membrane in a same size and shape of the incision, and the incision will ureter from the circular mouth skin in vitro. Interrupted suture ureteral wall and the external oblique tendon membrane, with a fixed ureter. In an absorption line interrupted suture ureteral wall and circular, skin incision. Longitudinal incision ureteral0.5cm, the ends of ureteral valgus and fold. Right end of the ureter is prominent papillary leather0.5cm,6f silicone tube from the nipple to the ureter, about20cm depth, or the " J" tube, nipples pocket to collect urine after another.(2) on both sides:take a ventral midline incision, from the superior border of pubic symphysis, about15cm long. Layered cut organization, extraperitoneal respectively to find the bilateral ureteral middle segments and transaction, far end in4thread sewing, a circular from each respectively in on both sides of the abdominal incision, ca.0.6cm in diameter, excision of subcutaneous tissue underneath, and on the external oblique tendon membrane in a same size and shape of the incision, and the puncture the internal oblique muscle and transverse abdominal incision, respectively bilateral ureter from the circular incision around in vitro. At a4-0line can be absorbed and the external oblique tendon suture ureteral wall film, with a fixed ureter.5-0absorbable thread interrupted suture ureteral wall and circular, skin incision. Longitudinal incision ureteral0.5cm, the ends of ureteral vague, fold. Bilateral ureteral end in papillary highlight the leather face is0.5cm.
Health related quality of life refers to the different cultures and value systems; the individual is affected by the illness and treatment, the subjective feeling of life and the environment, including the physical symptoms, social relationship and interaction between the psychological moods, environment evaluation. Medical mode has changed, as these changes, in clinical work; medical workers not only focus on physical therapy and rehabilitation, but also focus on the patient's physical, psychological and social changes.
This study by prospective studies traditional ureteral skin colostomy surgery is associated with improved patients' clinical data, the application of bladder cancer specificity scale FACT-BL to our hospital to accept traditional ureteral skin for and improvement of two kinds of surgical patients, the questionnaire survey to compare two kinds of surgical operation time, intraoperative blood loss, postoperative hospital stay, the incidence of postoperative complications related to the overall quality of life and bladder cancer related aspects of the difference of quality of life, and to explore the reasons of these differences, for the selection of ureteral skin incision surgery the basis of health related quality of life, thus improve the patients quality of life after surgery.
Methods:
Between December2006and February2013, in department of Urology,***Hospital, the improvement of the late malignant tumor of the bladder or adjacent organs, extensive involvement, the bladder capacity, repeated bleeding, under the oppression ureter section of the cause of renal failure patients;2from neuropathic bladder dysfunction, accompanied by bladder ureter reflux, upward kidney sweeper, repeated infection, and kidney function is damaged, can't tolerate larger surgery patients.
The patient's inclusion criteria:(1) For various reasons ureteral skin colostomy performer;(2) Patients without a mental illness, can correctly understand the content of the questionnaire and fill in the questionnaire independently;(3) The patients signed informed consent.
Treatment team can be divided into traditional surgery group and modified surgical group.19patients carried traditional ureteral skin incision after operation,22patients carried modified ureteral skin incision after operation. Patient group standards:from the clinical practice, patient group may not be randomized. Our research the patience were divied into two groups according to the surgeon, which is given priority to with the professor Xie in the treatment group improved surgery; in other skilled ureteral skin doctors to give priority to operate in the treatment group of conventional surgery.
This research will be traditional ureteral colostomy skin and improve skin patients of ureter as the research object, a total of53cases,41cases of completed follow-up, including12cases lost follow-up,6died of postoperative tumor recurrence and metastasis,2cases died of other diseases, due to various reasons failed to complete the follow-up in4patients. Meets the criteria for the cases of41patients,19underwent traditional ureteral skin colostomy,22modified routine surgery. To record into the group of patients with surgery information collected, including the operation time, intraoperative blood loss, postoperative hospital stay, postoperative complications, such as data and statistical analysis. Obtained the consent of the patient to collect the basic information, including name, gender, age, date of surgery, patients with operation method, the types of disease, patients with pathological type, tumor stage, grade and family address, phone number, E-mail and other content, investigate the application of bladder cancer specificity scale FACT-BL, regularly invited to patients to our hospital outpatient care, on-site to complete the questionnaire at the same time, or by mail with return postage and envelope, or E-mail to send electronic questionnaires or calls to complete the survey the postoperative complications in patients with two kinds of operative methods and postoperative1month,3months,6months,9months,12months many times the quality of life of different time points, such as questionnaire survey, and dynamic observation of two kinds of operation, the change of the quality of life of patients after surgery, patients with two operation ways and the different time points compared the quality of life.
Measurement data use (x±s), rate between groups compares use the x2, between groups of mean more use independent sample t-test (Independent Samples t test), compares the two sample rank and inspection (the Mann-Whitney Test) is analyzed, with P=0.05as the inspection level. The statistic analysis was completed by SPSS13.0.
