Hpl NGH] KHOA HQC U N THLf VII. HQI TlfeT NigU - T H A N HQC VigT NAM (VUNA)
NHAN XET KET QUA CAT BANG QUANG TAN GOC:
HIEU QUA C O A BAO TON B 6 M A C H THAN KINH
Bko Quang Oanh', Nguyen D90 Thuan', Van Thanh Trung'
T6M
ih:
D^t v a n d e & m u c t i e u : So vdi the gidi, nu'dc ta co ty le ung thu" bang quang (BQ) rat cao. Ooi vdl ung thu* da xam Ian Idp cd thi cSt bang quang tan goc la phau thuat du'dc chpn ly'a.
Tuy nhien gan day, ngay ca doi vdi giai doan chuei xam Ian cd nhu'ng co nguy cd cao thi phau thuat tren van di/dc khuyen cao. Tao hinh thay the bang quang la phu'dng thilTc nen lam khi cat bang quang. Van de hien nay la chu trpng den chat lu'dng dieu trj. Bao ton bo mach - than kinh la ky thuat gop phan tang cai thien chat lu'dng song sau phau thuat. Muc tieu: Oanh gia hieu qua cua ky thuat bao ton bo mach than kinh tren chat lu'dng song cua benh nhan sau phau thuat di/a tren 2 tieu chi: tieu khong kiem soat va roi loan cu'dng (RLC).
Doi tu'dng va phu'dng phap: Tien CUXJ, can thiep lam sang, mo ta. Ky thuat bao ton bo mach-than kinh du'dc thi/c hien tren nhu'ng tru'dng hdp (TH) ung thu' BQ giai doan T l nguy cd cao va T2. Chu'c nang cu'dng du'dc ghi nhan tru'dc va sau mo. SLT hoi phuc cua chifc nang di tieu va chu'c nang cu'dng du'dc theo doi va danh gia sau mo 6 thang.
K e t qua: Tong cpng co 28 TH bao ton bo mach than kinh. Tuoi trung binh 58,1 ± 10,7 tuoi (39 - 74). 18 benh nhan khong RLC va 10 benh nhan RLC nhe tru'dc mo. Sau mo: Chii'c nang kiem soat di tieu 26 TH (92%) tot, 2 TH (7,3%) trung binh. Chii'c nang tinh dye 12 TH (42,9%) tot, 6 TH (21,4%) kha, 7 TH (25%) trung binh v a 6 T H ( 2 1 , 4 % ) x a u .
' Khoa Ni$u B - B?nh vi?n Binh Dan
Phan bien khoa hpc: PGS.TS. Vu Nguyen Khdi Ca
K e t luan: Bao ton bd mach than kinh gop phan t5ng hieu qua kiem soat nu'dc tieu va phyc hoi chii'c nSng cu'dng sau mo.
TCr k h 6 a : c3t bang quang tan goc, bao ^n bo mach - than kinh, tieu khong kiem soat, roi loan cu'dng.
S U M M A R Y
EVALUATION OF NEURO-VASCULAR BUNDLES PRESERVATION I N RADICAL CYSTECTOMY
I n t r o d u c t i o n & o b j e c t i v e s : Comparing to other countries in the world, the rate of bladder cancer is quite high in Vietnam. Radical cystectomy is recommended for muscle-invasive bladder cancer. However, recently, it is also a choice for non muscle-invasive stage but high- risk tumors. Bladder replacement should be performed after cystectomy. The problem now is focused on quality o f life. Neuro-vascular preservation techniques help to improve quality of life after surgery. Objectives: Evaluahon the effectiveness of neuro-vascular bundles preservation on the quality of life after surgery based on two criteria: urinary continence and erectile dysfunction (ED).
P a t i e n t s a n d m e t h o d s : Prospective, descriptive clinical study. Neuro-vascular bundles preservation were performed in radical surgery of bladder cancer high risk stage T l and stage I Z Erectile function were evaluated and compared before and after surgery. The urinary continent and erectile function was evaluated after 6 months.
