引用本文
朱俊成, 李炯明, 刘建和, 刘开明, 姜永明, 方克伟, 王光, 李沛, 石鑫, Prashant, 段飞. 腹腔镜下根治性膀胱切除术中髂外血管淋巴结转移侵犯的处理[J]. 微创泌尿外科杂志, 2018,7(3): 166-169.
Zhu Juncheng, Li Jiongming, Liu Jianhe, Liu Kaiming, Jiang Yongming, Fang Kewe, Wang Guang, Li Pei, Shi Xin, Prashant, Duan Fei. Management of external iliac metastatic lymph nodes during laparoscopic radical cystectomy. JOURNAL OF MINIMALLY INVASIVE UROLOGY,2018,7(3): 166-169.  
Doi:10.19558/j.cnki.10-1020/r.2018.03.006
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腹腔镜下根治性膀胱切除术中髂外血管淋巴结转移侵犯的处理
朱俊成1, 李炯明1, 刘建和1, 刘开明2, 姜永明1, 方克伟1, 王光1, 李沛1, 石鑫1, Prashant1, 段飞1
1昆明医科大学第二附属医院泌尿外科三病区 650101 昆明
2陆良县人民医院泌尿外科
通信作者:李炯明,jiongmingli@aliyun.com
收稿日期: 2018-03-25
摘要

目的: 探索腹腔镜下根治性膀胱切除术中转移性淋巴结侵犯血管的处理方法。方法: 2012年9月~2017年10月,对12例膀胱癌合并转移性淋巴结侵犯髂血管的患者进行了根治性膀胱切除术。切除淋巴结前,充分解剖出淋巴结近端的髂外动脉或髂总动脉以及淋巴结远端的髂外静脉,作好血管阻断准备,沿髂血管鞘与血管之间游离切除淋巴结。结果: 12例患者均在腹腔镜下完成了侵犯髂血管的淋巴结切除术。切除一侧髂外淋巴结的时间为15~35 min。术中出现1例髂外静脉损伤,无髂外动脉损伤,无严重出血发生。术后无髂血管继发性出血和髂外静脉栓塞发生。结论: 在充分做好髂外动脉和髂外静脉阻断的前提下,可对侵犯髂血管的较大的转移性淋巴结实施安全的切除,进一步提高根治性膀胱切除术中盆腔淋巴结切除的彻底性。

关键词: 膀胱肿瘤; 髂外血管; 淋巴结切除术
中图分类号:R737.14 文献标志码:A
Management of external iliac metastatic lymph nodes during laparoscopic radical cystectomy
Zhu Juncheng1, Li Jiongming1, Liu Jianhe1, Liu Kaiming2, Jiang Yongming1, Fang Kewe1, Wang Guang1, Li Pei1, Shi Xin1, Prashant1, Duan Fei1
1Department of Urology, Second Affiliated Hospital of Kunming Medical University, Kunming 650101, China
2Department of Urology, Luliang County People's Hospital
Corresponding author: Li Jiongming, jiongmingli@aliyun.com
Abstract

Objective:To explore the management of metastatic lymph node during laparoscopic radical cystectomy.Methods:From September 2012 to October 2017, 12 patients underwent radical cystectomy and lymphadenectomy for invasive bladder cancer and lymph node metastasis of iliac vessel. Before lymph node dissection, the proximal end of external iliac artery or common iliac artery and distal end of external iliac vein were fully anatomized, vessels were fully occluded, and the lymph nodes were dissociated and dissected along the vascular sheath and blood vessels.Results:All 12 patients underwent laparoscopic lymphadenectomy invading the iliac vessels. Time of unilateral removal of lymph node was 15-35 min. There was 1 case of external iliac vein injury. No injury of external iliac artery and no serious bleeding occurred. No postoperative bleeding and external iliac venous embolism occurred.Conclusions:If we fully occluded the external iliac artery and vein, we can safely and effectively remove the larger metastatic iliac lymph nodes completely.