Results:
1. Two groups of patients with gender, age, the number of men, tumor pathological staging no statistical difference (P>0.05);2. Two groups of patients with postoperative1month,3months,6months,9months,12months of HRQOL scores all showed a trend of increasing gradually, after1month,3months,6months,9months HRQOL scores close to two groups of patients, no statistically significant difference (P>0.05).12months postoperatively, the patient improved group HRQOL scores higher than that of patients with traditional surgery group, the difference was statistically significant (P<0.05).Two groups of patients in physiology, society, family situation, emotional state and FACT-G HRQOL scores close, no statistically significant difference (P>0.05), and improved group patients in the field of functional status, the BSS scores and FACT-BL in total score higher than the traditional group of patients, the difference was statistically significant (P<0.05).
Conclusion:
Modified cutaneous ureterostomy in operation time, intraoperative blood loss, postoperative hospital stay, postoperative incision after12months of skin infections, HRQOL aspects when way is better than traditional surgeries. Therefore, under the condition of the patients' physical condition allows, choosing ureteral skin incision approach line priority should be given to improvement of ureteral skin incision surgery, in order to improve the patients quality of life after surgery.
引文
[1]Jemal A, Bray F, Center MM, et al. Global cancer statistics 2008.CA Cancer J Clin,2011,61:69-90.
[2]郝捷,陈万青.膀胱癌//2012年中国肿瘤登记年报.军事医学科学出版社,2012,97.
[3]韩苏军,张思维,陈万青,等.中国膀胱癌发病现状及流行趋势分析.癌症进展,2013,1
[4]Fleshner NE, Herr HW, Stewart AK, et al. The National Cancer Data Base report on bladder carcinoma. Cancer,1996:78:1505-1513
[5]尿路上皮肿瘤的诊断和治疗.见：吴阶平主编.吴阶平泌尿外科学.济南：山东科学技术出版社,2004.959-980.
[6]董胜国,周荣祥,主编.膀胱肿瘤.北京：人民卫生出版社,2007.22-45
[7]Kantor AF, Hartge P, Hoover RN, et al. Epidemiological characteristics of squalors cell carcinoma and adenocarcinoma of the bladder. Cancer Res,1988, 48:3853-3855
[8]Lynch CF, Cohen MB. Urinary system cancer,1995,75(suppl):316-328.
[9]Bennett JK, Wheatly JK, Walton KN.10-year experience with adenocarcinoma of the bladder. J Urol,1984,131:262-263
[10]Nielsen K, and Nielsen KK. Adenocarcinoma in exstrophy of the bladder-the last case in Scandinavia? A case report and review of the literature. J Urol,1983, 130:1180-1182.
[11]Ozen H, Hall M C. Bladder cancer [J].Cur Opine Oncol,2000,12:255-259.
[12]Althausen AF, Hagen-Cook K, Hendren HW, et al. Non-refluxing colon conduit. Experience with 70 cases. J Urol 1978,120:35-39.
[13]Epstein JI, Amin MB, Reuter VR, et al. The World Health Organization/International Society of Urological Pathology consensus classification of urothelial(transitional cell)neoplasms of the urinary bladder. Bladder Consensus Conference Committee. Am J Surg Pathol,1998,22: 1435-1448.
[14]Sauter G, Algaba F, Amin M, et al. Tumor of urinary system:non-invasive urothelial neoplasia. WHO Classification of tumor of urinary system and male genital organs. Lyon:IARCC Press,2004.
[15]Sobin LH, Gospodariwicz M, Wittekind C (eds). TNM classification of malignant tumors. UICC International Union against Cancer.7th edn. Wiley-Blackwell,2009 Dec; pp.262-265.
[16]Lamm DL. Cancer in situ. Urol Clin North Am,1992,19:499-508.
[17]Roth A. Transabdominal transperitoneal bilateral omento-ureterostomy. Oral communication at the annual meeting of the North Central Station Section, AUA Cleveland, Ohio, Sept.27-30,1967.
[18]Kouba E, Sands M, Lentz A et al:A comparison of the Bricker versus Wallace ureteroileal anastomosis in patients undergoing urinary diversion for bladder cancer. J Urol 2007; 178:945.
[19]Knap MM, Lundbeck F and Overgaard J:Early and late treatment-related morbidity following radical cystectomy. Scand J Urol Nephrol 2004; 38:153.
[20]梅骅,陈凌武,高新.泌尿外科手术学(第3版)[M].北京：人民卫生出版社,2008.352-353.
[21]Deliveliotis C, Papatsoris A, Chrisofos M, et al. Urinary diversion in high-risk elderly patients:modified cutaneous ureterostomy or ileal conduit? Urology 2005 Aug; 66(2):299-304.
[22]Kilciler M, Bedir S, Erdemir F, et al. Comparison of ileal conduit and transureteroureterostomy with ureterocutaneostomy urinary diversion. Urol Int 2006; 77(3):245-50.
[23]Boyd SD, Lieskovsky G, Skinner DG. Kock pouch bladder replacement. Urol Clin North Am,1991,18:641-648
[24]Witjes JA, Comperat E, Cowan NC, et al. EAU Guidelines on Bladder Cancer Muscle-invasive and Metastatic, ed. European Association of Urology,2013.
[25]Madersbacher S, Schmidt J, Ebele JM, et al. Long-term outcome of ileal conduit diversion [J]. J Urol,2009,169(3):985-990.
