| Backgrounds and objectives:Bladder tumor(BT)is one of the most common urological diseases,which mostly derived from urothelium of urinary tract;other non-urothelial cancers,generally include squamous cell carcinoma and adenocarcinoma;besides,some rare cases might be related to other tissues,such as lymphoma,paraganglioma,fibroma and sarcoma,etc.Due to the localized development in bladder cavity,these rare cases would usually be misdiagnosed without pathological evidence,therefore,cystoscopy is considered of golden standard for the diagnosis of bladder cancer.With help of ultrasonagraphy and CT scan,urologists could preoperatively get disease stage and other useful information to draw up appropriate surgical plan,including transurethral resection of bladder tumor(TURBT)or radical cystectomy(RC)with urinary diversion(UD).To our knowledge,approximately 70-75% of BT is non-muscle invasive disease and 25-30% is muscle-invasive.For non-muscle invasive tumor,TURBT is usual selection following regular adjuvant introvesical chemotherapy.In the other,RC+UD are efficient for muscle invasive BT.There are several UD surgical options,which have different difficulties to urologists and bring different surgical trauma to patients,meanwhile,generate different life expectancies and qualities(Qo L)in long terms.UD is inevitable procedure after bladder is removed.Different UD options might be indicated for different patients as different economic situations and life demands.In China,UD is roughly divided into four types: Ileal Conduit,Orthotopic Neobladder,Cutaneous Ureterostomy and Sigmoid Colon pouch.RC+UD are recognized the most challenging surgery,which characteried of long operating time,hospital stay,morecomplications and blood loss,etc;however,with help of recent fast developing minimally invasive surgery technique,operating and recovery periods of patients were remarkably reduced,and how to perform the optimal surgery is becoming the highlight for urologists.As the safety and effectiveness of these advanced techniques remain unclear,whether patients can really get profits and reduce potential postoperative complications and improve Qo Ls are still big problems.We attempted to retrospectively analyze the 14 years experiences of RC+Mainz Ⅱ pouch and Laparoscopic Mainz Ⅱ pouch to identify the efficiency and safety of MIS of RC+UD in our single center.The aim of this study was as following:1.To elucidate the feasibility of total laparoscopic RD+Mainz Ⅱ pouch(LM)and identity the main characters of surgery,such as intraoperative blood loss,operating time,average hospital stay,and short-term postoperative complications,etc.To review the 15 cases of total laparoscopic RD+Mainz Ⅱ pouch and 257 cases of early open RD+ MainzⅡ pouch and partial endoscopic assistance in our single center.The long-term complications and Qo Ls remain follow up.2.To demonstrate the advantages and disadvantages of total laparoscopic RD+Mainz Ⅱ pouch and prospectively forecast the potential improvement of the minimally invasive techniques applied in this surgery methods.Material and method: A total of 272 cases of MIBC were collected in our clinical center during 2004-2018,57 cases were performed Laparoscopic Mainz Ⅱ pouch and200 cases open Mainz Ⅱ pouch.We focus on the 15 patients of LM(2010.10-2018.04)to identify the age,continence,operating time,blood loss,blood transfusion and long-term complications,which might explicit the safety and efficiency of LM by our clinical experience.Results:During 2004-2012,a total of 200 cases of muscle-invasive bladder cancer were admitted in our hospital and treated by open RC+ Mainz Ⅱ,incision infection or dehiscence appeared in 10 cases(5%).From 2012 to 2018,57 cases were performed Laparoscopic RC and open Mainz Ⅱ.Among these 257 patients,approximately,median operating time were 370.00min(320-610min),median blood loss were560.00ml(400-2500ml),median hospital stay time was 22.0(10-34)days,follow-up time was ranged from 3-167 months,long term complications including retrograde infection(4 cases),ureteral calculi(2 cases),unilateral hydronephrosis(5 cases),lung and bone metastasis(2 cases),intestinal tumor(1 case),and sigmoid colon-femoral canal skin fistula(1 case)were observed;In 15 cases of completely laparoscopic RC and Mainz Ⅱ,the mean age of patients was 58.1 ± 9.7 years old(38-70 Y.O),follow-up time was 31.5±4.72 months,mean operating time was 478.6±122.8min,blood loss was 437.3 ± 114.1 ml,mean hospital stay time was 25.7 ± 5.6 days,3patients accepted blood transfusion,2 patients got complications post-op and 1 patient was die due to diabetes complications in 18 months post-op.Conclusion: Laparoscopic Mainz Ⅱ pouch could be considered as a safe and efficient surgery for MIBC if patients were well prepared and selected.Better preoperative preparation might be benefit to patients’ better outcomes and decrease the surgery difficulties and hospital stay times.Backgrounds and objectives:Ureteral injuries usually lead to ureteral stricture,which develops hydronephrosis,even renal dysfunction if not managed properly in time.Common causes include retroperitoneal fibrosis,iatrogenic injuries during open or endourological surgery,radiation/chemical damage and chronic inflammatory,etc.Nephrostomy could temporarily decrease the raised creatine level,possibility of AKI/ARF and save the kidney.However,life quality would be lowered,infection might happen after nephrostomy and the tube of nephrostomy need nursing.Reports on long ureteral defect substitution surgery were rare,management of long ureteral defects is still challenging to urologists.Two methods could be applied in these cases: one was the balloon dilation which is indicated for short defects(<2cm),the other was tissues substitution reconstruction with ileal,clone,appendix,etc.As shortage of cases,the surgery is not well known world widely.An ideal replacement should meet the requirement of good drainage while minimizing absorption,allowing for ureteral repair of varied lengths and locations with maximal preservation of the urinary tract.It is critical to maintain the stability of anastomosis,avoiding urine leakage and re-stricture.Ileal for long length ureteral defects replacement includes “U-shape replacement”,“seven-shape replacement”,Yang-Monti surgery,etc.Because of small number of cases and complex surgical process,these procedures are not widely used in China.In this study,two cases in our clinical center during 2013 to 2016 were enrolled.We attempted to review the cases and surgical modifications,to conduct a systemic literature review,which might provide some help to ureteral replacement surgery in the future.The aim of our study was as following:1.To identify the common causes and potential risks on basis of 2 cases and systemic review.The prevention of postoperative and long-term complications could be conducted.2.To evaluate modifications on Yang-Monti principles and provide helpful information for future development of the ileal ureteral replacement.Methods: During April 2013 to June in 2015,2 patients were performed ileal ureteral substitution using a reconfigured ileal segment in our clinical center.“Yang-monti”principle was used and some modifications were made,then our follow-up was carried out up to 12 months.In our systemic review,eligible studies were retrieved by searching Pub Med,Google Scholar and the Cochrane Library database from January1996 through June 2016.Results: No significant intra/post-operative complications occurred on these 2 cases.serum creatinine(Scr)and blood urea nitrogen(BUN)of both patients decreased to normal 1 year after operation.Glomerular filtration rate(GFR),renogram and pyelography showed a stable split renal function.As to literature review,we identified10 out of 644 publications,which including 269 patients from cohort studies.The most usual indications for Yang-monti procedure were probably iatrogenic stricture and retroperitoneal fibrosis.Infection and ileus were the main short time post-op complications while the fistula and re-strictures probably happen in long-terms.Conclusions: Above all,we believe Yang-Monti Principle be a safer and efficient technique for clinical partial and complete ureteral substitution if patients and potential risks could be well prepared.Our experiences and review findings might be helpful to some urologists and beneficial to some proper patients.Multi-center experiences and long-term follow-up remain necessary in future. |
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