HQI NGH! KHOA HQC LAN THCT VII, Hpl Tt£T NIEU - THJiN HOC VigT NAM (VUNA)
PHAU THUAT CAT BANG QUANG TAN GOC, TAO HINH BANG QUANG
" BANG HOI TRANG TAI BENH VIEN CHO RAY
Thai Minh Sam', Do Quang Minh', Tran Ngoc Sinh^ va CS.
TOM TAT:
D a t v a n iTe va m u c t i e u : CSt bang quang tan goc, nao hach va chuyen lu'u nu'dc tieu la tieu chuan vang trong dieu trj bu'du ac BQ xam lan cd. Tao hinh bang quang bSng hoi trang la phu'dng phap ngay cang du'dc uei chuong. I*^uc tieu: tong ket tinh hinh phau thuat cat bang quang tan goc, tao hinh bang quang bSng hoi trang tai BV Chd Ray tCr 2008 den 2012.
D o i t u ' d n g v a p h U t f n g p h a p : Nghien cu'u hang loat ca. Bu'du bang quang (BQ), giai doan T2-T4a, da co GPBL, du'dc mo m d hoac ngi soi 6 byng cat BQ tan goc, sau do lay hoi trang de tao liinh BQ trifc vj kieu iHautmann hay Studer hoSc tui chuyen li/u nu'dc tieu kieu Brlcker hoac tui Koch. Trong luc mo, sinh thiet lanh cac dien cat (nieu dao, nieu quan) va hach chau bjt 2 ben de danh gia giai doan bu'du chfnh xac. Danh gia ket qua sau phau thuat.
K e t q u a : 124 tru'dng hdp; nam/niJ': 108/16;
tuoi trung binh: 59 tuoi (25-84). Mo m d 114 TH (91,9%), mo noi soi 10 TH (8,1%). Tao hinh BQ tri/c vj kieu Hautmann 50 TH (40,3%), Studer 59 TH (47,6%) va chuyen lu'u nu'dc tieu kieu Bricker 15 TH (12,1%). Thdi gian mo m d trung binh:
355,3 phut. Mau mat trung binh: 475,4 ml. Thdi gian nam vien trung binh: 15,3 ± 7,4 ngay. Bien chu'ng ro nUdc tieu va nhiem trung vet mo: 8 TH (6,4%), tir vong 2 TH (1,6%).
K e t l u a n : Phau thuat cSt bang quang tan goc tao hinh bang quang hoi trang trong dieu tri ung thu' bang quang la mot phau thuat Idn va kho trong tiet nieu. Tuy nhien cd the du'dc thiJc ' Khoa Tiet N i | u , Benh vi^n Cho Ray 2 Bp mon Ni?u, Dai hgc Y Dugc TP H o Chi M i n h Phan bien khoa hpc: PGS.TS. Tran VSn Hinh
hi&n an toan va hieu qua neu nam vi^ng ky thuat va dieu kien gay me hoi SIJ'C cho phep.
Tu" k h o A : Cat bang quang tan goc, tao hinh BQ hoi trang.
S U M M A R Y
SURGICAL OUTCOME OF ILEAL NEOBUDDER C O N T R U C T E D A F T E R R A D I C A L CYSrECTOMY AT
CHO RAY HOSPITAL
I n t r o d u c t i o n & o b j e c t i v e : Radical cystectomy w/ith lymphadenetomy and urinary diversion Is the gold standard for muscle invasive bladder cancer. The Ileal orthotopic bladder substitute has gained increasing populanty in recent years. We report surgical outcomes in patients (pts) with ileal reconstructed during 5 years from 1-2008 to 12-2012 at Cho Ray hospital.
P a t i e n t s a n d M e t h o d : Retrospective case series. T2-T4a bladder cancer pts undenvent open or laparoscopic radical cystectomy and orthotopic ileal neobladder reconstructed using Hautmann or Studer technique or ileal conduit diversion with Bricker technique. Froozen section biopsied margins for staging. We evaluate early outcomes of the operation.