[26]Pycha A, Comploj E, Martini T, et al. Comparison of complications in three incontinent urinary diversions. Euro Urol.2008 Oct; 54(4):825-32.
[27]Green fields, Nelson EC:Recent developments and future issues in the use of Health status assessment measures in clinical settings [J].Med Care, 1992(supply5); 30:23-41.
[28]徐建立.膀胱全切除后不同尿流改道方式患者生活质量比较.[D]天津医科大学,2009.4
[29]Engel GL:The need for a new medical model:A challenge for biomedicine [J].Science,1977,196:129-136.
[30]Green fields, Nelson EC:Recent developments and future issues in the use of Health status assessment measures in clinical settings [J].Med Care, 1992(supply5); 30:23-41.
[31]万崇华.生命质量测定与评价方法[M].昆明：云南大学出版社,1999.224-227。
[32]梅骅,陈凌武,高新.泌尿外科手术学(第3版)[M].北京：人民卫生出版社,2008.353-357。
[33]Celia DE, Tulsky DS, Gray G, et al. The functional assessment of cancer therapy scale:development and validation of the general measure [J] Clin. Oncol,1993, 11(3):570-579.
[34]Elmajian, Donald Abet. The Kock ileal neobladder:updated experience in 295 male Patients. J Urol.1996SeP:156(3):920-5.
[35]Steven K, Poulsen AL. The orthotopic Kock ileal neobladder:functional results, urodynamiefeatures, complications and survival in 166 men。 Urol.2000Ang:164(2):288-95.
[36]Yang WJ, Cho KS, Rha KH et al:Long-term effects of ileal conduit urinary diversion on upper urinary tract in bladder cancer. Urology 2010; 68:324.
[37]Pantuck AJ, Han KR, Perrotti M et al:Ureteroenteric anastomosis in continent urinary diversion:long-term results and complications of direct versus nonrefluxing techniques. J Urol 2000; 163:450.
[38]Evangelidis A, Lee EK, Karellas ME et al:Evaluation of ureterointestinal anastomosis:Wallace vs. Bricker. J Urol 2008; 175:1755.
[39]Lee CT, Chen BT, Gong E et al:Comparison of modified Taguchi and Bricker ureteral reimplantation techniques after radical cystectomy. Urology 2012; 64: 940.
[40]Morgan PR, Murdoch JB, Lopes A et al:The Wallace technique of ureteroileal anastomosis and its use in gynecologic oncology:a study of 81 cases. Obstet Gynecol 1993; 82:594.
[41]HomPson CA, shanafelt TD, loprinzi CL. Andropause:symptom management for Prostate cancer Patients treated with hormonal ablation [J].Oneologist, 2003,8:474-487.
[42]Patrickdl, Ericksonp. Assessing health related of quality of life for clinical decision-making. In:Quality Of Life Assessment:key issues in1990.5.Walker SR, RMR osser (eds):Boston:Kluwer ACHT emic Publishers,1993, 1112-1116.
[43]AltweinJ, Ekinan P, Barry M, et al. How is quality of life in prostate cancer Patients influeneed by modern treatment? The wall en symposium [J].Urology, 1997,49 (4Asuppl):66.
[44]HobischA, Tosuk, Kinzl J. Life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion.Semin Urol Oncol 2001,19:18-23.
[45]Fujissawa M, Isotanis S, Gotoh A. et al. Health-related quality of life with orthotopic neobladder versus ileal conduit according to the SF 36survey.Urology2000,55:862-865.
[46]Kikuchi E, Horiguchi Y, Nakashing J et al. Assessment of long-term quality of life using the FACT-BL questionnaire in Patients with an ideal conduit, Ontinent reservoir or orthotopic neobladder.. JPnJ Clin Oncol 2006,36: 712-716.
[47]Gilbert SM, Wood DP, Dunn RL et al. Measuring healthy-related quality of life outcomesin bladder cancer Patients using the Bladder Cancer index (BCI). Caneer2007,109:1756-1762.
[48]Gerharz EW, Masnson A, Hunt S, et al.Quality of life after cystectomy and urinary diversion:an evidence based analysis [J]. J Urol,2010, 174(5):1729-1736.
[49]Gerharz EW, Masnson A, Masnson W. Quality of life in patients with bladder cancer[J]. Urol Oncol,2005,23(4):201-207.
[50]Hobisch A, Tosun K, Kinzl J, et al. Life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion[J]. Semin Urol Oncol,2013, 21(3):118-123.
[51]Porter MP, Wei JT, Penson DF. Quality of life issues inbladder cancer patients following cystectomy and urinary diversion [J]. Urol Clin North Am,2005, 32(2):207-216.
[52]Wright JL, Porter MP. Quality-of-life assessment in patients with bladder cancer [J]. Nat Clin Pract Urol,2011,6(3):247-254.
[53]Gill IS, Kaouk JH, Meraney AM, et al. Laparoscopic radical cystectomy and continent orthotopic ileal neobladder performed completely intracorporeally: the initial experience. JUrol,2012,168(1):13-18.
[54]Abdel-Hakim AM, Bassiouny F, Abdel Azim Ms, et al. Laroscopic radical cystectomy with orthopic neobladder. J Endourol,2002,16(6):377-381.