Y HQC VI$T NAM THANG 8 - s6p<j^C B | £ T / 2 0 1 3 Results: I n total, 28 cases of nerve
presen/ation. Mean age 58.1 ± 10.7 years (39- 74). Preop: 18 patients no ED and 10 patients with mild ED. Postop: Urinary continence: 26 cases (92%) good, 2 cases (7.3%) moderate results Sexual function 12 cases (42.9%) good, 6 TH (21.4%) fairly good, 7 cases (25%) moderate va 6 cases (21.4%) bad results.
Conclusions: Neuro-vascular bundles preservation contribute to the recovery of urinary continence and erectile function after surgery.
Keywords: radical cystectomy, nerve- sparing, urinary incontinence, erectile dysfunction.
I- OAT V X N oi
So voi th^ giai, nuac ta co ty le ung thu bang quang rat cao. Ung thu bang quang hien nay vIn la ung thu hang dau cua he tiet nieu tren benh nhan nhap vien [3]. Khac han ung thu tuyen tien iiSt ma da so dien tien cham, ung thu bang quang c6 dien tien nhanh hon nhieu va c6 nguy ca tu vong cao han. Nhieu thong ke tren the giai trong ITnh vuc ph^u nghiem tii thi cho thay hau nhu khong co phat hien tinh ca ung thu bang quang tren nguoi tu vong. Do ung thu bang quang co ty le tai phat cao nSn quan diem chung hien nay la khi chan budu da den lop ca thanh bang quai^ thi nen ck bo bang quang. De tang du hau song con, nhieu tac gia con khuyen nen cat bo som bang quang ngay ca khi buou con trong giai doan chua xam Ian ca neu la ung thu d nhieu vi tri, biet hoa kem, tai phat hay CO hien dien bucru det Carcinoma In Situ.
= Trd ngai ddi vai viec chap nhan phau thuat la chdt lupng s6ng sau mo. Phuong phap tgo hinh bang quang thay thd da dupe thuc hien 20 nam nay tai benh vien Binh Dan, da gop phkn giai quy^t dupe vkn de tieu tien cho benh nhan (BN) [3]. Yeu c4u vk chdt
luang song ngay cang cao dat them van de ve dai song tinh dye sau mo. Walsh [17] da chung minh rang roi loan cuong sau m6 la do t6n thuang bo mach-than kinh den the hang di sdt ben bo ngoai tuyen tien liet. Ky thuat bao ton than kinh dupe ap dung dau tien trong cat tuyen tien li?t tan goc, sau nay ky thuat nay dupe trien khai trong cat bang quang tan goc va tao hinh bang quang thay the [6]. Ky thuat bao ton bo mach-than kinh CO 2 tac dung: (I) giup tang them hieu qua kiem che nuac tieu, (2) gdp phan bao ve chuc nang cucmg.
Hipn nay BV Binh Dan, ky thuat bao ton bo mach-thdn kinh vkn chua dupe trien khai mpt each thuang qui. Chiing toi thuc hien nghien cuu danh gia hieu qua ciia ky thuat bao ton bo mach than kinh tren chat lupng song cua BN sau phku thuat dua tren 2 tieu chi: lieu khong kiem soat va roi loan cuang (co so sanh truac va sau mo).
Muc tieu nghien cuu:
Danh gia hieu qua ciia ky thuat bao ton bo mach than kinh tren chat luong song ciia BN sau phlu thuat dua tren 2 tieu chi: tieu khong ki8m soat va roi loan cuang.
II- o 6 l TUONG VA PHUONG PHAP NGHtEN Ciru
1. Doi tyomg nghien ciru:
Tieu chudn chgn benh
- Tdt ca BN ung thu bang quang giai doan Tl nguy co cao (nhieu budu, tai phat, biet hoa kem) va T2 (chan buou chua xam idn d6n lap ca ngoai thanh bang quang) co chi dinh cdt tan gdc va tao hinh bang quang thay thd, co chuc nang cuong dat tdng sd IIEF-S tir 17 didm trd len (khdng RLC hoac chi RLC nhe).