R e s u l t s : Total 124 pts. Male/female:
108/16; Mean age: 59 yo (25-84). Open operations 114 (91.9%), laparoscopic operations 10 ( 8 . 1 % ) . Reconstruction of ileal neobladder using Hautmann account for 50 cases (40.3%), Studer 59 cases (47.6%) and Bricker 15 cases (12.1%). Mean open operation time: 355.3
Y HOC VI$T NAM THANG 8 - S6' D A C BigT I 2013 minutes. Mean blood loss: 475.4 ml. Mean
Hospital stay: 15.3 ± 7,4 days. Urine leakage and wound infection: 8 cases (6.4%), mortality: 2 cases (1.6%).
Conclusion: Radical cystectomy following by reconstruction of Ilea! neobladder in treatment of bladder cancer is a difficult operation in urolory but can be performed safely and effectively.
Keywords: Radical cystectomy, Orthotopic bladder substitution.
I- OAT V A N o f
Budu ac bang quang (BQ) la mot benh ly thudng gap, xep thu hai trong ung thu dudng tiet nieu sinh due. Ve dieu tri, phau thuat cat bang quang tan goc, nao hach va chuyen luu nuac tieu la tieu chuan vang de dieu tri ung thu BQ xam lan lap ca. Trong cac phuong phap chuyen lua nude tieu, tao hinh bang quang bang rupt non la phuang phap da ducrc chung minh la cd hieu qua va ngay cang dugc ua chuong trd thanh dieu tri tieu chuan d cac benh vien va trung tam Idn nhieu noi tren the giai. Chung toi thuc hien nghien ciiu danh gia tinh hinh phau thuat cat bang quang tan gdc kem tao hinh bang quang bang hdi trang trong ung thu BQ tai BV Chg Riy trong thdi gian 5 nam tu 2008-2012.
II- 06\ l a O N G V A P H U O N G P H A P NGHtEN CCru
2.1. Phuffng ph^p nghien cii'u: Nghien cuu mo ta hang loat ca.
2.2. Doi tu-pTig nghien cihi: BN nhap BV Chg Ray tir 1-2008 dSn 12-2012 dugc chan doan budu bang quang xam lan lap ca (T2) trd len chua cd dau hieu xam Ian ra ngoai b^g quang hoac budu cd do ac tinh cao hoac tai phat nhidu Ikn.
2.3. Phu-oTig phap tien hanh:
Budu BQ dugc chan doan giai doan va dd biet hda. Giai thich nhiJng vkn dk lien quan dSn benh, nguy ca cua cua phlu thuat va nhiing van de thudng xay ra ddi vdi BQ rupt trong thdi ky hau phdu gkn cung nhu xa, van de hda tri hd trg sau md,..
Chuan bj rupt dirge thuc hien 2 - 3 ngay trudc phau thuat, bao gdm thudc nhuan trang, khang sinh du phdng va ch6 dp an Idng.
Quy trinh phau thuat: ti^n hanh c4t BQ tan goc bang md md hoac PT npi soi. Co gang bao tdn bd mach than kinh sinh due.
Tien hanh cat lay bd BQ va ti6n liet tuy^n toan phan. Lay cac mau md ciia mdm nieu quan 2 ben va mdm nieu dao gdi lam sinh thiet lanh.
Tien hanh nao bach chau bit 2 ben va gdi lam sinh thiet lanh ciing vdi cac mau vua thu.
Neu ket qua cac mau thu am tinh hoac hach chau duang tinh nhimg mdm nieu dao am tinh tha trang BN kha tdt-> Lky 40-60 cm doan cuoi hdi trang de tao hinh BQ kieu Hautmann hoac Studer. Neu mau thu mdm nieu dao ducmg tinh tao tui chuyen luu nude tieu theo kieu Bricker hoac tiii Kock.
Khau phuc hdi luu thdng cua rupt non bing soir hoac Vicryl 3.0, 4.0. Cam 2 nieu quan vao BQ bang ky thuat Le Due, Wallace hoac Hassan. Khau ndi bang quang tan tao vao nieu dao (chuyen luu true vi) bang 6-8 miii chi Vicryl 2.0 hoac 3.0.
Bang quang tan tao dugc md ra da bang Foley 20- 22Fr theo dudng giiia. Dan luu canh BQ 2 ben ra 2 hd chau. Ddng thanh bung.