[55]万崇华,孟琼,汤学良等.癌症患者生命质量测定量表FACT-G中文版评价[J].实用肿瘤杂志,2006,21(1)：77-80.
[56]崔勇,颜纯海,单玉喜.输尿管皮肤造口在膀胱全切除术中的应用[J].江苏医药杂志,2002,28(12)：940.
[57]Pycha A, Comploj E, Martini T, et al. Comparison of complications in three incontinent urinary diversions. Euro Urol 2013; 58:825-32.
[1]Jakse Q Algaba F, Foss S, et al. Guidelines on Bladder cancer Muscle-invasive and Metastatic [J].European Association of Urology, 2012(7):11-34.
[2]Stein J P, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer:Long term results in 1054 patients [J].J Clin Oncol, 2001,19:666-675.
[3]Gschwend J E, Vieweg J, Fair W R, et al. Early versus delayed cystectomy for invasive bladder cancer:impact of disease specific survival? [J]. J Urology, 1997,157:1507.
[4]Stein JP, L.G., Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer:long-term results in 1054 patients. J Clin Oncol,2001,19: 666-675
[5]Gschwend JE, V.J., Fair WR, et al., Early versus delayed cystectomy for invasive bladder cancer:impact of disease specific survival? J Urol,1997,157: 1507
[6]Stein JP, Q.M., Skinner DG, Lymphadenectomy for invasive bladder cancer: historical perspective and contemporary rationale. BJU Int,2006,97:227-231
[7]World Health Organization (WHO) Consensus Conference in Bladder Cancer, Hautmann RE, Abol-Enein H, Hafez K, Haro I, Mansson W, Mills RD, Montie JD, Sagalowsky Al, Stein JP, Stenzl A, Studer UE, Volkmer BG. Urinary diversion. Urology 2007 Jan; 69(1 Suppl):17-49.
[8]Ghoneim MA, E.-M.M., El-Baz MA, et al., Radical cystectomy for carcinoma of the bladder:critical evaluation of the results in 1026 cases. J Urol,1997,158: 393-399.
[9]Witjes JA, Comperat E, Cowan NC, et al. EAU Guidelines on Bladder Cancer Muscle-invasive and Metastatic, ed. European Association of Urology,2013.
[10]王章才.全膀胱切除术治疗膀胱癌手术时机的探讨.临床泌尿外科杂志,2000.15：283
[11]Huang J, Lin T, Liu H, et al. Laparoscopic radical cystectomy with orthotopic ileal neobladder for bladder cancer:oncologic results of 171 cases with a median 3-year follow-up. Eur Urol 2010; 58(3):442-449
[12]Haber GP, Crouzet S, Gill IS. Laparoscopic and robotic assisted radical cystectomy for bladder cancer:a critical analysis. Eur Urol 2008; 54(1):54-62.
[13]Hellenthal NJ, Hussain A, Andrews PE, et al. Surgical margin status after robot assisted radical cystectomy:results from the International Robotic Cystectomy Consortium. J Urol 2010; 184(1):87-91.
[14]Chade DC, Laudone VP, Bochner BH, et al. Oncological outcomes after radical cystectomy for bladder cancer:open versus minimally invasive approaches. J Urol 2010 Mar; 183(3):862-69.
[15]Cathelineau X, A.C., Rozet F, et al. Laparoscopic assisted radical cystectomy: the montsouris experience after 84 cases. Euro Urol,2005,47:780-784
[16]Ng CK, Kauffman EC, Lee MM, et al.A comparison of postoperative complications in open versusrobotic cystectomy. Euro Urol 2010 Feb; 57(2):274-81.
[17]陈光富,张旭,史立新,等.机器人辅助腹腔镜下根治性膀胱切除加尿流改道术的临床分析《中华泌尿外科杂志》-2012年10期
[18]沈周俊,钟山,何威,等.机器人外科手术系统辅助腹腔镜在膀胱及前列腺手术中的优势(附4例报道) 《上海医学》2011年1期
[19]Lin T, Huang J, Han J, et al. Hybrid laparoscopic endoscopic single-site surgery for radical cystoprostatectomy and orthotopic ileal neobladder:an initial experience of 12 cases. J Endourol 2011; 25(1):57-63.
[20]Kaouk JH, Goel RK, White MA, et al. Laparoendoscopic single-site radical cystectomy and pelvic lymph node dissection:initial experience and 2-year follow-up. Urology2010; 76(4):857-861.
[21]刘春晓,徐啊白,郑少波,等.单孔腹腔镜下根治性膀胱切除术10例报告.中华泌尿外科杂志2011；32(2)：90-93.
[22]Ma LL, Bi H, Hou XF, et al. Laparoendoscopic single-site radical cystectomy and urinary diversion:initial experience in China using a homemade single-port device. J Endourol 2012; 26(4):355-359.
[23]Jakse G, Algaba F, Foss S, et al. Guidelines on Bladder cancer Muscle-invasive and Metastatic [J].European Association of Urology,2004:13-14.
[24]Lein J P, Skinner D G. Campbell'surology [M].Harcourt Asia PTE LTD: Singapore,2002:3835-3868.