Hpl NGHj KHOA HQC LAN THtf VII. Hpl Tieu chuan logi trir: BN bj RLC tir trung binh nhp ddn nang: c6 tdng sd diem IIEF-5 tir 16 didm trd xuong.
2. Phutfng phap nghien cihi Nghien ciru tien cim md la, cd can thipp lam s^ng v^ khdng c6 nhdm chirng.
2.1. Ghi nhgn nhung # c diim tien phdu - Chdt lupng di tieu ciia BN.
- Ddi song tinh d\ic ciia BN (tdng sd diem IIEF-5)
- Khao sdt ve thd trang chung cua BN dk xac dinh BN cd thd chiu d\rng dupe cupc phau thu§t.
11 Qui trinh ^ t/tugt trong luc phdu thugt Mpt sd didu cdn tuan thii de tranh tdn thuong bo mach-thdn kinh trong khi md.
That su rdt khd nhin rd dupe bd m^ch-than kinh. Di^u cdt ydu la can bam sat mat ngoai tuydn tiln liet va gidi ban tdi da sir dung dao dipn. Qui trinh thao tac idn luot nhu sau:
- Phau tich cdn than, khdng dimg dao ddt dien.
- Vao mat trudc-ben tuyen tien liet.
- Cat cdt can than tTnh mach lung.
Tdn thuang tdi thieu day chang mu - tuyen tien Het.
TI£T NigU - THAN HQC VI$T NAM (VUNA) - cat xe la tren ciia mac ndi chau, khong ph^m day chSng mu-tuydn tien liet
- Xd la duai va ven ddy bd m^ch-thin kinh ra ngoai thanh ben tuyen tidn liet
- Djnh vi va khau cpt m^ng tinh mtich Santorini, cdt cao d khoang giiia tuydn ti^n lipt.
- Tidp tyc ph§u thuat cdn lai: bdc tachva cat idy trpn tuydn tidn liet sau dg la ca bang quang.
- Bao tdn bd mach than kinh 2 bdn.
- Phdn cat bd bang quang va n^o hach tidn hanh nhu binh thudng.
2.3. Chirc ndng kiim soat nude tieu.
Tiiy theo mirc dp kiem soat dupe nuoc tieu, ban ngay va ban dem, ma phan lam 3 mirc dp: tdt, trung binh, xau [1] theo lieu chuan ma chung tdi da de ra trong cdng trinh tao hinh bang quang bdng rupt. Thudng thi sir phuc hdi dien tien cham d thang dau tien, khi bang quang cdn tiet nhieu chdt nhay va cdn nhirng con co that tu phat. Sau do thay ddi nhanh dan va den thang thu 6, da so bang quang tan tao dn dinh. Ket qua dupe danh gia 6 thang sau md.
Bang 1: Tieu chudn danh gia chirc nSng kidm soat nuac tidu.
Tot Trung binh
Kiem soat du'dc hoan toan ban ngay, thinh thoang khdng du'dc ban dem
Ban ngay cd liic khong kiem soat du'dc, ban dem khong du'dc
Khong kiem soat dUdc ca ngay lin dem
2.4. Chirc ndng tinh d^c:
Ap dung bang cau hdi qudc te ve chirc nSng tinh due (IIEF-5) [12] dd danh gia chirc nang cuang ciia BN truoc va sau khi phau thuat. Loai trir khdng dua vao nghidn cuu neu nhu BN thupc nhdm rdi loan cucmg n^g, trung binh, trung binh nhp. Muc dp RLC dugc xep theo tong sddiem IIEF-5:
RLC nSnq 5 - 7 diem
RLC trunq binh 8 - 11 diem
RLC trunq binh nhe 12 - 1 6 diem
RLC nhe 17 - 21 diem
Khonq RLC 22 - 25 diem So sanh kha nang cuang truoc va sau khi phau thuat. Phan lam 4 mure dp: tdt, kha, trung binh, xau. Kdt qua dupe danh gia 6 thang sau md.
