微创时代的膀胱根治性切除和尿流改道术

2014-04-17 22:15姜昊文丁强
上海医药 2014年6期
关键词:尿流根治性淋巴

姜昊文+++丁强

摘 要 传统开放性膀胱根治性切除术是治疗肌层浸润的局限性膀胱癌和复发性高级别膀胱癌的金标准。目前,腹腔镜膀胱根治性切除术因其出血少、术后疼痛轻、恢复快和切口小、美观性好等优点,越来越多地应用于临床。此外,单通道腹腔镜与机器人辅助腹腔镜技术也逐渐发展起来并应用于该领域。这些微创技术显示出广阔应用前景,但安全性和有效性仍需进一步证实。

关健词 膀胱肿瘤 腹腔镜手术 外科手术

中图分类号:R699.5 文献标识码:A 文章编号:1006-1533(2014)06-0011-04

Radical cystectomy and urinary diversion in the era of minimally invasive surgery

DING Qiang, JIANG Haowen

(Department of Urology of Huashan Hospital, Fudan University, Shanghai 200041, China)

ABSTARCT Open radical cystectomy is the gold standard treatment of locally muscle-invasive and high-grade recurrent bladder cancer. Currently, laparoscopic radical cystectomy has been a popular procedure for its advantages of decreased blood loss, postoperative pain, surgical wound and better recovery. Additionally, laparoendoscopic single-site surgery and robot-assisted laparoscopic techniques are undergoing a development in this field. The minimally invasive techniques present a promising application whereas the efficacy and safety require further validation.

KEY WORDS bladder tumour; laparoscopic surgery; surgery

根治性膀胱切除术(radical cystectomy,RC)是治疗肌层浸润的局限性膀胱癌和复发性高级别膀胱癌的标准方法,包括双侧盆腔淋巴结清扫、膀胱根治性切除和尿流改道。传统开放性膀胱癌根治术治疗的良好效果已在长期大样本随访中得到证实,是目前的治疗金标准。腹腔镜手术因其出血少、术后疼痛轻、恢复快和切口小、美观性好等优点,自20世纪90年代开始逐渐应用于RC,并诞生了腹腔镜膀胱根治性切除术(laparoscopic radical cystectomy,LRC)。

1 适应证和禁忌证

LRC和尿流改道术的适应证与开放手术基本一致,适用于有肌层浸润的局限性膀胱移行细胞癌(T1-T3、N0-x、M0)、复发性膀胱移行细胞癌、原位癌以及膀胱非移行细胞癌等。正位回肠膀胱术还应满足以下条件:(1)尿道残端2 cm内无肿瘤侵犯,即男性膀胱颈以下、女性膀胱三角区以下无肿瘤;(2)无前尿道狭窄,尿道括约肌及盆底肌功能正常;(3)无肠道切除史;(4)术中快速冰冻病理切片证实尿道残端无肿瘤。禁忌证主要包括严重的心肺疾患、腹壁或腹腔内感染以及膀胱癌周围脏器侵犯或转移。

2 盆腔淋巴结清扫

盆腔淋巴结清扫(pelvic lymph node dissection)与患者预后关系密切。越来越多的证据表明,扩大淋巴清扫术不仅为疾病的分期和预后提供信息,且无论对于淋巴结阳性还是阴性的患者都具有积极的临床意义。然而,目前对于淋巴清扫的范围尚未达成共识[1-5]。当前主要术式有:(1)常规盆腔淋巴结清扫术,包括闭孔、髂内、髂外和髂总淋巴结;(2)扩大盆腔淋巴结清扫术(图1[6]),清扫范围在常规清扫术范围的基础上加上骶前淋巴结清扫;(3)局限性盆腔淋巴结清扫术,清扫范围包括前侧髂外静脉后缘、后侧闭孔神经、头侧髂外和髂内静脉汇合处、尾侧耻骨韧带的髂耻分支、内侧脐内侧襞和外侧盆腔侧壁肌群;(4)改良的盆腔淋巴结清扫术,清扫髂内和闭孔淋巴结。一般认为,对膀胱癌需行常规或扩大的盆腔淋巴结清扫术,因约有25%术前分期为N0的患者术后病理发现有局部淋巴转移[7-10],而且实际切除的阳性淋巴结数目直接关系到预后[1,7]。目前推荐至少清扫20枚淋巴结,然而各中心报道的淋巴结清扫数目差别甚大(8~80枚)[8-9,11-16],这主要与术者对淋巴清扫范围的界定、淋巴结取出方法(分别套取或en bloc)以及病理医师的甄别有关。