Keyword: bladder cancer; external iliac vessels; lymphadenectomy

根治性膀胱切除术, 同时行盆腔淋巴结清扫是治疗肌层浸润性膀胱癌的金标准[1, 2]。盆腔淋巴结切除术是手术的重要部分之一, 是提高肌层浸润性膀胱癌患者生存率、预防复发和避免远处转移的有效方法[3, 4, 5, 6, 7, 8]一旦转移性淋巴结侵犯髂血管, 将给手术带来较大的困难, 处理不慎就会导致血管损伤, 引起严重出血。昆明医科大学第二附属医院2012年9月~2017年10月采用腹腔镜技术, 对12例根治性膀胱切除术中转移性淋巴结侵犯髂血管的患者进行淋巴结切除术, 有效避免了髂血管损伤和由此引起的严重出血, 报告如下。

1 资料与方法
1.1 临床资料

本组12例, 男10例, 女2例, 年龄46~72岁, 平均65岁。患者均因肉眼血尿入院, 超声或CT检查发现膀胱占位性病变, 5例合并肾脏积水; 同侧输尿管全程扩张。膀胱镜检见肿瘤呈菜花样或火山口样, 肿瘤基底宽为2.5~6.0 cm, 5例肿瘤侵犯一侧输尿管口, 8例为多发肿瘤, 4例为单发肿瘤。病理检查结果膀胱移行上皮癌11例, 鳞癌1例。术前肿瘤临床分期分别为T3a期2例、T3b期4例、T4a期5例、T4b期1例。CT或MRI增强扫描提示, 12例患者髂外血管周围有增大淋巴结, 且肿大淋巴结短径均大于8 mm(目前临床上多将膀胱癌患者影像学检查中短径超过8 mm的盆腔淋巴结和超过1 cm的腹腔及腹膜后淋巴结考虑为肿瘤侵犯), 其中右侧6例, 左侧5例, 双侧1例, 淋巴结大小1.0~2.6 cm。12例患者均未发现远处转移。

1.2 手术要点

①静吸复合全身麻醉, 头低脚高与水平成30° 仰卧位。②常规五孔法经腹腔建立手术通道, 观察镜Trocar置于脐缘上2 cm, 便于行扩大淋巴结清扫。③沿髂血管走形切开腹膜, 首先游离出输尿管[2]至髂总动脉上方, 以避免损伤, 显露髂外血管及周围组织, 探查肿大淋巴结部位。④切除髂外动脉周围淋巴结, 于髂总动脉分叉下方游离出髂外动脉或分叉上方游离出髂总动脉, 穿过一橡皮圈作为阻断该血管时牵引用, 从髂血管分叉处切开血管鞘, 沿血管鞘与动脉壁之间进行分离, 处理侵犯血管淋巴结时, 术者左手用分离钳提起淋巴结, 助手用分离钳从相反方向牵拉血管形成对抗, 用超声刀或组织剪紧贴淋巴结与血管之间进行分离, 将淋巴结从血管表面分开, 游离出整段髂外动脉。⑤切除髂外静脉周围淋巴结, 切除髂外动脉周围淋巴结后, 于旋髂静脉近端游离出髂外静脉, 于血管下方穿过一橡皮圈, 从髂总血管分叉水平切开静脉鞘, 沿静脉鞘与静脉壁之间由近向远游离髂外静脉, 处理侵犯髂外静脉淋巴结的方法同处理髂外动脉的方法一致, 完全切除髂外静脉周围淋巴结及脂肪组织。⑥血管损伤的处理, 手术过程中一旦出现血管损伤, 先用周围组织压住血管破口, 然后提起预置的橡皮圈, 用无损伤血管钳将该血管阻断, 动脉破裂从近端阻断, 静脉破裂从远端阻断, 侵犯血管的淋巴结切除后, 再对损伤的血管进行缝合处理。