Y HQC VigT NAM THANG 8 - SO PAC BIET / 2013
Bang 2: Tidu chuan danh gia chu:c nang tinh due dua tren su thay ddi RLC,
GiC nguyen hoac tot hdn
Trung binh Giam hai bac (trOr RLC trung binh nhe)
Giam nhieu hdn
III- KET Q O A NGHllN COU 1. So li^u chung
Tdng cpng 28 bpnh nhan, (tre tudi nhat: 39 tudi, idn tudi nhat: 74 tudi) Tudi trung binh: 58,1 ± 10,7 tudi; sd lupng BN ddng nhat d lua tudi 50 - 70 tudi
Bang 3: Phan phoi b^nh nhan theo tudi.
S o T t i (%) 6 (21,43)
LuTa tuoi < 5 0 tuoi 5 0 - 6 0 tuoi 6 0 - 7 0 tuoi > 7 0 tuoi 12 (42,86) 5 (17,86) 5 (17,86)
Tong
28 (100) 2. Chuc ndng tinh due tryoc phau thuat
18 benh nhSn khdng RLC trudc md.
10 benh nhan RLC nhp trudc md.
Bang 4: Chirc nang tinh due trudc phau thuat (theo dp tudi) Chirc nang tinh due
Khong RLC RLC nhe
Tuoi benh nhan
< 50 tuai 6 0
50 - 70 tuoi 12 5
> 70 tuoi 0 5
S6TH Ty le (%)
18 (64,3) 10(3S.7) 3. Ket qua chat lu'piig cuoc song sau phau thuat.
3.1. Chirc ndng kiem soat nwdc tieu
26 BN (92%) kidm soat nude tidu dupe hoan toan ban ngay, thinh thoang cdn sdn tidu ban dem khi ngii quen. Chi cd 2 BN (7,3%) la cdn chua tieu sdn vd dem.
Bang 5: Chijrc nang kidm soat nude tieu sau khi cat BQ tan gdc.
Chii'c nang kiem soat nu'dc tieu
Trung binh
S o T H r'Vo) 26 1^^2,7;
2 (7,3)
3.2. Chirc ndng tinh due sau phdu thudt
Tdng sd didm IIEF-5 trung binh trudc phSu thuat = 22,15 ± 7,6 didm.
Tdng sd diem IIEF-5 trung binh sau phau thuat = 16,41 ± 6,3 didm.
Bang 6: Danh gia chuc nang tinh due sau PT cdt BQ tan gdc (sd TH (%)) Tru'dc m6
Khong RLC 18 TH
RLC nhe 10 TH
Sau mo Khonq RLC = 7 /'38,9%1 RLC nhe = 5 (27,8%) RLC trunq binh nhe = 3 (16,7%) RLC trunq binh = 3 fiey/o) RLC nhe = 5 (S0%) RLC trunq binh nhe = 1 (W%) RLC trung binh = 4 ('•lO'/oJ
Danh gia Tot Kha Trunq binh
Xau Tot Kha Trung binh
Hpl NGHj KHOA HQC LAN THLT Vlf. HQI T|£T NigU - THAN HQC VI$T NAM (VUNA) Kdt qu& cho thdy cd 18/28 BN (64,9%)
phyc hdi chiic nang cuang tdt va kha. Trong dd cd 12 BN (42,9%) phyc hdi tdt, 6 BN (21,4%) phyc hoi khd. 7 BN (25%) thuOc nhdm trung binh va 6 BN (21.4%) thupc nhdm xdu.
Khi kiem tra mdi tucmg quan giCta chuc nSng cuang va dp tuoi bdng phdp kiem Chi binh phucmg (p = 0,043 < 0,05), thay c6 mdi lien hp vdi nhau. Nhiing BN cd dp tudi cang nhd phyc h6i chuc nang tinh dye tdt, nh&ng BN Idn tudi kha nang phyc hdi cham hem.
