肠代膀胱的尿动力学表现课件

Urodynamic Study of Enterocystoplasty and Neobladder,沈 华 南京医科大学附属明基医院泌尿外科,南京医科大学附属明基医院泌尿外科,Company Logo,Overview,20世纪80年代中期前，很少采用肠道膀胱成形术，新膀胱术也没有成型。 临床上还没有意识到低的膀胱并发症的重要性，在晚期膀胱癌的治疗中回肠膀胱仍然是“金标准”方法，但回肠膀胱却显示存在较高的后期并发症。 从社会心理学观点来看，采用外部集尿器会影响患者获得满意的生活质量。,南京医科大学附属明基医院泌尿外科,Company Logo,从20世纪80年代开始，神经原性膀胱已经成为肠道膀胱成形术的相对适应证，而如今主要由于采用间断自家导尿来排空膀胱的方法被广泛接受，神经原性膀胱患者成为施行膀胱成形术的最重要人群。 肠道膀胱成形术在难治性逼尿肌过度活动及低顺应性膀胱患者中是一种安全有效的方法，但对难治性间质性膀胱炎患者效果不佳。 可控尿流改道和新膀胱已经成为膀胱癌膀胱全切后的一种经典的改道方式，在高危的膀胱癌患者中回肠膀胱仍是主要的改道方式。,南京医科大学附属明基医院泌尿外科,Company Logo,肠道成行手术和新膀胱的目的在于形成一个低压、高容量的储尿囊，储尿囊的排空或依靠间断自家导尿(intermittent catheterization)，或排尿反射(activation of the micturition reflex)，或腹压排尿(straining)。(Case 1、2、3) 新膀胱的手术方法很多。偶尔情况下，当膀胱癌患者施行较大范围的膀胱部分切除术时可进行膀胱扩大成形。(Case 6) 当不能通过尿道间断导尿时，带可控的能导尿的输出道的尿流改道方式是一种选择，但有时合并症较明显。施行膀胱扩大手术的患者若不能经尿道导尿时也可做可控的输出道。,南京医科大学附属明基医院泌尿外科,Company Logo,Urodynamic Findings in Orthotopic Ileocecal and Ileal Neobladder,Comparison of Clinical and Urodynamic Outcome in Orthotopic Ileocecal and Ileal Neobladder. Europeon Urology, 2003, 43(3): 258-262.,南京医科大学附属明基医院泌尿外科,Company Logo,Case 1,35岁女性脊髓多发性硬化患者，7年前因难治性逼尿肌-外括约肌协同失调(DESD)施行回肠膀胱扩大成形术。 她每日导尿4次，并且能控尿。,Augmentation enterocystoplasty in a 35-year-old woman with exacerbating, remitting multiple sclerosis who underwent the operation 7 years earlier because of refractory detrusor-external sphincter dyssynergia (DESD). She is on intermittent catheterization 4 times a day and remains continent.,南京医科大学附属明基医院泌尿外科,Company Logo,Urodynamic tracing shows and acontractile bladder with a capacity of over 750ml, FSF435ml, 1st urge650ml, severe urge750ml.,南京医科大学附属明基医院泌尿外科,Company Logo,X-ray obtained at 550ml.,南京医科大学附属明基医院泌尿外科,Company Logo,Case 2,43岁女性，难治性特发性膀胱过度活动症(OAB)。 患者于18个月前施行回肠膀胱扩大术。,Urodynamic study in a 43-year-old woman who underwent ileal augmentation cystoplasty 18 months earlier because of refractory idiopathic overactive bladder (OAB).,南京医科大学附属明基医院泌尿外科,Company Logo,Urodynamic study: FSF=415ml, 1st urge=574ml, and severe urge=600ml. Pressure flow study: Qmax=8ml/s, PdetQmax=43cmH2O, Pdetmax=54cmH2O, voided volume=216ml, PVR=975ml.,南京医科大学附属明基医院泌尿外科,Company Logo,After the catheter was removed, in the privacy of the bathroom, she voided to completion with a bell shaped curve and Qmax=25ml/s. VOID: 25/462/200. This corresponds to a mild grade 1 urethral obstruction on the Blaivas-Groutz nomogram.,南京医科大学附属明基医院泌尿外科,Company Logo,Case 3,54岁男性患者，2年前因浸润性膀胱癌行Studer回肠新膀胱术。 患者白天每46小时用腹压排尿1次，夜间不排尿，有时有遗尿，但否认其他的下尿路症状(LUTS)。