TAP CHi NGHIEN CU'U Y HQC
TAG VAN C H 6 N G TRAD NGLPgC NIEU Q U A N - BANG QUANG KI^U THANH NGOAI THANH C a TRONG THEO PHU'ONG PHAP
TAG HJNH BANG QUANG ABOL - ENEIN
T r i n Chi Thanh Binh win Viet DOc Nghiin cuv nhim danh gii kit qua tao ky thuat van chdng trio nguoc nieu quan - bing quang Ideu thinh ngoii thanh co tmng tao hinh bang quanh theo phuong phip Abol - Enein tai binh viin Viit Diic Nghien cuv md ta tiin cuv tren 35 benh nhan (31 nam, 4 nu) duoc tao hinh bang quang theo phuong phap Abol - Enein. Chl tliu nghien citu bao gdm: then gian md, biin chimg trong vi sau md, trao ngugc bang quang - miu quan, hep miing ndi bang quang miu quan. Kit qua cho thiy ty li hep miing ndi bing quang niiu quan 1,4% dan vi mieng noi. 2.85% theo ddi hep, khdng cd trwang hgp niio trao ngugc. Ty li giif nudc tliu chu ddng ban ngay 88.6%, ban dim 82,9%. Phuvng phap cSm nieu quan bang quang chong bao nguoc theo dang van thinh ngoii thanh co an toan va hiiu qua.
Td khoa: Van chdng trao nguQ^, t^o hinh bang quang, ung t h i / bang quang
I. DAT
VANBt
Ung thu bang quang la loai ung t h u dung hang thd 6 trong cdc bdnh ung thu. Tgi cdng hda Phdp cd khoang 10700 trudng hpp m i c mdi m i l ndm va 4500 ttudng hpp t u vpng trong mpt nam. Tai My cd khoang 53000 trudng hop mdc mdi mdi nam, ty Id mdc bdnh d nam g i p 2,5 lan d n u ; d nam ung thu bdng quang ddng thd 3 sau ung thu tuydn t i i n Met, ung thu phoi vd ung t h u dai true trdng c h i i m khpang 6,2% trpng cdc bdnh ung thu ndi Chung, d n d ung thu bdng quang dung t h u 8 trong cdc loai ung thu thudng gap va chidm 2,3% ttong tong s i cac benh u dc tinh Ung thu bang quang hay gdp d Ida tuoi 69 tuoi (nam), 71 tuoi (nd) va ty id ndy tdng theo t u i i t d 142/100000 ddn (nam), 33/100000 ddn
Bia chllien h0: Tran Chi Thanh, Khoa dieu tn theo yeu ciu, b$nh vi$n Viet Diic
Email: tranchithanh73@yahoo com Ngay nhan. 21/2/2015 Ngiy duqc chip thuin- 18/5/2015
(nd) d Ida tuoi 65 - 69 nhung ty fg ndy len din 296/100000 ddn (nam), 74/100000 dan d li>a t u i i tren 85 [1]. Tai Viet Nam, theo nghidn cdu eua tae gia Nguydn Ky, bdnh hay gap d li>a tuoi t u 40 - 70 t u i i (78%), ty Id nam/nd la 6/1 [2, 3].