3 LRC及尿流改道术

LRC的手术方法基本成熟并已标准化,此处不再赘述,其分离操作与腹腔镜下前列腺癌根治术类似,为防止肿瘤播散,应先关闭尿道再切除膀胱,淋巴清扫一般在膀胱切除后进行。LRC后均需行尿流改道,除了简单的输尿管腹壁造口外,各种异位可控和正位可控的膀胱替代成形及尿流改道术已成为当今的主流。目前,多数中心采用体外尿道改流术,需在脐周作5~7 cm切口并在体外完成肠道操作及输尿管肠管吻合(图2[17]),尿道肠管吻合均在腹腔镜下完成[18]。与开放手术相比,LRC除手术时间较长外,其在失血量、术后肠道功能恢复、手术并发症及术后镇痛药物使用等方面均优于开放手术[19-21]。然而,相比体外尿流改道术,完全体内尿流改道LRC,鉴于其输尿管肠道吻合技术难度大,既增加了手术时间和出血量,又增加了术后并发症和二次手术的发生率,目前已遭部分中心弃用[22-23]。在切缘阳性率和淋巴结清扫数目方面,LRC已被证实与开放手术差异无统计学意义[18,20-21],而腹腔镜特有的通道切口肿瘤种植仅在机器人辅助的LRC中有1例报道[24]。目前,LRC术后2年的肿瘤特异生存率高达80%[25-26]。

4 单通道腹腔镜(LESS)

近年来,LESS在泌尿外科的发展迅速,与传统腹腔镜的多通道相比,LESS可减少多套管造成的并发症并具有更好的美容效果。目前,LESS已应用于单纯肾切除、部分肾切除、肾上腺摘除等诸多泌尿外科手术,取得了良好的效果[27]。Kaouk等[28]首次报道LESS应用于2例男性及1例女性的根治性膀胱切除及双侧盆腔淋巴结清扫,其尿流改道采用体外Bricker式,手术平均时间315 min,平均出血217 ml,平均取出淋巴结16枚。3例中无一切缘阳性,随访2年后无一复发或转移。Lin等[26]通过改良的自制手套套管在12例男性开展LESS根治性膀胱切除并采用体外回肠正位新膀胱术进行尿流改道(图3[6]),大大解决了器械操作空间狭小的难题,并取得了与LRC相当的效果。

5 机器人辅助腹腔镜技术(RRC)

机器人手术系统操作因其灵巧和稳定性特别适用于耗时长、难度大、操作空间小的手术,使诸多学者对体内尿流改道术重燃希望。最近的几项报道提示RRC完成体内尿流改道术是可行的,并与RRC体外尿流改道术效果相当[29-32]。RRC对于膀胱切除及淋巴清扫的手术方法已基本标准化(图4[33]),一些非随机对照研究提示RRC在术后并发症等方面优于开放手术,短期效果与开放手术相当。尽管RRC在淋巴清扫方面较LCR具有更清楚的视野及更细致的操作,目前尚无证据支持RRC可达到与开放手术相当的淋巴清扫水平[33]。

综上所述,LRC和尿流改道术已经开展十余年,与传统开放手术相比,该术式具备相当的手术效果及明显的微创优势,并已显示出广阔应用前景。但因难以设计良好的随机前瞻性研究和多中心大样本长期随访的回顾性研究,该术式的安全性和有效性仍需进一步证实。

参考文献

[1] Bruins HM, Stein JP. Risk factors and clinical outcomes of patients with node-positive muscle-invasive bladder cancer[J]. Expert Rev Anticancer Ther, 2008, 8(7): 1091-1101.

[2] Stein JP. Lymphadenectomy in bladder cancer: how high is ‘high enough?[J]. Urol Oncol, 2006, 24(4): 349-355.

[3] Stein JP, Quek ML, Skinner DG. Lymphadenectomy for invasive bladder cancer: I. historical perspective and contemporary rationale[J]. BJU Int, 2006, 97(2): 227-231.

[4] Stein JP, Quek ML, Skinner DG. Lymphadenectomy for invasive bladder cancer. II. Technical aspects and prognostic factors. BJU Int 2006, 97(2): 232-237.

[5] Mills RD, Fleischmann A, Studer UE. Radical cystectomy with an extended pelvic lymphadenectomy: rationale and results[J]. Surg Oncol Clin N Am, 2007, 16(1): 233-245.

[6] 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]. J Endourol, 2011, 25(1): 57-63.

[7] Karl A, Carroll PR, Gschwend JE, et al. The impact of lymphadenectomy and lymph node metastasis on the outcomes of radical cystectomy for bladder cancer[J]. Eur Urol, 2009, 55(4): 826-835.

[8] Leissner J, Ghoneim MA, Abol-Enein H, et al. Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study[J]. J Urol, 2004, 171(1): 139-144.

[9] Stein JP, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1 054 patients[J]. J Clin Oncol, 2001, 19(3): 666-675.