,Ileal neobladder. This is a 54-year-old man 2 years status post ileal (studer) neobladder for invasive bladder cancer. He voids by, straining, about every 46 hours during the day and does not have nocturia. He has occasional enuresis, but denies any other lower urinary tract symptoms (LUTS).,南京医科大学附属明基医院泌尿外科,Company Logo,Urodynamic tracing. FSF=559ml, 1st urge=1028ml, severe urge=1297ml, and bladder capacity=1311ml. The electromyography (EMG) channel was not working properly during this study.,南京医科大学附属明基医院泌尿外科,Company Logo,Uroflow without the catheter shows a straining pattern.,南京医科大学附属明基医院泌尿外科,Company Logo,Straining to void.,南京医科大学附属明基医院泌尿外科,Company Logo,Case 4,62岁男性患者，施行保留神经的膀胱前列腺切除术，采用Studer方法重建回肠新膀胱。 患者按计划大约每天排尿6次，从来没有排尿感。 白天及夜间均无尿失禁。,Studer neobladder: 62-year-old man status post nerve sparing cystoprostatectomy and construction of ileal neobladder with Studer limb. He voids about 6 times a day, by design, but never senses an urge to void. He is never incontinent, day or night.,南京医科大学附属明基医院泌尿外科,Company Logo,Cystogram obtained 3 weeks postoperatively with 100ml in the bladder.,Straining to void.,南京医科大学附属明基医院泌尿外科,Company Logo,Case 5,另一新膀胱患者3年后尿动力学检查图：,In the filling phase of the study, he did not perceive the urge to void, but felt a vague fullness beginning at about 900ml. He voided voluntarily by marked abdominal straining at a bladder volume of about 1l. Qmax=11ml/s, voided volume=492ml, and PVR=510ml.,南京医科大学附属明基医院泌尿外科,Company Logo,A magnified view during voiding.,南京医科大学附属明基医院泌尿外科,Company Logo,X-ray obtained during uroflow.,南京医科大学附属明基医院泌尿外科,Company Logo,Uroflow obtained prior to the urodynamic study show a very different pattern than that seen during the study. VOID: 13/333/0.,南京医科大学附属明基医院泌尿外科,Company Logo,Case 6,87岁男性患者，因膀胱移行细胞癌(T2N0M0)施行“膀胱部分切除术+膀胱扩大术”。 术后6个月出现双侧膀胱输尿管反流及无症状性逼尿肌过度活动。,Bilateral vesicoureteral reflux (VUR) and asymptomatic detrusor overactivity in an 87-year-old man 6 months status post partial cystectomy and augmentation cystoplasty for transitional cell carcinoma of the bladder (T2,N0,M0).,南京医科大学附属明基医院泌尿外科,Company Logo,Urodynamic study: There are multiple low magnitude involuntary detrusor contractions during bladder filling that do not result in incontinence. FSF=750ml, 1st urge=950ml, severe urge=1001ml, PVR=850ml。,南京医科大学附属明基医院泌尿外科,Company Logo,南京医科大学附属明基医院泌尿外科,Company Logo,Case 7,68岁男性患者，因膀胱癌在本院行“全膀胱切除+Sigma直肠膀胱术”。 术后半年行尿动力学检查。,南京医科大学附属明基医院泌尿外科,Company Logo,尿动力学检查显示：FSF=110ml，1st urge=235ml，severe urge=465ml。灌注至180ml、220ml、254ml时患者出现少量漏尿。灌注过程中代膀胱压力与腹压同步上升，至465ml时嘱其排尿，排出尿量=284ml。,南京医科大学附属明基医院泌尿外科,Company Logo,排尿期图形：Qmax=74.2ml/s，达峰时间=4s。,南京医科大学附属明基医院泌尿外科,Company Logo,Case 8,59岁女性