' • * -•' ~^^'^' ' " ' Y HOC VIET NAM THANG 11 -SO 2/2010
PHAU THUAT TAO HINH BANG QUANG TLf DOAN HOI TRANG THEO PHUrONG PHAP STUDER CAI TIEN:
KINH NGHIEM 25 TRl/ONG HOP
• u . i i f i
Hoang Van Tung*, Tran Ngoc Khanh**, Pham Ngoc Hung*
Le Lirong Vinh**, Le Dinh Khanh*
TOM TAT:
Phau thuat cat bang quang va tao hinh bang quang tit quai rudt non de dieu trj ung thd bang quang xam lan du'dc thiic hien tai benh vien TW Hue tit nam 2003. Tru'dc day chiing tdi da sit dung ky thuat Studer tao hinh bang quang cho gan 30 tru'dng hdp [1,2,3]. Sau nhieu nam thiic hien theo ky thuat Studer, t i i 1/2007 chung tdi da cai tien ky thuat nay va ap dung cho 25 benh nhan dau tien thu dddc ket qua kha kha quan:
rut ngan thdi gian phau thuat, giam mat mau, giam chi phi phau thuat, giam bien chu'ng sau mo. Tii dd cd the md rdng chi djnh cat va tao hinh bang quang cho cac benh nhan Idn tudi, cd benh ly khac kem theo... Chiing tdi neu ky thuat va nhan xet sd bo ket qua 25 tru'dng hdp dau tien.
SUMMARY
BLADDER RECONSTRUCTION FOLLOWING MODIFIED STUDER PROCEDURE ON TREATMENT OF INVASIVE BLADDER CANCER:
EXPERIENCE IN 25 CASES
Purpose: The authors evaluated the results of simple cystectomy and reconstruction by ileal loop following modified Studer technique on treatment of invasive bladder cancer.
Patients and methods: 25 cases invasive bladder cancer ( pT2,pT3,N0,M0) have been made simple cystectomy since 1/2007 at Hue Central Hospital. After cystectomy, the modified Studer technique is used for bladder reconstruction. The ileal loop is divided in 2
* Dgi hoc Y Dirge Hue, ** Benh vien Trung uang Hue
parts. In the loop that the ureters are inserted we used Studer technique. But in the rest, we made neobladder following Hautmann procedure.
Results: The author presented many modifications in technique with good results: the average time of operation reduced (240 ± 30 minutes), the blood transfusion normally only need Vi unit (100 ± 35ml), reduce expenditure cost of treatment. No severe operative complication have been noted. Simple technique can be performed extendely for the older patients, patients with other diseases.
LDATVANDE:
Phau thuat cat bang quang va su dung quai ruot de tao hinh bang quang mdi trong dieu tri ung thu bang quang da dugc thuc.
hien nhieu nudc tren the gidi tu nhiing nam
dau the ky 20, cd nhieu phuong phap khac
nhau de tao hinh bang quang nhu cua Camey,
Studer, Hautmann, Koch...[7]. Trong nudc
benh vien Binh Dan su dung chii yeu ky
thuat Camey, mdt sd benh vien khac dung ky
thuat Studer... Tir nam 2003 Benh vien TW
Hue chiing tdi da su dung ky thuat cat bang
quang de lai mot phan tien liet tuyen va sau
dd dung doan hdi trang tao hinh bang quang
theo phuong phap Studer, sau gan 3 nam
thuc hien vdi gan 30 trudng hgp da thu dugc
nhieu ket qua dang khich le. Khoang 2 nam
trd lai day tir hai ky thuat nguyen ban Studer
va Hautmann, chiing tdi da cai tiln tao hinh
m
HQI NGHj KHOA HOC LAN THLf IV • HOI TIET NIEU - THAN HOC VIET NAM
bang quang theo kinh nghiem rieng ciia benh vien chiing tdi vdi 25 trudng hgp dau tien dat kit qua tit, nit ngSn thdi gian phau thuat, giam ti le biln chiing dd nudc tieu sau md, giam chi phi phau thuat va thdi gian dieu tri...