Sau md tir ngay hau phau thii 2 se bom rira BQ tan tao 2 lan mdi ngay, bn se an nhe trd lai tir ngay thu 3. Nhimg ngay dau sau mo s6 nuoi ducmg bSng dudng tmh mach vai phdi hop 3 loai dudng dam md sao cho du so
Hpl NGHj KHOA HQC LAN THCf Vlt, Hpl TlfiT NigU - THAN HQC VigT NAM (VUNA) calori. Khang sinh chich diing trong 7 - 1 0
ng^y dau, BN dugc khuyen ngoi d|iy va van dpng sdm. Theo ddi sy hdi phyc cung nhu bien chung neu cd.
Thdng ni$u dgo dugc rut bd sau 10 - 14 ng^y, thdng md hkng qua ra da dugc rut bd sau 3-4 tu4n. Ddnh gia khd ndng giiJ nude tieu vk tinh trang di tieu ciia BN sau nit thdng. Sau khi BN dn djnh thudng sau 4-6 tu^n sg tai khdm va xet chi djnh hda trj ho trg
3.1. Gidi:
dudng toan thdn neu cd chi djnh. Tdi kham djnh ky mdi thdng trong nam dau sau do m8i 3 thdng ngu BN 6n.
Ml- KET QOA NGHIEN COU
Tir thang 1-2008 d^n 12-2012, cd 124 tmdng hgp dugc phau thuat cdt bang quang t^n gdc do budu dc bang quang tgi khoa Tilt Ni^u BV Chg Ray, trong dd;
Bang Gidi Nam NO- TONG CONG
1: Phan bo theo giai So tru'dng h^p
108 16 124
Tv l9 % 87.1 12.9 lOO Nhdn xet: Nam gidi chiem da sd
3.2. Tuoi: Tudi trung_binh: 60^(^5-84)^tap trung chii ygu^ dp tudi 50-70.
So tri/cfng
38 39
Am
<40 40-50 SO-60 60-70 70-80 >80 Nhnr
Bieu do 1: Phan bd theo tudi.
3.3. So trudng hop mo theo cAc nam:
2008 2009 2010 2011 2012
Bieu do 2: Phan bd sd BN md theo cac nam.
Y Hpc VIET NAM T H A N G 8 - S 6 D A C BigT / 2013
Nam 2012 chiing tdi ghi nhan sd lugng md cdt BQ tan gdc tao hinh BQ rudt cd giam hon so vdi cac nam trudc nhimg sd lugng md budu BQ chung van khdng giam thdm chi cdn tang hon nhung ti 1? md cdt BQ toan phan dua 2 nieu quan ra da tang nhieu do BN den tri.
3.4. Ti^n can m^ BBQ tru'dc
Bang 2: Phan bd theo tien can phau thuat
Tien can phau t h u a t Khonq tien can PT CONS Cat ban phan BO CONS + Cat ban phan PTKhac
Tonq conq
So tru'dng hdp 92 20 6 2 4 124
TV i6 % 74.2 12.8 4.4 1.5 3.1 100
Nhdn xet: Cd 28 trudng hgp da dirge md budu BQ trudc do chiem 22,58%.
3.5. Chan doan giai doan bu-du.
Bang 3: Phan bd theo giai doan budu
Giai doan bu'du T2aNoMo T2bNoMo T2bNlMo T3aNoMo T3bNoMo T3bNlMo T 3 b N l M l T4aNxMx TONG CONG
S o t r i r d n g hdp 4 86 2 12 13 2 1 4 1 2 4
Ti le »/o 3.2 69.4 1.6 9.7 10.5 1.6 0.8 3.2 1 0 0 . 0
Nhan xet: Buou a giai doan T2NoMo va T3NoMo chiem da so.
3.6. Ky thuat tjo hinh bing quang.
Ky t h u a t tao hinh Studer
Hautmann
K o c h * TONG CONG
S o T H 59 50 12 3 1 2 4
TV le Vo 47.58 40.32 9,67 2,41 1 0 0 . 0
(•) chi dinh cho nhttng trucmg hpp buou xam ijn viing chau hay co quan lan can hoac co di can hach hoac BN gia yin, nhieu benh ly kem...