c a t bdng quang vd t u y i n t i i n lidt todn bd (nam), cdt bo phan t r u d c chau hdng: cdt bang quang vd cdt t u cung todn bd (nd) la phuong phdp dieu tri co ban ttong bdnh ly ung thu t i bao b i i u md c h u y i n t i i p bdng quang xam lin eo khu tnj (> pT2NoMo). ung thu te bdo vay, ung thu b i i u md t u y i n vd ung thu to ehue lien k i t . Tap hinh bdng quang bdng mpt doan mgt duoe Couveiair R. thdng bao ddu tidn vdo ndm 1951 nhung mai d i n nam 1980 thi phupng phdp ndy m d i d u o e p h i b i i n rdng rai vdi nhieu ky thudt vd vdt lieu khac nhau (hii trdng, h i i manh trang, dai trang). Phuang phdp tap hinh bang quang iy tudng phai dam bap cac yeu c i u : bap vd hd t i i t nidu ttdn (ching trdp nguoc, dp luc ttong bang quang
TCNCYH 93 (1) - 2015
• Ti?Lp CHi NGHIEN CCFU Y HQC t h i p trcng qud trinh dp d i y bdng quang vd khi
r^n ddi). Cd ba cdeh tac van c h i n g trdo nguac: chong trap ngupc b i n g ap lyc c0t n u d c (Studer), van c h i n g trap ngupc k i i u thanh d u d i nidm mgc (LeDuc, Walaee), van c h i n g trdp ngup-c k i i u thdnh ngodi thanh c o (Abol - Enein), van chdng trao ngupc k i i u nurn (Hemi - Koch). Ty Id hep midng noi mdu quan - bang quang m d i khi ldm van c h i n g trao ngugc d u d i nidm mac (3% - 11%), hodc thu thudt khd, t i n thdi gian va t i n dogn rudt neu Idm van e h i n g trdc ngupc k i i u num.
Phupng phap Abol - Enein duoe tdc gia md ta ndm 1986 chp phep thu thuat c i m nigu quan vdo bdng quang d o n gian khi Idm van ehong trao n g u o c k i i u thdnh ngoai thanh c o [4]. Tgi Viet Nam, phuang phap tao hinh bdng quang bdng mpt dpgn h i i trdng da dupe mpt s i tac gia md ta thep p h u p n g phap Camey - LeDuc hoge Studer, nhung chua cd tac gia nap dng dung p h u a n g phdp Abol - Enein [5, 6, 7]. Chinh vl vay chung tdt thyc hien dd tai ndy vdi muc tidu
Ddnh gid ket qua tgc ky thudt van ehong trdo ngupc mdu quan - bdng quang k i i u thdnh ngodi thanh c o trpng tgo hinh bang quang theo phupng phdp Abol - Enein tai b$nh vidn Vigt Ddc.
II. D 6 | TU'gNG VA PHU'aNG PHAP
1. D d i tu'O'ng
T i t ca cdc b0nh nhdn d u p c tao hinh bang quang bdng phuang phdp Abol - Enein tgi b§nh vidn Vidt D d c t d thdng 1/2009 den thang 6/2013.
2. P h u o n g phap: nghien c u u md ta t i i n
K$ thudt tao van chong trao nguac: thuc hidn trong khi tao hinh mdt sau bang quang (hinh 1)
Cdc chi tidu nghien cdu: tuoi, gidi, phdn logi VI the, thdi gian mo, b i i n chdng trong mo, b i i n Chung sau mo, ty Id hep midng n i l sau mo, ty Id trdo ngupc bdng quang nigu quan sau m i
Hinh 1 . Hinh anh dm nieu q u a n v d o bang quang theo phiFong phap tgo v a n c h d n g trao ngu'p'c k i l u t h a n h ngoai t h a n h c o
3. D a o diPC n g h i e n CIFU: T i t ca cdc bdnh nhdn deu t u nguygn tham gia nghidn cdu. D d lidu rieng t u cua b§nh nhdn d u p c giu kin. Cdc bdnh nhdn d u o c theo ddi chdt che, n i u c6 bien ehung se d u g c d i i u trj kjp thdi.
TAP CHi NGHIEN cCPU Y HQC
III.
K£T QUATil thang 1/2009 - 6/2013 c6 35 benh nhan du'p'c tao hinh bSng quang trong dti tuoi trung binh 57, 02 tuoi (38 - 75 tu6i), 88,6% nam 11,4% nO'.
Bang 1 . Phan b6 t u 6 i t r o n g n h 6 m b^nh nhan n g h i e n c i r u
< 4 0 4 0 - 5 0 5 1 - 6 0 6 1 - 7 0
> 7 0 Tong s6
Tu6i n
1 12 11 10 1 35
%
2,85 34,4 31,4 28,5 2,86 100
Ddc d i i m giai phdu bdnh: 100% ung thu t i bao chuyen t i i p . Giai doan benh eua ung thu t i bao chuyin t i i p d u p c phdn bo theo bang 2.