[25]周祥福,梅骅.尿流改道与膀胱替代.见：吴阶平.吴阶平泌尿外科学.济南：山东科学技术出版社,2004.2057-2082
[26]Boyd SD, Lieskovsky G, Skinner DG. Kock pouch bladder replacement. Urol Clin North Am,1991,18:641-648
[27]Witjes JA, Comperat E, Cowan NC, et al. EAU Guidelines on Bladder Cancer Muscle-invasive and Metastatic, ed. European Association of Urology,2013.
[28]Hautmann RE, de Petriconi R, Gottfried HW, et al. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol 1999; 161:422-7.
[29]Abol-Enein H, Ghoneim MA. Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation:experience with 450 patients. J Urol 2001; 165:1427-32.
[30]Stein JP, Dunn MD, Quek ML, et al. The orthotopic T pouch ileal neobladder: experience with 209 patients. J Urol 2004; 172:584-7.
[31]Kessler TM, Burkhard FC, Perimenis P, et al. Attempted nerve sparing surgery and age have a significant effect on urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. J Urol, 2004.172:1323-1327.
[32]Bhatta Dhar N, Kessler TM, Mills RD, et al. Nerve-Sparing Radical Cystectomy and Orthotopic Bladder Replacement in Female Patients. Eur Urol, 2007.52(4):1006-1014.
[33]Bricker E M. Bladders Substitution after pelvic evis-ceration[J]. Surg Clin N A mer,1950,30:1511.
[34]Pycha A, Comploj E, Martini T, et al. Comparison of complications in three incontinent urinary diversions. Eur Urol.2008 Oct; 54(4):825-32.
[35]Nieuwenhuijzen JA, de Vries RR, Bex A, et al. Urinary diversions after cystectomy:the association of clinical factors, complications and functional results of four different diversions. Eur Urol,2008,53(4):834-844
[36]Madersbacher S, Schmidt J, Eberle JM, et al. Long-term outcome of ileal conduit diversion. J Urol,2003,169(3):985-990
[37]Wood DN, Allen SE, Hussain M, et al. Stomal complications of ileal conduits are significantly higher when formed in women with intractable urinary incontinence. J Urol,2004,172(6 Ptl):2300-2303
[38]Deliveliotis C, Papatsoris A, Chrisofos M, et al. Urinary diversion in highrisk elderly patients:modified cutaneous ureterostomy or ileal conduit? Urology, 2005,66(2):299-304
[39]Fisch M, Wammack R, Hohenfellner R. The sigma rectum pouch (Mainz pouch Ⅱ). World J Urol,1996,14:68-72
[40]El Mekresh MM, Hafez AT, Abol-Enein H, et al. Double folded rectosigmoid bladder with a new ureterocolic antireflux technique. J Urol,1997, 157:2085-2089.
[41]尿路改道与膀胱替代.见：吴阶平.吴阶平泌尿外科学.济南：山东科学技术出版社,2004.2072-2073.
[42]王绍勇、林海群、魏来临.膀胱癌与尿流改道治疗策略.医学与哲学(临床决策论坛版).2011；32-33.
[2]郝捷,陈万青.膀胱癌//2012年中国肿瘤登记年报.军事医学科学出版社,2012,97.
[3]韩苏军,张思维,陈万青,等.中国膀胱癌发病现状及流行趋势分析.癌症进展,2013,1
[4]Fleshner NE, Herr HW, Stewart AK, et al. The National Cancer Data Base report on bladder carcinoma. Cancer,1996:78:1505-1513
[5]尿路上皮肿瘤的诊断和治疗.见：吴阶平主编.吴阶平泌尿外科学.济南：山东科学技术出版社,2004.959-980.
[6]董胜国,周荣祥,主编.膀胱肿瘤.北京：人民卫生出版社,2007.22-45
[7]Kantor AF, Hartge P, Hoover RN, et al. Epidemiological characteristics of squalors cell carcinoma and adenocarcinoma of the bladder. Cancer Res,1988, 48:3853-3855
[8]Lynch CF, Cohen MB. Urinary system cancer,1995,75(suppl):316-328.
[9]Bennett JK, Wheatly JK, Walton KN.10-year experience with adenocarcinoma of the bladder. J Urol,1984,131:262-263
[10]Nielsen K, and Nielsen KK. Adenocarcinoma in exstrophy of the bladder-the last case in Scandinavia? A case report and review of the literature. J Urol,1983, 130:1180-1182.
[11]Ozen H, Hall M C. Bladder cancer [J].Cur Opine Oncol,2000,12:255-259.
[12]Althausen AF, Hagen-Cook K, Hendren HW, et al. Non-refluxing colon conduit. Experience with 70 cases. J Urol 1978,120:35-39.
[13]Epstein JI, Amin MB, Reuter VR, et al. The World Health Organization/International Society of Urological Pathology consensus classification of urothelial(transitional cell)neoplasms of the urinary bladder. Bladder Consensus Conference Committee. Am J Surg Pathol,1998,22: 1435-1448.
[14]Sauter G, Algaba F, Amin M, et al. Tumor of urinary system:non-invasive urothelial neoplasia. WHO Classification of tumor of urinary system and male genital organs. Lyon:IARCC Press,2004.
