朱俊成 李炯明 劉建和 劉開(kāi)明 姜永明 方克偉 王光 李沛 石鑫 Prashant 段飛
1昆明醫(yī)科大學(xué)第二附屬醫(yī)院泌尿外科三病區(qū) 650101 昆明 2陸良縣人民醫(yī)院泌尿外科
根治性膀胱切除術(shù),同時(shí)行盆腔淋巴結(jié)清掃是治療肌層浸潤(rùn)性膀胱癌的金標(biāo)準(zhǔn)[1, 2]。盆腔淋巴結(jié)切除術(shù)是手術(shù)的重要部分之一,是提高肌層浸潤(rùn)性膀胱癌患者生存率、預(yù)防復(fù)發(fā)和避免遠(yuǎn)處轉(zhuǎn)移的有效方法[3~8]一旦轉(zhuǎn)移性淋巴結(jié)侵犯髂血管,將給手術(shù)帶來(lái)較大的困難,處理不慎就會(huì)導(dǎo)致血管損傷,引起嚴(yán)重出血。昆明醫(yī)科大學(xué)第二附屬醫(yī)院2012年9月~2017年10月采用腹腔鏡技術(shù),對(duì)12例根治性膀胱切除術(shù)中轉(zhuǎn)移性淋巴結(jié)侵犯髂血管的患者進(jìn)行淋巴結(jié)切除術(shù),有效避免了髂血管損傷和由此引起的嚴(yán)重出血,報(bào)告如下。
本組12例,男10例,女2例,年齡46~72歲,平均65歲?;颊呔蛉庋垩蛉朐海暬駽T檢查發(fā)現(xiàn)膀胱占位性病變,5例合并腎臟積水;同側(cè)輸尿管全程擴(kuò)張。膀胱鏡檢見(jiàn)腫瘤呈菜花樣或火山口樣,腫瘤基底寬為2.5~6.0 cm,5例腫瘤侵犯一側(cè)輸尿管口,8例為多發(fā)腫瘤,4例為單發(fā)腫瘤。病理檢查結(jié)果膀胱移行上皮癌11例,鱗癌1例。術(shù)前腫瘤臨床分期分別為T(mén)3a期2例、T3b期4例、T4a期5例、T4b期1例。CT或MRI增強(qiáng)掃描提示,12例患者髂外血管周?chē)性龃罅馨徒Y(jié),且腫大淋巴結(jié)短徑均大于8 mm(目前臨床上多將膀胱癌患者影像學(xué)檢查中短徑超過(guò)8 mm的盆腔淋巴結(jié)和超過(guò)1 cm的腹腔及腹膜后淋巴結(jié)考慮為腫瘤侵犯),其中右側(cè)6例,左側(cè)5例,雙側(cè)1例,淋巴結(jié)大小1.0~2.6 cm。12例患者均未發(fā)現(xiàn)遠(yuǎn)處轉(zhuǎn)移。
①靜吸復(fù)合全身麻醉,頭低腳高與水平成30°仰臥位。②常規(guī)五孔法經(jīng)腹腔建立手術(shù)通道,觀(guān)察鏡Trocar置于臍緣上2 cm,便于行擴(kuò)大淋巴結(jié)清掃。③沿髂血管走形切開(kāi)腹膜,首先游離出輸尿管[2]至髂總動(dòng)脈上方,以避免損傷,顯露髂外血管及周?chē)M織,探查腫大淋巴結(jié)部位。④切除髂外動(dòng)脈周?chē)馨徒Y(jié),于髂總動(dòng)脈分叉下方游離出髂外動(dòng)脈或分叉上方游離出髂總動(dòng)脈,穿過(guò)一橡皮圈作為阻斷該血管時(shí)牽引用,從髂血管分叉處切開(kāi)血管鞘,沿血管鞘與動(dòng)脈壁之間進(jìn)行分離,處理侵犯血管淋巴結(jié)時(shí),術(shù)者左手用分離鉗提起淋巴結(jié),助手用分離鉗從相反方向牽拉血管形成對(duì)抗,用超聲刀或組織剪緊貼淋巴結(jié)與血管之間進(jìn)行分離,將淋巴結(jié)從血管表面分開(kāi),游離出整段髂外動(dòng)脈。⑤切除髂外靜脈周?chē)馨徒Y(jié),切除髂外動(dòng)脈周?chē)馨徒Y(jié)后,于旋髂靜脈近端游離出髂外靜脈,于血管下方穿過(guò)一橡皮圈,從髂總血管分叉水平切開(kāi)靜脈鞘,沿靜脈鞘與靜脈壁之間由近向遠(yuǎn)游離髂外靜脈,處理侵犯髂外靜脈淋巴結(jié)的方法同處理髂外動(dòng)脈的方法一致,完全切除髂外靜脈周?chē)馨徒Y(jié)及脂肪組織。⑥血管損傷的處理,手術(shù)過(guò)程中一旦出現(xiàn)血管損傷,先用周?chē)M織壓住血管破口,然后提起預(yù)置的橡皮圈,用無(wú)損傷血管鉗將該血管阻斷,動(dòng)脈破裂從近端阻斷,靜脈破裂從遠(yuǎn)端阻斷,侵犯血管的淋巴結(jié)切除后,再對(duì)損傷的血管進(jìn)行縫合處理。