Bai vilt nay bao cao nhiing kinh nghiem ban dku tren 25 benh nhan ung thu bang quang sau dugc phau thuat cat bang quang don thuin (dl lai mdt phan tien liet tuyen) va tao hinh bang quang theo ky thuat cai tien.
I I . SO LIEU VA PHl/QNG PHAP NGHIEN cCrU:
2.1. So lieu:
- Tir 1/2007 - 3/2009, 25 benh nhan nam ung thu bang quang xam lan, chua cd di can hach dugc phau thuat cat bang quang va tao hinh bang quang theo ky thuat Studer cai tien. ,..
2.2. Ky thuat mo:
- Benh nhan nam ngua, hoi gap ngang vung hdng lung.
- Gay me ndi khi quan. - • v .1 t "' Phau thuat gdm hai thi chinh:
2.2.1 Cdt bd bdng quang:
- Raeh da dudng giiia dudi rdn hoac vdng qua rdn 3-4cm.
- Bdc Id khoang Retzius va cac khoang ben phai va trai canh bang quang, di dan den bd mach chau, nao vet hach chau theo tieu chuan hai ben va lam xet nghiem GPB tiic thdi. Neu ket qua am tinh thi tiln hanh cat bang quang.
- Boc Id va cat bd dng dan tinh phai va trai, cd the giii lai tuy trudng hgp.
- Boc Id va cat nieu quan den sat tan bang quang, mdm cat nieu quan cd ket qua giai phau benh tiic thdi am tinh.
- Phau tich mat sau bang quang, md can Denonvilliers va dl dang bdc tach theo mat sau tlii tinh din tan cd bang quang.
- Phlu tich mat trudc bang quang din vung CO bang quang tien liet tuyen. Khau cam mau chu ddng dam rdi tTnh mach lung duong vat bang chi Vicryl 1.0.
- Cat lan lucrt hai canh ciia bang quang (cd chiia cac mach nudi bang quang), den tan cd bang quang - tien liet tuyen. Khau cim mau vdi chi Vicryl 1.0
- Cat ngang tien liet tuyen dudi co bang quang tu 0.5- 1cm. Khoet bd nhan tien liet tuyen neu thay TLT ldn. Mdm cit viing cl bang quang can lam xet nghiem GPB tiic thdi am tinh.
2.2.2 Tgo hinh bdng quang:
- Chuan bi doan rudt non cd chieu dai khoang 60-70cm, each gdc hdi manh trang 15-20cm. Phan rudt cdn lai dugc tai lap luu thdng theo kieu ndi tan tan.
- Dau xa doan rudt da chgn de tao hinh dugc xe dgc khoang 50cm, de lai dau gan khoang 10cm de cam hai nieu quan theo kieu chdng trao ngugc cua Studer.
- Phan rudt da chon dugc xe doc roi khau gap thanh 4 phan deu nhau nhu kieu cat va gap ciia Hautmann (tao thanh hinh W).
Sau do diing chi Vicryl 2.0 ndi phan thap nhat cua quai rudt da gap nay vao nieu dao tien liet tuyen bang miii khau vat. Thong thudng chiing tdi diing 2 sgi chi Vicryl bat dau khau a vi tri 6 gid ve hai hudng thuan va ngugc chieu kim ddng hd de cung ket thiic a vi tri 12 gid. Do cd de lai mdt phan tien liet tuyen nen mdm cat nieu dao tien liet tuyen du dai va rdng de thao tac khau ndi ma khong gap khd khan nao. ;. -,
MAW rim, inu y HOC VIET NAM THANG 11 - 3 0 2/2010
js% tt l^r•^V
*-. •.
Hinh 1: Doan rudt xe dugc khau gap W va ndi phin thip nhit vao nieu dao
- Cam hai nieu quan vao dau gan d doan rudt 10 cm chua lai khdng xe doc, dat thdng nong nieu quan xuyen qua thanh bang quang mdi va dua ra ngoai qua da. Din luu bang quang bang sonde pezzer. Dat dng thdng tieu. Dan luu d md.
Hinh 3: Ndi phan thap ciia bang quang mdi vao vd tien liet tuyen. Hai nieu quan cam vao dau gan cua quai mot theo kieu Studer.