[15]Sobin LH, Gospodariwicz M, Wittekind C (eds). TNM classification of malignant tumors. UICC International Union against Cancer.7th edn. Wiley-Blackwell,2009 Dec; pp.262-265.
[16]Lamm DL. Cancer in situ. Urol Clin North Am,1992,19:499-508.
[17]Roth A. Transabdominal transperitoneal bilateral omento-ureterostomy. Oral communication at the annual meeting of the North Central Station Section, AUA Cleveland, Ohio, Sept.27-30,1967.
[18]Kouba E, Sands M, Lentz A et al:A comparison of the Bricker versus Wallace ureteroileal anastomosis in patients undergoing urinary diversion for bladder cancer. J Urol 2007; 178:945.
[19]Knap MM, Lundbeck F and Overgaard J:Early and late treatment-related morbidity following radical cystectomy. Scand J Urol Nephrol 2004; 38:153.
[20]梅骅,陈凌武,高新.泌尿外科手术学(第3版)[M].北京：人民卫生出版社,2008.352-353.
[21]Deliveliotis C, Papatsoris A, Chrisofos M, et al. Urinary diversion in high-risk elderly patients:modified cutaneous ureterostomy or ileal conduit? Urology 2005 Aug; 66(2):299-304.
[22]Kilciler M, Bedir S, Erdemir F, et al. Comparison of ileal conduit and transureteroureterostomy with ureterocutaneostomy urinary diversion. Urol Int 2006; 77(3):245-50.
[23]Boyd SD, Lieskovsky G, Skinner DG. Kock pouch bladder replacement. Urol Clin North Am,1991,18:641-648
[24]Witjes JA, Comperat E, Cowan NC, et al. EAU Guidelines on Bladder Cancer Muscle-invasive and Metastatic, ed. European Association of Urology,2013.
[25]Madersbacher S, Schmidt J, Ebele JM, et al. Long-term outcome of ileal conduit diversion [J]. J Urol,2009,169(3):985-990.
[26]Pycha A, Comploj E, Martini T, et al. Comparison of complications in three incontinent urinary diversions. Euro Urol.2008 Oct; 54(4):825-32.
[27]Green fields, Nelson EC:Recent developments and future issues in the use of Health status assessment measures in clinical settings [J].Med Care, 1992(supply5); 30:23-41.
[28]徐建立.膀胱全切除后不同尿流改道方式患者生活质量比较.[D]天津医科大学,2009.4
[29]Engel GL:The need for a new medical model:A challenge for biomedicine [J].Science,1977,196:129-136.
[30]Green fields, Nelson EC:Recent developments and future issues in the use of Health status assessment measures in clinical settings [J].Med Care, 1992(supply5); 30:23-41.
[31]万崇华.生命质量测定与评价方法[M].昆明：云南大学出版社,1999.224-227。
[32]梅骅,陈凌武,高新.泌尿外科手术学(第3版)[M].北京：人民卫生出版社,2008.353-357。
[33]Celia DE, Tulsky DS, Gray G, et al. The functional assessment of cancer therapy scale:development and validation of the general measure [J] Clin. Oncol,1993, 11(3):570-579.
[34]Elmajian, Donald Abet. The Kock ileal neobladder:updated experience in 295 male Patients. J Urol.1996SeP:156(3):920-5.
[35]Steven K, Poulsen AL. The orthotopic Kock ileal neobladder:functional results, urodynamiefeatures, complications and survival in 166 men。 Urol.2000Ang:164(2):288-95.
[36]Yang WJ, Cho KS, Rha KH et al:Long-term effects of ileal conduit urinary diversion on upper urinary tract in bladder cancer. Urology 2010; 68:324.
[37]Pantuck AJ, Han KR, Perrotti M et al:Ureteroenteric anastomosis in continent urinary diversion:long-term results and complications of direct versus nonrefluxing techniques. J Urol 2000; 163:450.
[38]Evangelidis A, Lee EK, Karellas ME et al:Evaluation of ureterointestinal anastomosis:Wallace vs. Bricker. J Urol 2008; 175:1755.
[39]Lee CT, Chen BT, Gong E et al:Comparison of modified Taguchi and Bricker ureteral reimplantation techniques after radical cystectomy. Urology 2012; 64: 940.
[40]Morgan PR, Murdoch JB, Lopes A et al:The Wallace technique of ureteroileal anastomosis and its use in gynecologic oncology:a study of 81 cases. Obstet Gynecol 1993; 82:594.
[41]HomPson CA, shanafelt TD, loprinzi CL. Andropause:symptom management for Prostate cancer Patients treated with hormonal ablation [J].Oneologist, 2003,8:474-487.
[42]Patrickdl, Ericksonp. Assessing health related of quality of life for clinical decision-making. In:Quality Of Life Assessment:key issues in1990.5.Walker SR, RMR osser (eds):Boston:Kluwer ACHT emic Publishers,1993, 1112-1116.
[43]AltweinJ, Ekinan P, Barry M, et al. How is quality of life in prostate cancer Patients influeneed by modern treatment? The wall en symposium [J].Urology, 1997,49 (4Asuppl):66.