Bang 2. Giai doan giai p h l u benh cua n h o m benh nhan ung thu* te bao chuyen tiep
pTINoMo pT2 pT33 pT3b Tong so
Tudi n
8 19 7 1 35
%
22,8 54,3 20 2,9 100
Thdi gian m i todn bd tnjng binh 387 phut (345 phut - 490 phut).Thdi gian tgo hinh bang quang trung binh 214 phut (190 phOt - 255 phut). Thdi gian tac midng noi nidu quan bang quang trung binh15,2 phut/mieng ndi.
Biin Chung trong mo: 2,85% rach mach mdu mgc treo h i i trdng trong khi c6 dmh bdng quang ngoai phue mae do mae tteo bang quang edng. M i t mdu trung binh ca cudc mo 240 ml (200 ml - 500 ml). Ty lg truyen mdu trong m i . 34,2%. Hep midng n i l nieu quan
bang quang 2,85% (1,42% don vj mieng nof), bdnh nhan dup'c mp lat cdm nteu quan vao bdng quang sau mo 1 nam. Hai bdnh nhan dan nieu quan trdi sau mo nhung khdng bin t r i i n theo thdi gian hidn dang theo ddi. Trao ngupc bang quang nidu quan thi ran vd thi rdn dai trdn phim chyp bdng quang - nieu dao can quang 0% (2 bdnh nhdn khdng d i n sau mo). 2,85% benh nhan cd tdng creatinin i n dinh sau m i .
Dung tich bdng quang c h d c ndng thdng
TCNCYH 93 (1) - 2015
• T A P CHf NGHIEN CLFU Y HQC t h u nhat sau ra vi§n 255 ml (220 ml - 300
ml), sau thdng t h d 3 Id 375 ml (240 ml - 800 ml) vdi ty lg ton d u n u d c t i i u < 10% Ty lg chu ddng g i d n u d e t i i u ngay 88,6%, ty le ehu ddng g i u n u d c t i i u v i ddm 82,9%. B i i n chdng: bdn t i c rudt sau m i 2,85%, tdc rudt 2,85%, nhiem trting vet mo 2,85%, thoat vj thdnh bung sau mo 2,85%. N h i i m khuan t i i t
mgu 0%. Ty Id song sau 1 ndm 96%, 2 ndm 88,2%, sau 3 ndm 62,5%. Nhdng bdnh nhdn tdi phat tai ch$u hdng vdn dt chu d i n g di tieu.
Di cdn xuang 5,71%, tdi phdt tgi chdu hdng 14,2 %. Ha Natri mdu, tSng nong dd ion Clo xay ra trdn 1 bdnh nhdn c h i i m 2,85 %.
Thdi gian theo doi tnjng binh 25,8 thdng (6 - 48 thdng).
Bang 3. Cac b i d n c h i f n g c h u n g cua n h d m benh nhdn nghien c i r u
Biln chu'ng n
%
Bi6n chi>ng trong mo
Rach mach mau mac treo hoi trang 1 2,85
Bien ChLFng sdm sau mo Ban t^c ruot
Tac rupt N h i i m khuan v i t mo
1 1 1
2,85 2,85 2,35 Bi6n chi>ng xa
Thoat V! thanh bung Ha Natri v ^ Clo mau Tong s6
1 1 5
2,85 2,85 14,25
IV. BAN LUAN
Nam 1911, nghidn c d u t h y c nghidm trdn chd cua Coffey lam hd m d vai trd cua tao van chong trdc n g u p c bac ve h§ t i i t nigu trdn khi m d thdng nidu quan vdo dai ttdng sigma.