2.2.3 Sdn sdc hgu phau: '" tac sonde dan luu lam cang bang quang gay
- Hau phiu ngay thii ba, bang quang dd, vd bang quang. Bom rua bang quang
dugc bom riia hing ngay vdi nudc mudi sinh dugc thuc hien cho din khi riit sonde tilu va
ly khoang 300ml - 500 ml moi lan, muc dich sonde dan luu bang quang (khoang ngay 14
liy sach chit nhiy cua rudt tiet ra de tranh saumd). ^,,,
m
HOI NGH! KHOA HOC LAN THtf IV • HOI TIET NIEU - THAN HOC VIET NAM
- 2 sonde nieu quan riit vao ngay thii 12 sau md, sonde nieu dao khoang 13 ngay sau md va sonde Pezzer dugc nit sau cung khoang ngay thii 14 sau md.
2.2.4. Phuang phdp nghiin ciru:
- Nghien ciiu tien ciiu
- Sd lieu dugc xu ly bang cac phep toan thong ke y hgc thdng thudng.
I I I . KET QUA:
3.1. Ket qua chung:
Tv oi trung binh ciia benh nhan : 64,2 ± 8 (nhd nhit: 54 tudi, ldn nhat: 85 tudi)
Sd ngay dieu tri trung binh: 29,07 ± 6,06 (sdm nhat 19 ngay, mudn nhat 40 ngay)
Sd ngay dieu tri trudc md: 6,2 ± 1 , 8 (sdm nhat: 4 ngay, mudn nhat: 10 ngay)
Sau md: 22,8 ± 6,02 (sdm nhat: 15 ngay, muon nhat: 35 ngay)
3.2. Ket qua phau thuat:
Thdi gian phau thuat trung binh: 234 phiit ± 22 phiit-(sdm nhat: 195 phiit, mudn nhit 270 phiit)
Trong dd: Thdi gian cit bang quang: 92
±15 phiit
Thdi gian tao hinh bang quang: 145 ± 15 phiit
Lugng mau mat trong md: khoang 300ml
Cd 5 benh nhan cd chuyen mau trong m6 trung binh 1 don vi (250ml) / benh nhan.
The tich bang quang do ngay trong ml:
trung binh 150ml
3.3. Ket qua som sau mo
Tdc do ddng tieu trung binh: 8 ± 1,5 rnVs The tich can bang quang: 75,5 ± 8,5 ml 3.4. Cac bien chung som sau mo Tac rudt:
Dd nudc tieu qua chan dan luu bang quang: 2 trudng hgp, dugc dat lai sonde tilu sau do dudng dd tu lien.
Nhiem tning vet md: 1
Tieu khdng tu chii ban dem: 12 Tieu sdn thinh thoang ban ngay: 2 3.5. Ket qua tai kham: Cd 20 benh nhan cd tai kham sau md
Bang 1: sd benh nhan dugc tai kham sau md
Thdi gian (thang) 3
6 12
So benh nhan 10
5 5
Tyle 5 0 % 2 5 % 25%
^ ^ ^ ^ , ^ BN
< 150 ml 150- 300 ml
> 300 ml Tong
Bang 2: The tich bang quang mdi sau md 3 thang BN 3 thang
0 4 6 10
BN 6 thang
5 5
BN 12 thang
5 5
Tong 0 4 16 20
- The tich nudc tieu tdn dong sau di tieu a nhdm benh nhan tai kham:
Trung binh 58,5 ± 26,02 ml, nhilu nhit: 100ml, it nhit 15ml
- Cd 2 benh nhan (15,3%) tilu khdng tu chu thinh thoang bail ngay, 12 benh nhan tilu
khdng tu chii thinh thoang ban dem. Khdng cd benh nhan nao sdn tilu lien tuc.