[44]HobischA, Tosuk, Kinzl J. Life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion.Semin Urol Oncol 2001,19:18-23.
[45]Fujissawa M, Isotanis S, Gotoh A. et al. Health-related quality of life with orthotopic neobladder versus ileal conduit according to the SF 36survey.Urology2000,55:862-865.
[46]Kikuchi E, Horiguchi Y, Nakashing J et al. Assessment of long-term quality of life using the FACT-BL questionnaire in Patients with an ideal conduit, Ontinent reservoir or orthotopic neobladder.. JPnJ Clin Oncol 2006,36: 712-716.
[47]Gilbert SM, Wood DP, Dunn RL et al. Measuring healthy-related quality of life outcomesin bladder cancer Patients using the Bladder Cancer index (BCI). Caneer2007,109:1756-1762.
[48]Gerharz EW, Masnson A, Hunt S, et al.Quality of life after cystectomy and urinary diversion:an evidence based analysis [J]. J Urol,2010, 174(5):1729-1736.
[49]Gerharz EW, Masnson A, Masnson W. Quality of life in patients with bladder cancer[J]. Urol Oncol,2005,23(4):201-207.
[50]Hobisch A, Tosun K, Kinzl J, et al. Life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion[J]. Semin Urol Oncol,2013, 21(3):118-123.
[51]Porter MP, Wei JT, Penson DF. Quality of life issues inbladder cancer patients following cystectomy and urinary diversion [J]. Urol Clin North Am,2005, 32(2):207-216.
[52]Wright JL, Porter MP. Quality-of-life assessment in patients with bladder cancer [J]. Nat Clin Pract Urol,2011,6(3):247-254.
[53]Gill IS, Kaouk JH, Meraney AM, et al. Laparoscopic radical cystectomy and continent orthotopic ileal neobladder performed completely intracorporeally: the initial experience. JUrol,2012,168(1):13-18.
[54]Abdel-Hakim AM, Bassiouny F, Abdel Azim Ms, et al. Laroscopic radical cystectomy with orthopic neobladder. J Endourol,2002,16(6):377-381.
[55]万崇华,孟琼,汤学良等.癌症患者生命质量测定量表FACT-G中文版评价[J].实用肿瘤杂志,2006,21(1)：77-80.
[56]崔勇,颜纯海,单玉喜.输尿管皮肤造口在膀胱全切除术中的应用[J].江苏医药杂志,2002,28(12)：940.
[57]Pycha A, Comploj E, Martini T, et al. Comparison of complications in three incontinent urinary diversions. Euro Urol 2013; 58:825-32.
[1]Jakse Q Algaba F, Foss S, et al. Guidelines on Bladder cancer Muscle-invasive and Metastatic [J].European Association of Urology, 2012(7):11-34.
[2]Stein J P, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer:Long term results in 1054 patients [J].J Clin Oncol, 2001,19:666-675.
[3]Gschwend J E, Vieweg J, Fair W R, et al. Early versus delayed cystectomy for invasive bladder cancer:impact of disease specific survival? [J]. J Urology, 1997,157:1507.
[4]Stein JP, L.G., Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer:long-term results in 1054 patients. J Clin Oncol,2001,19: 666-675
[5]Gschwend JE, V.J., Fair WR, et al., Early versus delayed cystectomy for invasive bladder cancer:impact of disease specific survival? J Urol,1997,157: 1507
[6]Stein JP, Q.M., Skinner DG, Lymphadenectomy for invasive bladder cancer: historical perspective and contemporary rationale. BJU Int,2006,97:227-231
[7]World Health Organization (WHO) Consensus Conference in Bladder Cancer, Hautmann RE, Abol-Enein H, Hafez K, Haro I, Mansson W, Mills RD, Montie JD, Sagalowsky Al, Stein JP, Stenzl A, Studer UE, Volkmer BG. Urinary diversion. Urology 2007 Jan; 69(1 Suppl):17-49.
[8]Ghoneim MA, E.-M.M., El-Baz MA, et al., Radical cystectomy for carcinoma of the bladder:critical evaluation of the results in 1026 cases. J Urol,1997,158: 393-399.
[9]Witjes JA, Comperat E, Cowan NC, et al. EAU Guidelines on Bladder Cancer Muscle-invasive and Metastatic, ed. European Association of Urology,2013.
[10]王章才.全膀胱切除术治疗膀胱癌手术时机的探讨.临床泌尿外科杂志,2000.15：283
[11]Huang J, Lin T, Liu H, et al. Laparoscopic radical cystectomy with orthotopic ileal neobladder for bladder cancer:oncologic results of 171 cases with a median 3-year follow-up. Eur Urol 2010; 58(3):442-449
[12]Haber GP, Crouzet S, Gill IS. Laparoscopic and robotic assisted radical cystectomy for bladder cancer:a critical analysis. Eur Urol 2008; 54(1):54-62.
[13]Hellenthal NJ, Hussain A, Andrews PE, et al. Surgical margin status after robot assisted radical cystectomy:results from the International Robotic Cystectomy Consortium. J Urol 2010; 184(1):87-91.