2 结果

本组12例患者均在腹腔镜下完成了根治性膀胱切除、腹壁尿流改道手术, 其中9例行Bricker尿流改道术, 3例行输尿管皮肤造瘘术, 无中转开放手术。术中出血50~230 ml, 平均110 ml, 均未输血。8例行标准盆腔淋巴结清扫, 4例行扩大盆腔淋巴结清扫, 完全切除侵犯髂外血管的淋巴结, 病理检查均为肿瘤转移性淋巴结。切除一侧髂外血管周围淋巴结的时间为15~35 min, 平均23 min。术中出现1例髂外静脉损伤, 及时用无损伤钳对静脉远端进行阻断, 完成淋巴结切除后用4-0血管缝合线进行修补。无髂外动脉损伤。术中无直肠损伤, 术后无继发性髂外血管出血、髂外静脉栓塞、淋巴瘘发生。1例肠梗阻于术后3周行手术处理。

3 讨论

随着手术水平的提高和手术设备的进步, 腹腔镜技术已越来越多地应用于泌尿外科复杂手术。腹腔镜下完成的根治性膀胱切除已在很大程度上替代了传统的开放手术[9, 10, 11, 12, 13]。腹腔镜手术不仅有效减少了手术的创伤, 而且由于腹腔镜的放大作用, 可使手术的精准性得到提高, 特别是3D腹腔镜更能提高手术的精细程度, 进一步保证了手术的安全和疗效[14, 15, 16]。

膀胱肿瘤易发生盆腔淋巴结转移[17], 文献显示, 膀胱癌行根治性膀胱切除标本中, 有13%~30%发现盆腔淋巴结转移[18]。因此根治性膀胱切除中, 必须尽可能彻底切除盆腔淋巴结[6, 19~22]。积极的膀胱根治性切除加盆腔淋巴结清扫, 对减少肿瘤的复发、远处转移和改善生存率等方面有着重要的意义[23, 24]。膀胱肿瘤盆腔淋巴结转移与临床分期关系密切[17], 报道显示, T3~T4期膀胱癌患者髂外血管周围淋巴结较易发生转移[25]。髂血管周围小的转移性淋巴结容易切除, 但如果淋巴结较大、融合成团, 特别是侵犯髂外血管, 与周围组织粘连较重时, 切除则较困难, 一旦损伤髂外血管, 会引起严重的出血, 甚至危及患者生命[26]。 由于担心髂外血管的损伤, 以致一些手术医生会放弃对侵犯髂血管淋巴结的切除, 影响到手术的疗效。安全有效地切除较大的侵犯髂外血管的淋巴结对外科医生来说是一种挑战, 如何较好地处理这一问题, 为广大泌尿外科医生所关注。

本组在总结了前期开放手术和腹腔镜根治性膀胱切除手术[27, 28, 29]经验的基础上, 设计了安全切除侵犯髂外血管转移性淋巴结的手术方法, 其目的在于尽可能切除侵犯髂血管的转移性淋巴结, 努力提高手术的疗效。手术要点:①在切除淋巴结前, 先游离出受侵犯的髂外动脉近端(髂动脉分叉处或髂总动脉)和髂外静脉远端(旋髂静脉上方)游离出, 做好阻断髂外动静脉的准备, 术中一旦出现血管损伤, 可及时对其进行阻断, 待淋巴结切除后, 再对血管进行修补。②切除淋巴结时, 尽可能沿血管鞘与血管壁之间进行[30], 以增加切除的彻底性, 但要注意避免超声刀对血管的热损伤。本组12例均按设计的手术方法完成了侵犯髂血管淋巴结的切除, 术中1例发生髂外静脉损伤, 按预案进行了有效处理, 无明显出血发生。无髂外动脉损伤发生。 术后无髂血管继发性出血和髂外静脉栓塞发生。

根治性膀胱切除术中, 在充分做好髂外动脉和髂外静脉阻断的前提下, 可对已侵犯髂血管的较大的转移性淋巴结实施安全的切除, 以进一步提高盆腔淋巴结切除的彻底性。

The authors have declared that no competing interests exist.

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