Y HOC VIET NAM THANG 11 - 3 0 2/2010
Hinh 4: Hinh anh chup cat ldp bang quang sau md 6 thang A: BN Bui Thanh X B BN Pham Hdng X
IV. BAN LUiDLN: "^
1. Cat bang quang de lai tien liet tuyen:
Ky thuat cit bang quang dl lai mdt phan tien liet tuyen dugc thuc hien dau tien d vien Montsouris tii nam 1992. Tieu chuin lua chon dl dugc md la khdng cd ung thu tien liet tuyin va kit qua giai phiu benh tiic thdi ciia mom cit nieu dao tien liet tuyen am tinh.
Qua kinh nhiem cua chiing tdi tat ca benh nhan dugc phlu thuat (tren 50 trudng hgp) [2] trong vdng 6 nam chua cd trudng hgp nao tai kham phat hien ung thu tiln liet tuyin, chi
1 trudng hgp ung thu bang quang tai phat tai
mieng ndi nieu dao tien liet tuyen sau 8
thang. Ky thuat nay lam giam thdi gian md,
giam mat mau, bao tdn co that ngoai va mdt
phan doan nieu dao tien liet tuyen tao thuan
lgi cho khau ndi bang quang mdi vao vd tien
liet tuyen de dang theo kieu khau vat. Mieng
ndi rdng va khdng cd trudng hgp nao bi hep
mieng ndi sau md. Theo Vallancien vdi ky
thuat bao tdn vd tien liet tuyen, tieu tu chii
ban ngay 97%, ban dem 95%) [6]. Trong
nghien ciiu cua chiing tdi tieu tu chii ban
ngay d nhdm cd tai kham la 18/20 (90 %>).
• 1
HOI NGH! KHOA HOC LAN THtf IV • HOI TIET NIEU - THAN HQC VIET NAM
2. Tao hinh bang quang mdi theo phuong phap Studer cai tien:
That su trong phuang phap tao hinh bang quang nay chiing tdi chi su dung mot phan nhd cua ky thuat Studer d doan dng ruot dai 10 cm chira lai de cam hai nieu quan.
Chung tdi chon ky thuat nay vi don gian de thuc hien, doan hdi trang de nguyen nam kha cao de cam hai nieu quan. Tac dung chdng trao ngugc ciia doan mot nay ciing kha tdt [4].
Doan ruot dugc xe doc de tao hinh bang quaT^-, mdi chung tdi khau gap lam 4 phan bing nhau nhu chii W, gan gidng nhu ky thuat cua Hautmann [7]. Do mdm cat nieu
dao di ngang qua tiln liet tuyen kha rong, j nam cao nen chiing tdi manh dan sir dung j mieng ndi true tilp tu phan thap nhat cua ; quai rudt vao mdm cit tien liet tuyen bang i miii chi khau vit vicryl 2.0. Vdi ky thuat nay i chiing tdi khdng can phai due Id d phan thap i ciia quai rudt va khdng can ndi vao nieu dao ; bang cac miii chi rdi. Ky thuat nay da lam ' giam dang ke thdi gian phau thuat tu trung i binh 5h den 8h cho mdt ca md, den nay ; chiing tdi chi cdn mat khoang 3h30' din 4h i cho mdi trudng hgp (234'± 22'). Tu do lam \ giam chi phi cho cugc md, benh nhan mau i
hdi phuc sau md. \ Bang 3: Thdi gian phau thuat va lugng mau mat
Tac gia Si<inner DG Lllien &. Camey Rogers & Scandino Oao Quang Oanh Hoang Van Tung
So benh nhan 44 88 20 113
25
Thdi gian mo 387' ± 13'
540' 360' 355' ± 32'
235' ± 15
Lu'dng mau mat 1578 ± 127 ml
2500 ml 480 ml
300 ml
Do thdi gian md ngan, benh nhan khdng mat nhieu mau nen phau thuat trd nen nhe nhang hon, tu do chiing toi da manh dan md rgng chi dinli cho cac benh nhan ldn tudi, cd benh ly man tinh kem theo nhu dai thao dudng... Tuoi trung binh cho 25 trudng hgp dau tien ap dung ky thuat cai tien la 64,2 ± 8.
Trudng hgp ldn tuoi nhat ma chiing tdi thuc hien la 85 tudi, co benh ly dai thao dudng thi 1.