IV- BAN LUAN
I. Ly do can thiet phai bao ton bd mach - than kinh.
Ung thu bang quang, nhu trdn da trinh bay, cd nguy ca cao va dien tien nhanh hon ung thu tuyen tidn liet nhieu. Do dd, luc dau da cd nhieu nghi ngd khi van de bao tdn bd mach - than kinh dugc dat ra. ngay ca khi da cd nhifng bao cao vdi ket qua khich Id cua ky thuat nay sau cdt tuyen lien liet tan gdc. Cd chii truong cho rdng didu cdt yeu la idy hdt mo ac tinh, ciiru sdng BN va khdng nen vi pham nhitag tidu chuan co ban ciia mdt phSu thuat u ac tinh: cat rpng va nguyen khdi.
Ngupc l^i, van cd nhihig phan bac lap luan trdn. Cac tac gia nay cho rSng, neu that su mudn t5ng dy hau sdng cdn thi khdng ndn chd dpi den giai doan tien tridn de phai tidn hanh cat rpng; ma ndn cdt bang quang sdm hon, ngay ca trong giai d o ^ chua xam Ian co neu thay cd nguy co tidn trien ho^c tai phat
cao. Khi mudn thuc hien phau thuat sdm thi chat lupmg song sau md phai that tdt thi moi Ihuyet phuc duac ngudi benh chdp nhan.
Hautmann va Studer la hai tac gia nhi6u kinh nghiem trong t^o hinh thay thd bang quang. N5m 2009, khi didm l^i hieu qu^ ciia phau thuat nay, hai dng da dua ra 10 loi khuyen [6] nen lam. Mdt trong nhihig len khuyen dd la sy can thidt phai bao ton bo mach - than kinh. Studer, trong rnpt hpi nghj tai Bangkok - Thai Lan, da phat bieu: n^u khdng bidt ky thuat bao tdn bd mach - th5n kinh thi khdng nen thyc hien tao hinh bang quang. K^ thuat nay giup cai thien chiic nang kiem soat nude tidu, dac biet ddi vdi bang quang true vj tren phy nir, ddng thdi cai thien ddi song tinh due trdn ca hai giai [6,7,8,14].
2. Chirc ndng kiem soat nvdc tilu.
Rdi loan chOrc nang kidm soat nude tieu va rdi loan chuc nang cucmg la nhihig bien chimg thudng gap sau phau thuat cdt tuyen tien liet tan gdc va cdt bang quang tan goc Bao tdn bd mach-than kinh cd hieu qua ro rang ddi vdi chuc nang kidm soat nude tieu sau md. Nhimg bao cao vd kha nang kiem soat nude tidu lot sau tao hinh bang quang khi chua tridn khai ky thuat bao tdn bo mach - than kinh thudng chi trong khoang 80 - 90% [3]. Ndu cd bao tdn bd mach - than kinh thi cd the nang ty Id kidm soat nude tieu cao han. Khi tham khao cac nghien curu tr^n, nhan thay nhieu tac gia ciing cd ket qua tuang tu chiing tdi.
Bing T^c qia KesslerTMFQl Venn SN [151 Nqhien cunj nay
7: Chuc nang kiem scat nuac tieu sau m6.
Tv l« kiem soat nirdc tiSu tot 92%
80%
92%
Thdi gian theo doi 12 thanq 12 thanq 6 thanq
Y HOC VIET NAM THANG 8 - S 6 D^C BI$T / 2013 Turner va cs [14] da thuc hien so sanh
hieu qua cua bao tdn than kinh vdi 3 nhdm BN: nhdm (1) 20 BN, bao tdn 2 bdn; nhdm (2) 96 BN, bao tdn 1 ben; nhdm (3) 49 BN khong bao tdn than kinh. Nhdm (1) phyc hdi nhanh hon ba nhieu han nhdm (2) va (3).