Trong thi rSn dp lye trpng Idng dgi trang len d i n 200 cm HzO gdy trap nguoc phan len nidu quan va thdn md hdu qua ddn den vidm thdn be thdn vd shock n h i i m ttijng. Hdu qua cua qud trinh trdo n g u p e bdng quang nigu quan se dan d i n hidn tup-ng trdo n g u p c trpng i n g than khi dp Iyc ddi b i thdn cao hpn ap lyc trong i n g thdng t d 10 - 15 cm HzO. Trdo T\girgc n u d c t i i u trong ong thgn cCing vdi
viem ddi be thdn man tinh ngupc ddng dp vi khuan bdi y i u t i ttiudn Ipi la ddng n u d c t i i u l u i n quan trpng nieu quan vd b i than Id co c h i ton thuang nhu md than do benh ly trdo ngupc gay ndn. Sau bdc cdc eua Coffey va cdng s u tat ca cdc mi^ng n i l mgu quan - dgi trdng d u p c ldm van c h i n g ttdP ngupc kieu thdnh d u d i niem mgc. T u khi cd phuang phdp d i n luu nudc tieu c6 b i ehua hcdc tap hinh bang quang ra ddi thi kJ thuat ndy d u p c dng dung vdi n h i i u phuong phdp khdc nhau khi c i m ni^u quan vap b i chua hodc vdo bdng quang mdi. Trong nghidn c u u cua Yasser
TAP CHi NGHIEN CLPU Y HQC •
Osmen, ttong so bdnh nhdn trdo ngupc bang quang nidu quan thi 30,7% don vj midng n i l cd ton ttiuong thgn ttdn xa hinh thdn. Nhu vdy, thu thugt c h i n g trdo ngup-c bang quang nidu quan cd tae dung bao vg hd t i i t nidu ttdn [8]
Ky thudt edm nidu quan vdo bdng quang k i i u LeDuc - Camey d o n gian nhat, m d m i t Id tgi thdnh bang quang m d i cd ehleu ddt b i n g dudng kinh eua nieu quan, luon dogn euoi nieu quan vdo Idng bdng quang, c h i i u dai cua dogn nieu quan trong bdng quang 3 -
•4 cm. Khau dinh mdm mgc cua rudt vdi thdnh nidu quan. Phuang phdp nay don gian nhung ty Id hep midng noi nieu quan bdng quang cao t u 5% d i n 3 1 % .
Nhung nghien c d u gdn day, ty le hep midng n i i nidu quan bang quang da giam xudng d u d i 5% [6]. Ky thudt tgo van num trong phuang phdp Hemi - Kock cho k i t qua chdng trao nguoc tot nhung ty Id 4%i hgp nidu quan - bang quang, 1 % tut van, 6% sdi bang quang [10; 11]. Ky thudt cdm nigu quan vao bang quang cua Goodwin khi dung dgi trdng ldm bang quang mdi (van chong ttao nguoc kieu thanh d u d i nidm mgc) cd ty Id hep mieng n i l tCr 5% - 1 5 % . Mdt ky thuat khdc tao van c h i n g trdo ngupc dua vdp dp luc cpt nudc s u dung trong phuang phap Studer, tdc gia dung 18 - 20 cm hdi trdng nguydn ven, cdm nidu quan ttuc t i i p vdo dogn rudt nay.
Nhd cd nhu ddng mdt ehieu va ap lyc cdt nude ndn ky thudt ndy dam bao duoc tae dung ehdng trdo ngupc. Nhupc diem cua phuong phdp ndy t i n doan rudt non nhung lai ed uu (Sim trong nhdng trudng hpp doan nidu quan edn Igi n g i n thi doan njdt ndy vua cd tac dyng chong trdo nguoc vda ed tdc dung thay t h i dogn nidu quan. Vay, do mdt nguyen nhdn ndo dd md doan nidu quan cdn lai n g i n thi phupng phdp tgo hinh Studer cd u u t h i hon cac phuong phdp khdc. tuy nhidn
phuong phap Hemi - Kock cOng Id mOt lira chpn t i t . Ty 1$ hep midng noi nidu quan - bang quang eua phuang phdp Studer tmng binh khoang 2 % nhung ty 1$ vtdm thdn - b i than 7% [12]. Ky thudt tap van chdng ttao nguac k i i u thdnh ngpdi thanh c o thep Abol - Enein cho hi$u qua chong trdo nguoc eao, ty Id hep midng noi ni$u quan - bdng quang thdp; ben canh dd p h u o n g phdp nay edn eho phep k i i m fra vd can thigp dieu ttj hep migng na nigu quan - bdng quang bdng dung cu soi nidu dgo bang quang v) vj ttf hai Id nieu quan n i m d vi tri giai phdu g i n vdt vi tti v i n c6 cua nd. Trpng nghien c d u sp sdnh ngiu nhien mu dan giua p h u a n g phap tao hinh bang quang theo p h u a n g phap Abol - Enein vdi phuang phdp tgo hinh T - pouch ctia Yasser Osmen va cdng s u , ty Id trao ngupc bang quang nidu quan ciia phuang phdp Abol - Enein la 0% ttong khi cua phucmg phap T - pouch 28,8 % don vj midng na (n = 60) [8]. Trong nghien c d u ndy ty Id ttao ngupc 0% (mat tin 5,71%), hgp midng nm 2,85%.