179
Hpl NGHj KHOA HpC LAN THfl VII. Hpl Tlgl NIEU - THAN HpC Vl|T NAM (VUNA) 3.7. Ky thujt cam nifu quan
Co 3 Icy thu^t duoc ap dyng tuy thoi quen cua PTV (bang 5) Kv thuat dim nieu quan
Le Due cai bien Wallace Hassan
Tonq conq
SoTH 19 70 35 124
TV le % 15,32 56,45 28,22 100.0 3.8. Phu'O'ng ph^p mo - Thcri gian
Bang 6: Phan bo phuong phap Phu'dng phap mo
Mo md Noi sol TONG CONG
S«TH 114
10 124
Tv le % 91.9
8.1 100
mo - Thfri gian nam vifn
mo - Thai gian mo TB va thai pian nam vien T.qian mo TB (phut)
355.3 ± 47.7 744 ± 93.5
T.gian nSm vien TB (nqay) 16.89 ± 5.4 30.60 ± 13.4
3.9. Ket qua:
3.10. Bien chirng sau mo
Bang 7: Phan bd theo ket qua Ket qua
Thanh cdnq Bien chuYiq
SoTH 116 8 (tronq dd tiT vonq 2)
Ti le o/o 93,5 6,45(1,6%)
Bien chu'ng Nhiem trijnq VM Ban tac ruot Ro bang quang ruot Ro mieng noi hoi trang Ro true tranq TCr vong
Bang 8: Phan bo theo bien chiing SoTH
5/124 2/124 2/124 1/124 1/124 2/124 (1 mo md, 1 mo ns)
Tv le % 4,03
1,6 1,6 0,8 0,8 1,6%
Xurtri N6I khoa N6I khoa FT khau ro, + Md HT ra da, + Md HMNT
- R 6 B Q , V P M , NTH/xdgan - Ro BO+HT, XHTH IV- BAN LUAN
4.1. Vc chi dinh:
Tuoi md:
Tac qia Studer Hautmann Dao Ouanq Oanh Nqhien ciru chunq toi
Tuoi trunq binh 65 (36-84) 64 (20-84) 56,9±12,7 60 (25-84)
Y HOC V l i T NAM THANG 8 - SO OAC B I | T / 2013
6 BN > 80 t van cd chi dinh cat BQ tan g6c, cac nghien ciiu cho thay cd tang ti le bi6n chvtng sau md nhung khdng tang ti le tu vong.
Chi dinh: Cat b ^ g quang tieu chuan vang dieu tri BBQ xam lan ca. Cat BQ dugc chi dinh doi vdi budu d giai doan tir T2-T4a, No-Nx, Mo.
Trong NC chung tdi, danh gia giai doan duoc thuc hien trudc, trong va sau md. Trong m6, chiing tdi thuc hien sinh thiet lanh d tat ca BN nham danh gia bien phau thuat de chpn PP chuyen luu nude tieu hop ly nhat, day la mot uu diem cua BVCR.
4.2. Ve ky thuat cat bang quang tan goc:
Cat bang quang tan gdc bao gdm bang quang, TLT, tiii tinh va nao hach tieu chuan.
Nao hach tieu chuan bao gom 5 nhdm hach:
hach bit, chau ngoai, chau trong, chau chung, tnrdc xuong cung. Viec nao bach tang ti le song cdn, trong dd di can hach bit va chau trong la pho bien nhat. BN cua chiing tdi deu diroc nao hach theo tieu chuan.
Ngay nay ve phau thuat, van de bao tdn TK cirong la mot van de ma cac PTV thudng quan tam.
4.3. Ky thuat chuyen luu nvdc tieu:
C6 2 phuong phap: chuyen luu nude tieu khong kiem soat va cd kiem soat.
Chuyen luu nude tieu cd kiem soat (Studer, Hautmann) lam cai thien chat luang cugc sdng ciia BN. Trong dd su dung hdi trang dk tao hinh tu PT thuc nghiem da trd Ihanh phuong phap phd bien tai nhieu trung tam. Noi chung ve nguyen ly ky thuat ciia 2 pp Studer va Hautmann gan gidng nhau la de bao ton cuong mach, dl tao hinh BQ, dap ling muc tieu BQ tan tao: true vi, du thg tich, tiii chiia ap luc thdp -> bao ve dudng tik nieu tren. Ti le thanh cdng va b/c tuong
duang tuong duang nhau, chpn ky thuat nao thuang do thdi quen cua PTV.