Nhdm (3) kem nhat. Cac tac gia cho rdng ndn bao tdn than kinh khi ed thd dupe, ngay ca 1 ben.
Tinh trang di tieu sau md cdn bi anh hudng bdi cac yeu td nhu co that van khdng hi t6n thuong, bao tdn dupe tdi da doan nieu dao churc nang [8]. Hai ydu td can chu y la viec bao ton bd mach than kinh va tuoi tac.
Phdn than kinh quan trpng gdm cac nhanh viing chau va nhanh then trong cd anh hudng nhieu den tinh trang di tieu sau nay [14]. Tuy nhidn khdng chi cac nhanh than kinh ddn phan bo van dpng cho ca that nieu dao ma ngay ca eac nhanh hudng tam den nieu dao mang cung quan trong khdng kem. Dieu nay d3 dupe chung minh trong cac trudng hpp giam cam giac lai nieu dao mang de bi rdi loan di tidu sau md [8,9].
Khi thao lac lai dam roi Santorini, cac niit chi cam mau khdng ndn cot qua xa cho noi nidu dao va tuydn tidn liet dd tranh tdn thuong CO that. De cam mau chd nay chi can 1 mdi chi cdt theo mat phang ngang giita dam rdi tinh mach va nieu dao, vudng gdc vdi cu mu de cpt hdt dam rdi Santorini nhung khong cham den co that ngoai.
Ty le phyc hdi sau md d nhihig BN Idn tuoi thap. Cae nghidn cuu ve chiic nang co thdt cua ngudi Idn tudi, dp dai co that va ap luc ddng nieu dao tdi da liic nghi ngai va
trong Iiic co that ed ty chii giam ddn theo tudi. Mac dii khdng ro la cae dii iipu nay phan anh sy thay ddi binh thudng theo tudi tac hay mpt benh ly dudng tidu dudi di kem nhung tam quan trpng eiia tudi da dupe chung minh bdi tudi tae cd lidn quan den vipc giam phan bd cac spi than kinh den co chdp bang quang [4].
3. Chuc nang tinh due.
Tdng sd diem IIEF-5 trung binh trudc md la 22,15 ± 7,6 diem. Sau phau thugt, tdng sd didm IIEF-5 trung binh la 16,41 ± 6,3 didm. Sy thay ddi nay ed y nghTa thdng ke.
12/28 BN (42,9%) dupe danh gia la phuc hdi tdt. 6/28 BN (21,4%) phuc hdi chirc nang cucmg kha. Tuy tdng sd diem IIEF-5 cd giam di mdt bac nhung nhimg BN nay van cd kha nang giao hap va give cho duang vat dupe cucmg cimg eho den khi giao hpp xong la hoi khd khan. 7/18 BN (25%) phuc hdi chuc nang cuang trung binh; 6/28 BN (21,4%) thudc nhdm xau. Nhihig BN dupe danh gia la phuc hdi cucmg tdt ddu d lira tudi tuang ddi tre hon <60 tudi.
Walsh PC [16,17] la ngudi ddu lidn cho thdy bao tdn bd mach than kinh lam tang kha nang cuang d nhirng BN cat bang quang tan goc sau phau thuat, cd 9/11 BN (chiem 82%) cd kha nang boat dpng tinh dye sau 1 nam.
Brendler CB [1] bao cao 27 trong 52 BN (52%) cdt bang quang tuydn lidn liet cd bao Idn bd mach thdn kinh phyc hdi chii'c nang cuang lai dupe sau 1 nam. Ke tir nghidn cim dd cac tac gia khac ddu cho ty le tuong tu vd ty le cuong sau cdt bang quang tan gdc thay d d i t i r 4 2 - 7 1 % [ 9 ] , [ 1 5 ] .
Tac qia Walsh PC [161 Venn SN [15]
Bang 8: Chuc nang cucmg sau md.