[10] Vazina A, Dugi D, Shariat SF, et al. Stage speci?c lymph node metastasis mapping in radical cystectomy specimens[J]. J Urol, 2004, 171(5): 1830-1834.

[11] Weingartner K, Ramaswamy A, Bittinger A, et al. Anatomical basis for pelvic lymphadenectomy in prostate cancer: results of an autopsy study and implications for the clinic[J]. J Urol, 1996, 156(6): 1969-1971.

[12] Abol-Enein H, El-BazM, Abd El-HameedMA, et al. Lymph node involvement in patients with bladder cancer treated with radical cystectomy: a pathoanatomical study–a single center experience[J]. J Urol, 2004, 172(5 Pt 1): 1818-1821.

[13] Fleischmann A, Thalmann GN, Markwalder R, et al. Prognostic implications of extracapsular extension of pelvic lymph node metastases in urothelial carcinoma of the bladder[J]. Am J Surg Pathol, 2005, 29(1): 89-95.

[14] Capitanio U, Suardi N, Shariat SF, et al. Assessing the minimum number of lymph nodes needed at radical cystectomy in patients with bladder cancer[J]. BJU Int, 2009, 103(10): 1359-1362.

[15] Steven K, Poulsen AL. Radical cystectomy and extended pelvic lymphadenectomy: survival of patients with lymph node metastasis above the bifurcation of the common iliac vessels treated with surgery only[J]. J Urol, 2007, 178(4 Pt 1): 1218-1223.

[16] Fleischmann A, Thalmann GN, Markwalder R, et al. Extracapsular extension of pelvic lymph node metastases from urothelial carcinoma of the bladder is an independent prognostic factor[J]. J Clin Oncol, 2005, 23(10): 2358-2365.

[17] Irwin BH, Gill IS, Haber GP, et al. Laparoscopic radical cystectomy: current status, outcomes, and patient selection. Curr Treat Options Oncol, 2009,10(3-4): 243-255.

[18] Haber GP, Crouzet S, Gill IS. Laparoscopic and robotic assisted radical cystectomy for bladder cancer: a critical analysis[J]. Eur Urol, 2008, 54(1): 54-62.

[19] Basillote JB, Abdelshehid C, Ahlering TE, et al. Laparoscopic assisted radical cystectomy with ileal neobladder: a comparison with the open approach[J]. J Urol, 2004, 172(2): 489-493.

[20] Porpiglia F, Renard J, Billia M, et al. Open versus laparoscopy-assisted radical cystectomy: results of a prospective study[J]. J Endourol, 2007, 21(3): 325-329.

[21] Guillotreau J, Gamé X, Mouzin M, et al. Radical cystectomy for bladder cancer: morbidity of laparoscopic versus open surgery[J]. J Urol, 2009, 181(2): 554-559.

[22] Haber GP, Campbell SC, Colombo JR Jr, et al. Perioperative outcomes with laparoscopic radical cystectomy: “pure laparoscopic” and “open-assisted laparoscopic” approaches[J]. Urology, 2007, 70(5): 910-915.

[23] Cathelineau X, Jaffe J. Laparoscopic radical cystectomy with urinary diversion: what is the optimal technique?[J]. Curr Opin Urol, 2007, 17(2): 93-97.

[24] Gamé X, Mallet R, Guillotreau J, et al. Uterus, fallopian tube, ovary and vagina-sparing laparoscopic cystectomy: technical description and results[J]. Eur Urol, 2007, 51(2): 441-446.

[25] Berger A, Aron M. Laparoscopic radical cystectomy: long-term outcomes[J]. Curr Opin Urol, 2008, 18(2): 167-172.

[26] Stein JP, Penson DF. Invasive T1 bladder cancer: indications and rationale for radical cystectomy[J]. BJU Int, 2008, 102(3): 270-275.

[27] Jeon HG, Jeong W, Oh CK, et al. Initial experience with 50 laparoendoscopic single site surgeries using a homemade, single port device at a single center[J]. J Urol, 2010, 183(5): 1866-1871.

[28] Kaouk JH, Haber GP, Goel RK, et al. Single-port laparoscopic surgery in urology: Initial experience and 2-year follow-up[J]. Urology, 2008, 71(1):3-6.

[29] Schumacher MC, Jonsson MN, Wiklund NP. Robotic cystectomy[J]. Scand J Surg, 2009, 98(2): 89-95.

[30] Schumacher MC, Jonsson MN, Hosseini A, et al. Critical analysis of surgery related complications at robot-assisted radical cystectomy with intracorporeal urinary diversion[J]. Urology, 2011, 77(4): 871-876.

[31] Pruthi RS, Nix J, McRackan D, et al. Robotic-assisted laparoscopic intracorporeal urinary diversion[J]. Eur Urol, 2010, 57(6): 1013-1021.