4.4. Ve ket qua:
Ket qua v^ ti le thanh cdng ciing nhu bien chdng ciia chung toi cung tuang duong cac tac gia khac tren the gidi.
Ve bien chiing: Nhiem vet md chiSm ti ie cao nhat (4%) va rd nude tieu d BQ tan tao (1,6%) la BC sdm thudng gap. So sanh vdi Jensen. NTVM (9%) va rd nude ti^u (9%).
Ty le tii vong theo Skinner va Kaufman la 2%, Jensen la 1.5% va NC chiing tdi la 1,6%. Hai ca tii vong ciia chiing tdi, trong dd cd 1 ca md md tren BN xa gan, hau phlu Bn bi rd BQ tan tao, viem phiic mac, nhiSm trimg huyet va 1 ca PT noi soi tren BN ung thu TLT da xa trj trudc day, hau phau Bn bi rd BQ rupt non, xuat huyet tieu hoa va viem phdi..
V- KET LUAN
Cat bang quang tan gdc, tao hinh bang quang bang rupt la phuang phap dieu tri budu BQ xam Ian ca hieu qua cao. Day la mpt phlu thuat Idn va khd trong nieu khoa.
Phau thuat duac thuc hien an toan va hieu qua neu chi dinh diing va nam vung ky thuat. Phau thuat cat BQ tan gdc, tao hinh BQ rudt bang noi soi dang la khuynh hudng tren thS gidi. Chiing tdi cd 10 trudng hop, day la nhimg trudng hop dau tien tai BV Cha Riy.
TAt UEU THAM KHAO
1. Stein JP, Lieskovsky G, Cote R, et al.
Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol 2001;19:
666-75.
2. Madersbacher S, Hochreiter W, Burkhard F, et al. Radical cystec-tomy
Hpt NGHI KHOA HQC L A N THtf VII, H Q I T | £ T NigU - TH^N HQC V l g l NAM (VUNA)
for bladder cancer today a homogeneous series without neoadjuvant therapy. J Clin Oncol 2003; 21: 690-6.
Hautmann RE, Gschwend JE, de Petriconi RC, Kron M, Volkmer BG.Cystectomy for transitional cell carcinoma of the bladder: results ofa surgery only series in theneobladder era.
J Urol 2006;176:486-92, discussion 491-2.
Stenzl A, Cowan NC, De Santis M, et al. The updated EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Urol 2009; 55: 815-25 Jorgen Bjerggaard Jensen, Finn Lundbeck, Klaus Moller-Ernst Jensen (2006), "Complications and neobladder function of the Hautmann orthotopic ileal neobladder", Bju International, (98):
1289-1294
Skinner and Kaufman, 1980. Skinner DG, Kaufman JJ: Complications of radical cystectomy for carcinoma of the bladder. J Urol 1980; 123:640
Wassim Kassouf, Richard E.
Hautmann, Bernard H. Bochner, Seth
P. Lerner, Urs Studer (2010), "A critical analysis of orthotopic bladder substitutes in adult patients with bladder cancer: is there a perfect solution?", European Urology 58: 374-383.
8. Wataru Obara, Kazumasa Isunigi, Daisuke Kudo, Ryo Takata (2006)
"Eight Year Experience with Studer Ileal Neobladder" Jpn J Clin Oncol 36(7)418- 424.
9. Studer U E, Burkhard F C, Schumacher M, Kessler T M, Thoeny H, Fleischmann A (2006), "Twenty years experience with an orthotopic low pressure bladder substitute - Lessons to be learned", J Urol (176), 161-166.
10. Richard E. Hautmann, Bjoern G.
Volkmer (2006), "Long-term results of standard procedures in urology: the ileal neobladder". World J Urol 24:305-314.
11. Dao Quang Oanh (2008), "Bang quang true vi (thay the ndi vdi nieu dao): ket ,, qua tren nhihig trudng hpfp theo doi tren 3 nam tai BV Binh Dan", Y Hpc TP H6 Chi Minh (12), (l),tr 244 250. "