Do mieng noi nieu dao bang quang dugc thuc hien bang ky thuat khau vit nen d 25 trudng hgp nay chiing toi khdng gap trudng hgp nao dd tu mieng ndi ca, trong khi theo ky thuat ndi miii rdi cd din 5 trudng hgp dd trong 17 benh nhan [2].
Bang quang sau phau thuat cd hinh dang tron deu, sau 3 thang deu cd thi tich tren 300
ml (16 benh nhan) chi cd 4 benh nhan tai kham sau 3 thang cd the tich tu 150 ml- 300 ml. The tich can bang quang ciing d miic chap nhan dugc tnmg binh khoang 58,5 ± 26,02 ml.
Trong 13 trudng hgp phau thuat co mot sd bien chiing sdm dugc nghi nhan nhu nhiem triing vet md (1 benh nhan) dieu tri bing thay bang, dung khang sinh theo khang sinh do benh dn dinh. Tieu khdng tu chii ban dem (12 benh nhan) do thdi gian dau bang quang chua thich nghi, benh nhan ciing chua tao dugc thdi quen thiic day diing gid trong dem dl di tieu. Mdt trudng hgp cd bien chiing tac rudt sdm vao ngay thii 4 sau mo, chiing tdi phai md lai va tim ra nguyen nhan la do siic rudt khdng sach, cdn nhilu phan
Y HOC VIET NAM THANG 11 - 5 0 2/2010
Cling ddng khudn trong dai trang sigma va dai trang xudng. Benh nhan dugc lay sach phan qua dudng hau mdn va dn dinh ra vien sau 20 ngay.
Ndi chung sau phlu thuat do benh nhan can cd thdi gian de thich nghi vdi bang quang mdi nen ket qua do tdc do ddng tieu trudc khi ra vien khdng cao trung binh chi 8
± l,5ml/s. Thudng phai sau 6 thang benh nhan mdi cd su thich nghi tdt nhat vdi bang quang mdi.
V. KET LUAN:
c i t bang quang de lai mdt phan tien liet tuyin kit hgp vdi tao hinh bang quang tir doan hdi trang theo phuong phap Studer cai tiln giam dang ke thdi gian phau thuat va lugng mau mat trong md, giam bien chiing do sau md, giam chi phi dieu tri. Bang quang mdi cd hinh dang trdn deu, dung tich ldn va the tich can bang quang thap.
Ky thuat don gian de thuc hien cd the md rong chi dinh cho ca nhiing benh nhan cao tuli, cd benh ly khac kem theo. ,,.
TAI LIEU THAM KHAO
1. DAO QUANG OANH, VU VAN TY, ...Tao hinh bang quang bang mpt. Y hoc Viet nam, chuyen de tiet nieu than hoc, so 8- 2005,756-763.
2. HOANG VAN TUNG, TRAN NGQC KHANH,...Cat bang quang giu lai tien liet tuyen va tao hinh bang quang mdi bang doan hoi trang theo Studer. Y hoc thirc hanh, so 586-2007,61-65.
3. NGUYEN NGOC HIEN...Mot nhan xet qua 13 ca tao hinh bang quang theo phuong phap Camey. Y hoc Viet nam so 4,5,6 2001, 196- 205.
4. STUDER U., CASANOVA G., MOTTAZ A.,...Vessie de substitution construie au moyen de I'ileon replie. Rapport a la Societe Beige d'Urologie 25-26, mai 1991, p 263- 282.
5. SEBE P., TRAXER O., CUSSENOT O.,...
Cystectomie avee conservation prostatique dans le traitement des tumeurs de vessie:
bases anatomiques, techniques chirurgicales, indications et resultants. Progres en Urologie, 2003, 13,p.l279-1285.
6. VALLACIEN G., GUILLONEAU B.,...
Cystectomy with prostate sparing in bladder cancer, 100 patients, 10 years experience. J Urol, 168 pp 69-53.
7. ZERBIB M., BOUCHOT 0.,...Les traitements des tumeurs infintrantes de vessie. Rapport du Congres 2002 de AFU.
Progres en Urologie, 2002, p.833-840.
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