Comparison Between Modified And The Traditional Cutaneous Ureterostomy

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.