[14]Chade DC, Laudone VP, Bochner BH, et al. Oncological outcomes after radical cystectomy for bladder cancer:open versus minimally invasive approaches. J Urol 2010 Mar; 183(3):862-69.
[15]Cathelineau X, A.C., Rozet F, et al. Laparoscopic assisted radical cystectomy: the montsouris experience after 84 cases. Euro Urol,2005,47:780-784
[16]Ng CK, Kauffman EC, Lee MM, et al.A comparison of postoperative complications in open versusrobotic cystectomy. Euro Urol 2010 Feb; 57(2):274-81.
[17]陈光富,张旭,史立新,等.机器人辅助腹腔镜下根治性膀胱切除加尿流改道术的临床分析《中华泌尿外科杂志》-2012年10期
[18]沈周俊,钟山,何威,等.机器人外科手术系统辅助腹腔镜在膀胱及前列腺手术中的优势(附4例报道) 《上海医学》2011年1期
[19]Lin T, Huang J, Han J, et al. Hybrid laparoscopic endoscopic single-site surgery for radical cystoprostatectomy and orthotopic ileal neobladder:an initial experience of 12 cases. J Endourol 2011; 25(1):57-63.
[20]Kaouk JH, Goel RK, White MA, et al. Laparoendoscopic single-site radical cystectomy and pelvic lymph node dissection:initial experience and 2-year follow-up. Urology2010; 76(4):857-861.
[21]刘春晓,徐啊白,郑少波,等.单孔腹腔镜下根治性膀胱切除术10例报告.中华泌尿外科杂志2011；32(2)：90-93.
[22]Ma LL, Bi H, Hou XF, et al. Laparoendoscopic single-site radical cystectomy and urinary diversion:initial experience in China using a homemade single-port device. J Endourol 2012; 26(4):355-359.
[23]Jakse G, Algaba F, Foss S, et al. Guidelines on Bladder cancer Muscle-invasive and Metastatic [J].European Association of Urology,2004:13-14.
[24]Lein J P, Skinner D G. Campbell'surology [M].Harcourt Asia PTE LTD: Singapore,2002:3835-3868.
[25]周祥福,梅骅.尿流改道与膀胱替代.见：吴阶平.吴阶平泌尿外科学.济南：山东科学技术出版社,2004.2057-2082
[26]Boyd SD, Lieskovsky G, Skinner DG. Kock pouch bladder replacement. Urol Clin North Am,1991,18:641-648
[27]Witjes JA, Comperat E, Cowan NC, et al. EAU Guidelines on Bladder Cancer Muscle-invasive and Metastatic, ed. European Association of Urology,2013.
[28]Hautmann RE, de Petriconi R, Gottfried HW, et al. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol 1999; 161:422-7.
[29]Abol-Enein H, Ghoneim MA. Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation:experience with 450 patients. J Urol 2001; 165:1427-32.
[30]Stein JP, Dunn MD, Quek ML, et al. The orthotopic T pouch ileal neobladder: experience with 209 patients. J Urol 2004; 172:584-7.
[31]Kessler TM, Burkhard FC, Perimenis P, et al. Attempted nerve sparing surgery and age have a significant effect on urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. J Urol, 2004.172:1323-1327.
[32]Bhatta Dhar N, Kessler TM, Mills RD, et al. Nerve-Sparing Radical Cystectomy and Orthotopic Bladder Replacement in Female Patients. Eur Urol, 2007.52(4):1006-1014.
[33]Bricker E M. Bladders Substitution after pelvic evis-ceration[J]. Surg Clin N A mer,1950,30:1511.
[34]Pycha A, Comploj E, Martini T, et al. Comparison of complications in three incontinent urinary diversions. Eur Urol.2008 Oct; 54(4):825-32.
[35]Nieuwenhuijzen JA, de Vries RR, Bex A, et al. Urinary diversions after cystectomy:the association of clinical factors, complications and functional results of four different diversions. Eur Urol,2008,53(4):834-844
[36]Madersbacher S, Schmidt J, Eberle JM, et al. Long-term outcome of ileal conduit diversion. J Urol,2003,169(3):985-990
[37]Wood DN, Allen SE, Hussain M, et al. Stomal complications of ileal conduits are significantly higher when formed in women with intractable urinary incontinence. J Urol,2004,172(6 Ptl):2300-2303
[38]Deliveliotis C, Papatsoris A, Chrisofos M, et al. Urinary diversion in highrisk elderly patients:modified cutaneous ureterostomy or ileal conduit? Urology, 2005,66(2):299-304
[39]Fisch M, Wammack R, Hohenfellner R. The sigma rectum pouch (Mainz pouch Ⅱ). World J Urol,1996,14:68-72
[40]El Mekresh MM, Hafez AT, Abol-Enein H, et al. Double folded rectosigmoid bladder with a new ureterocolic antireflux technique. J Urol,1997, 157:2085-2089.
[41]尿路改道与膀胱替代.见：吴阶平.吴阶平泌尿外科学.济南：山东科学技术出版社,2004.2072-2073.
[42]王绍勇、林海群、魏来临.膀胱癌与尿流改道治疗策略.医学与哲学(临床决策论坛版).2011；32-33.