Ty le cu'dng sau phau thuat 82%
81,7%
Thdi gian theo doi 12 thanq 12 thanq
HQI NGHj KHOA HQC LAW THCf VII, Hpl T I E T N I S U - THijtN HQC VIET NAIVI (VUNA)
Salem HK ri31 Brendler CB f l l Girqin C [51 Nqhien cu\i nay
90%
52%
95%
58,8%
12 thanq 12 thanq 20 thang 6 thanq
Ty Ip cuong sau phau thu$t cua chiing tdi cd thdp so vdi mpt sd tkc gifi nhung cung tucmg ddng vdi mpt v^i nghien cuu 1^ do sd lupiig mau ciia chung Idi nhd va thdi gian theo ddi chua du dai.
Chung tdi khao sdi moi lien quan giiJa chirc nang tinh dye sau phau thuat va dp tuoi, nghidn cuu ciia chiing tdi ghi nhan cd lien quan giiJa ckc yeu td nay. Nhiing BN phyc hdi chuc nang tinh dye tdt cd 5 trong 6 trudng hpp nam d dp tudi < 50 tudi, cdn lai d dp tudi <60 tudi.
Rdi loan cuong la bien chung thudng gap d nhiJTig BN ed cat bang quang tan gdc.
Nam 1984. Walsh PC [16] cho rdng rdi loan cuong la do tdn thucmg dam roi than kinh chau, chi phdi than kinh cho the hang. Dua trdn didu nay, cac phau thuat tidn hanh cdt tuyen lidn liet t^n gdc va cat bang quang - tuydn lien liet tan gdc ddu cd gdng tranh tdn thuang than kinh thd hang nay.
Mpt sd y kidn lai cho rdng ky thuat bao ton bd mach thdn kinh se lao dieu kien bd sdt ung thu. Tuy nhidn, Brendler CB [1] chirng minh rdng ty Ip sdng 5 nam va ty le khdi hdn la 65 - 70% tuang ddng vdi phau thuat cdt bang quang - tuydn tien liet thudng qui. Ty Id tai phat tai cho sau 5 nam la 7.5%, cho thdy ky thuat nay khdng anh hudng ddn vipc kidm soat ung thu. Schoenberg MP (1996) cho rang ndu ap dyng cdt bang quang - tuydn tidn liet tan gdc cd bao ton bd mach thdn kinh ddi vdi ung thu chua xam idn thi ty Id sdng cdn sau 10 n5m cho cae giai doan dupe didu tri la 69% va ty Id khdng tai phat la 94%.
Khi phau thuat ndi soi d bung duoc triSn khai dp dyng trong cdt bang quang tan gdc va tao hinh thay the bang quang, thi ky thuat bdo ton than kinh cung dupe song song thirc hien [10]. Mot sd tac gia, ben canh chuc n&ig cuong, cdn mudn giu* lai cd chiic nang xuit tinh dd BN cd thd cd con sau md. Hautmann de nghi gi& lai 2 tui tinh [7], Girgin [4] va Nieuwenhuijzen [11] cdn dd nghi giif lai ca tuyen tien liet va tiii tinh.
Hien nay, hieu qua ciia bdo tdn bd mach than kinh sau md trdn ddi sdng tinh due ca tren phy niJ cung ducrc luu tam, ddng thoi hieu qua trdn chii ddng kidm soat nude ti^u cung rd rang hon [2,6,15].
V- KET LUAN
Neu chi dinh cat bang quang tan goc duoc thuc hien sdm d giai doan khu tni < T2, neu vj tri budu ndm cdch xa viing tam giac va cd bdng quang, ky thuat md tuan thii diing qui dinh thi vide bdo tdn bd mach thdn kinh cd hieu qua ro rang ve kidm soat di tidu va bao tdn chuc ndng tinh due. Ddc biet, chiic ndng tinh dye sau md kha quan han nhieu neu khdng bao tdn thdn kinh. Hieu qua con phy thudc vao dp tudi cua benh nhan: 6^
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TAI LIEU THAM K H A O
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