[32] Guru K, Seixas-Mikelus SA, Hussain A, et al. Robot-assisted intracorporeal ileal conduit: marionette technique and initial experience at Roswell Park Cancer Institute[J]. Urology, 2010, 76(4): 866-871.

[33] Schumacher MC, Jonsson MN, Wiklund NP, et al. Does extended lymphadenectomy preclude laparoscopic or robot-assisted radical cystectomy in advanced bladder cancer?[J]. Curr Opin Urol, 2009, 19(5): 527-532.

(收稿日期:2014-02-19)

[24] Gamé X, Mallet R, Guillotreau J, et al. Uterus, fallopian tube, ovary and vagina-sparing laparoscopic cystectomy: technical description and results[J]. Eur Urol, 2007, 51(2): 441-446.

[25] Berger A, Aron M. Laparoscopic radical cystectomy: long-term outcomes[J]. Curr Opin Urol, 2008, 18(2): 167-172.

[26] Stein JP, Penson DF. Invasive T1 bladder cancer: indications and rationale for radical cystectomy[J]. BJU Int, 2008, 102(3): 270-275.

[27] Jeon HG, Jeong W, Oh CK, et al. Initial experience with 50 laparoendoscopic single site surgeries using a homemade, single port device at a single center[J]. J Urol, 2010, 183(5): 1866-1871.

[28] Kaouk JH, Haber GP, Goel RK, et al. Single-port laparoscopic surgery in urology: Initial experience and 2-year follow-up[J]. Urology, 2008, 71(1):3-6.

[29] Schumacher MC, Jonsson MN, Wiklund NP. Robotic cystectomy[J]. Scand J Surg, 2009, 98(2): 89-95.

[30] Schumacher MC, Jonsson MN, Hosseini A, et al. Critical analysis of surgery related complications at robot-assisted radical cystectomy with intracorporeal urinary diversion[J]. Urology, 2011, 77(4): 871-876.

[31] Pruthi RS, Nix J, McRackan D, et al. Robotic-assisted laparoscopic intracorporeal urinary diversion[J]. Eur Urol, 2010, 57(6): 1013-1021.

[32] Guru K, Seixas-Mikelus SA, Hussain A, et al. Robot-assisted intracorporeal ileal conduit: marionette technique and initial experience at Roswell Park Cancer Institute[J]. Urology, 2010, 76(4): 866-871.

[33] Schumacher MC, Jonsson MN, Wiklund NP, et al. Does extended lymphadenectomy preclude laparoscopic or robot-assisted radical cystectomy in advanced bladder cancer?[J]. Curr Opin Urol, 2009, 19(5): 527-532.

(收稿日期:2014-02-19)

[24] Gamé X, Mallet R, Guillotreau J, et al. Uterus, fallopian tube, ovary and vagina-sparing laparoscopic cystectomy: technical description and results[J]. Eur Urol, 2007, 51(2): 441-446.

[25] Berger A, Aron M. Laparoscopic radical cystectomy: long-term outcomes[J]. Curr Opin Urol, 2008, 18(2): 167-172.

[26] Stein JP, Penson DF. Invasive T1 bladder cancer: indications and rationale for radical cystectomy[J]. BJU Int, 2008, 102(3): 270-275.

[27] Jeon HG, Jeong W, Oh CK, et al. Initial experience with 50 laparoendoscopic single site surgeries using a homemade, single port device at a single center[J]. J Urol, 2010, 183(5): 1866-1871.

[28] Kaouk JH, Haber GP, Goel RK, et al. Single-port laparoscopic surgery in urology: Initial experience and 2-year follow-up[J]. Urology, 2008, 71(1):3-6.

[29] Schumacher MC, Jonsson MN, Wiklund NP. Robotic cystectomy[J]. Scand J Surg, 2009, 98(2): 89-95.

[30] Schumacher MC, Jonsson MN, Hosseini A, et al. Critical analysis of surgery related complications at robot-assisted radical cystectomy with intracorporeal urinary diversion[J]. Urology, 2011, 77(4): 871-876.

[31] Pruthi RS, Nix J, McRackan D, et al. Robotic-assisted laparoscopic intracorporeal urinary diversion[J]. Eur Urol, 2010, 57(6): 1013-1021.

[32] Guru K, Seixas-Mikelus SA, Hussain A, et al. Robot-assisted intracorporeal ileal conduit: marionette technique and initial experience at Roswell Park Cancer Institute[J]. Urology, 2010, 76(4): 866-871.

[33] Schumacher MC, Jonsson MN, Wiklund NP, et al. Does extended lymphadenectomy preclude laparoscopic or robot-assisted radical cystectomy in advanced bladder cancer?[J]. Curr Opin Urol, 2009, 19(5): 527-532.

(收稿日期:2014-02-19)

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