本組12例患者均在腹腔鏡下完成了根治性膀胱切除、腹壁尿流改道手術(shù),其中9例行Bricker尿流改道術(shù),3例行輸尿管皮膚造瘺術(shù),無(wú)中轉(zhuǎn)開(kāi)放手術(shù)。術(shù)中出血50~230 ml,平均110 ml,均未輸血。8例行標(biāo)準(zhǔn)盆腔淋巴結(jié)清掃,4例行擴(kuò)大盆腔淋巴結(jié)清掃,完全切除侵犯髂外血管的淋巴結(jié),病理檢查均為腫瘤轉(zhuǎn)移性淋巴結(jié)。切除一側(cè)髂外血管周?chē)馨徒Y(jié)的時(shí)間為15~35 min,平均23 min。術(shù)中出現(xiàn)1例髂外靜脈損傷,及時(shí)用無(wú)損傷鉗對(duì)靜脈遠(yuǎn)端進(jìn)行阻斷,完成淋巴結(jié)切除后用4-0血管縫合線(xiàn)進(jìn)行修補(bǔ)。無(wú)髂外動(dòng)脈損傷。術(shù)中無(wú)直腸損傷,術(shù)后無(wú)繼發(fā)性髂外血管出血、髂外靜脈栓塞、淋巴瘺發(fā)生。1例腸梗阻于術(shù)后3周行手術(shù)處理。
隨著手術(shù)水平的提高和手術(shù)設(shè)備的進(jìn)步,腹腔鏡技術(shù)已越來(lái)越多地應(yīng)用于泌尿外科復(fù)雜手術(shù)。腹腔鏡下完成的根治性膀胱切除已在很大程度上替代了傳統(tǒng)的開(kāi)放手術(shù)[9~13]。腹腔鏡手術(shù)不僅有效減少了手術(shù)的創(chuàng)傷,而且由于腹腔鏡的放大作用,可使手術(shù)的精準(zhǔn)性得到提高,特別是3D腹腔鏡更能提高手術(shù)的精細(xì)程度,進(jìn)一步保證了手術(shù)的安全和療效[14~16]。
膀胱腫瘤易發(fā)生盆腔淋巴結(jié)轉(zhuǎn)移[17],文獻(xiàn)顯示,膀胱癌行根治性膀胱切除標(biāo)本中,有13%~30%發(fā)現(xiàn)盆腔淋巴結(jié)轉(zhuǎn)移[18]。因此根治性膀胱切除中,必須盡可能徹底切除盆腔淋巴結(jié)[6,19~22]。積極的膀胱根治性切除加盆腔淋巴結(jié)清掃,對(duì)減少腫瘤的復(fù)發(fā)、遠(yuǎn)處轉(zhuǎn)移和改善生存率等方面有著重要的意義[23, 24]。膀胱腫瘤盆腔淋巴結(jié)轉(zhuǎn)移與臨床分期關(guān)系密切[17],報(bào)道顯示,T3~T4期膀胱癌患者髂外血管周?chē)馨徒Y(jié)較易發(fā)生轉(zhuǎn)移[25]。髂血管周?chē)〉霓D(zhuǎn)移性淋巴結(jié)容易切除,但如果淋巴結(jié)較大、融合成團(tuán),特別是侵犯髂外血管,與周?chē)M織粘連較重時(shí),切除則較困難,一旦損傷髂外血管,會(huì)引起嚴(yán)重的出血,甚至危及患者生命[26]。 由于擔(dān)心髂外血管的損傷,以致一些手術(shù)醫(yī)生會(huì)放棄對(duì)侵犯髂血管淋巴結(jié)的切除,影響到手術(shù)的療效。安全有效地切除較大的侵犯髂外血管的淋巴結(jié)對(duì)外科醫(yī)生來(lái)說(shuō)是一種挑戰(zhàn),如何較好地處理這一問(wèn)題,為廣大泌尿外科醫(yī)生所關(guān)注。
本組在總結(jié)了前期開(kāi)放手術(shù)和腹腔鏡根治性膀胱切除手術(shù)[27~29]經(jīng)驗(yàn)的基礎(chǔ)上,設(shè)計(jì)了安全切除侵犯髂外血管轉(zhuǎn)移性淋巴結(jié)的手術(shù)方法,其目的在于盡可能切除侵犯髂血管的轉(zhuǎn)移性淋巴結(jié), 努力提高手術(shù)的療效。手術(shù)要點(diǎn):①在切除淋巴結(jié)前,先游離出受侵犯的髂外動(dòng)脈近端(髂動(dòng)脈分叉處或髂總動(dòng)脈)和髂外靜脈遠(yuǎn)端(旋髂靜脈上方)游離出,做好阻斷髂外動(dòng)靜脈的準(zhǔn)備,術(shù)中一旦出現(xiàn)血管損傷,可及時(shí)對(duì)其進(jìn)行阻斷,待淋巴結(jié)切除后,再對(duì)血管進(jìn)行修補(bǔ)。②切除淋巴結(jié)時(shí),盡可能沿血管鞘與血管壁之間進(jìn)行[30],以增加切除的徹底性,但要注意避免超聲刀對(duì)血管的熱損傷。本組12例均按設(shè)計(jì)的手術(shù)方法完成了侵犯髂血管淋巴結(jié)的切除,術(shù)中1例發(fā)生髂外靜脈損傷,按預(yù)案進(jìn)行了有效處理,無(wú)明顯出血發(fā)生。無(wú)髂外動(dòng)脈損傷發(fā)生。 術(shù)后無(wú)髂血管繼發(fā)性出血和髂外靜脈栓塞發(fā)生。
根治性膀胱切除術(shù)中,在充分做好髂外動(dòng)脈和髂外靜脈阻斷的前提下,可對(duì)已侵犯髂血管的較大的轉(zhuǎn)移性淋巴結(jié)實(shí)施安全的切除,以進(jìn)一步提高盆腔淋巴結(jié)切除的徹底性。
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