基于“三线五面”膜解剖的腹腔镜根治性膀胱切除术治疗男性膀胱癌的疗效观察（附34例报告）

Clinical observation of laparoscopic radical cystectomy based on three lines and five planes with membrane anatomy in treatment of male bladder cancer (34 cases)

摘要:

目的 探讨基于“三线五面”膜解剖的腹腔镜根治性膀胱切除术治疗男性膀胱癌的安全性、疗效与优势。方法 选取2018年1月－2020年4月郴州市第一人民医院泌尿外科收治的34例男性膀胱癌患者，均实施腹腔镜下根治性膀胱切除术。患者年龄54～83岁，平均（66.6±7.9）岁；多发肿瘤12例，单发肿瘤22例，其中位于三角区3例，左侧壁6例，右侧壁7例，底部4例，顶部2例；肿瘤直径1.5～7.5 cm，平均（3.6±1.6）cm；术前临床分期：cT₂N₀M₀ 20例，cT₃N₀M₀ 10例，cT_4aN₀M₀ 4例。手术均由同一高年资医师完成，按照“三线五面”（“三线”即三条主线：输尿管、输精管和脐内侧韧带；“五面”即五个无血管平面：输尿管鞘平面、直肠前平面、脐动脉外侧平面、骨盆侧壁平面、耻骨后平面）的手术思路，运用膜解剖技术精准分离，先行根治性膀胱切除术，再行盆腔淋巴结清扫，最后行尿流改道。结果 34例患者均顺利完成手术，根治性膀胱切除及盆腔淋巴结清扫术时间为160～240 min，平均（185.6±20.3）min，术中出血量200～500 mL，无输血病例。术后病检结果：pT₁N₀M₀ 2例，pT₂N₀M₀ 18例，pT₃N₀M₀ 11例，pT_4aN₀M₀ 3例；低级别尿路上皮癌4例，高级别尿路上皮癌30例，其中高级别尿路上皮癌伴肉瘤样癌1例；手术切缘均为阴性。术后肠道功能恢复时间（2.8±0.6）d，术后出现1例粘连性肠梗阻，经非手术治疗后肠道功能恢复，术中术后无严重并发症，术后住院时间10～15 d，平均（12.5±2.6）d，术后疼痛评分1～5分，平均（3.1±1.1）分，术后随访6～28个月，平均（12.5±7.8）个月，暂无局部复发与远处转移。结论 按照“三线五面”手术思路，运用膜解剖技术实施腹腔镜根治性膀胱切除术，术中解剖标志清晰、组织层次分明，并发症可控，手术安全性高，疗效满意，值得临床推广运用。

Abstract:

Objective To investigate the safety, efficacy and advantage of laparoscopic radical cystectomy for male muscle invasive bladder cancer according to three lines and five planes with membrane anatomy.Methods The clinical data of 34 male patients with bladder cancer underwent laparoscopic radical cystectomy from January 2018 to April 2020 were retrospectively analyzed. The average age of the patients was (66.6 ± 7.9) years old (range, 54 ~ 83 years). There were 12 patients with multiple tumors and 22 patients with single tumor, including 3 patients in the triangle region, 6 cases in the left wall, 7 cases in the right wall, 4 cases in the bottom, and 2 cases in the top. The tumor diameter was 1.5～7.5 cm, with an average of (3.6 ± 1.6) cm. The preoperative clinical staging: 20 cases of cT₂N₀M₀, 10 cases of cT₃N₀M₀ and 4 cases of cT_4aN₀M₀. All the operations were performed by the same senior physician, according to the operation idea of three lines and five plans (three lines are ureter, vas deferens and medial umbilical ligament; five planes are Ureteral sheath plane, anterior rectum plane, lateral plane of umbilical artery, pelvic lateral wall plane and posterior pubic plane), using membrane dissection technique, radical cystectomy was performed first, then pelvic lymph node dissection was performed, and finally urinary diversion was performed.Results All the 34 patients completed the operation successfully, the operation time of radical cystectomy and pelvic lymph node dissection was 160～240 min, with an average of (185.6 ± 20.3) min. Intraoperative blood loss was 200～500 mL, and there was no case of blood transfusion. The postoperative pathological examination results: 2 cases of pT₁N₀M₀, 18 cases of pT₂N₀M₀, 11 cases of pT₃N₀M₀, 3 cases of pT_4aN₀M₀, 4 cases of low-grade urothelial carcinoma, 30 cases of high-grade urothelial carcinoma and 1 case of sarcomatoid carcinoma. The surgical margins were negative. There was 1 case of adhesive intestinal obstruction after operation, and the intestinal function recovered after non-surgical treatment; there were no serious surgical complications during and after operation; the postoperative hospital stay was 10～15 days, with an average of (12.5 ± 2.6) days; the postoperative pain score was 1～5 points, with an average of (3.1 ± 1.1) points; the follow-up time was 6～28 months, with an average of (12.5 ± 7.8) months, with no local recurrence and distant metastasis.Conclusion Laparoscopic radical cystectomy based on three lines and five planes with membrane anatomy in treatment of male bladder cancer is safe and effective, which can provide the advantages of clear anatomical marks, distinct organizational planes and controllable complications. It is worthy of extending clinical application.