V. K £ T LUAN
Hidn nay cd n h i i u phuang phdp cdm nidu quan vdo bang quang ttong tao hinh bdng quang b i n g m$t quat rudt biet lap. Mdi phuong phap d i u cd nhung uu diem vd nhupc diem n h i t djnh. Phuang phdp cdm mdu quan vao bang quang kieu thdnh ngodi thanh co khdng nhung cho ty 1$ hep midng n i i (1,4% don vj midng n i i ) md edn ttao nguoc thap (0%).
Lo'i cam a n
Tdc gia xin bay to Idi cam o n chan thdnti d i n cdc benh nhdn va thdn nhdn cua hp da cdng tac vdi tci. Tac giai cung xin t)iy to s u biit on den Ban ldnh dgp b ^ h vidn, cdc thay vd cde ding nghidp cia giiip d d ttpng qud ttinh nghten edu.
98 TCNCYH 93(1)-2015
TAI LIEU THAIVI KHAO
1 . J . A. Witjes, E. Comperat, N.C. Cowan et al (2013). Epidemiology and risk fector.
Guidelines on musculo - invasive and metas- tatic bladder cancer. 2, 7 - 10.
2. Ky N g u y i n (1997). Nhan xet vd k i t qua dieu tn 436 trudng hap ung t h u bdng quang tai bdnh vidn Viet D u e trong 15 ndm t d 1 9 8 2 - 1996. A/goa/ khoa. 2, 19 - 29
3. N g u y i n Ky Nguydn Bii-u Tridu (1993).
K i t qua d i i u bi phdu thudt ung thu bang quang trong 10 ndm tai bgnh vidn Vidt D u e Tap san Ngoai Khoa. 3 , 7 - 1 5
4. Hassan Abol - Enein, Mohamed A.
Ghoneim (2001). Functional results of orthotopic ileal neobladder with serous - lined exttamural ureteral reimplamtation: experience with 450 patients. The Journal of urology, 165, 1 4 2 7 - 1 4 3 2 .
5. Hoang Van TiJng, T r i n Ngoc Khanh, Pham Ngoc Hung va cong su> (2010). Phdu thudt tao hinh bang quang t u hdi ttdng theo phuong phdp Studer cai tien. kinh nghiem qua 25 ttudng hpp. Y hoc Viet Nam. 2 , 4 8 5 - 4 9 1 .
6. Dao Quang Oanh, Vu Van An (1999) Phdu thudt thay the bang quang bdng hoi ttdng (kieu dp lue thap). Yhoc VietNam, 3(1),
-gTjfliP CHl NGHIEN C l / U Y
7. Pham Van Ydn, Vu Cong Binh (2012) K i t qud tao hinh bdng quang bdng h i i trdng nhdn 16 trudng hpp tgt bdnh vidn Vidt Tidp Hai Phdng. Y hgc Thdnh phd Hd Chi Minh. 18 (3), 523 - 526.
8. Yasser Osman Hassan Abpl - Enein, Mohsen El-Mekresh and Col. (2009) Com- parision between a serous - lined extramural tunnel and T - limb ileal procedure as an anti- reflux technique in orthotopic ileal substitutes:
a prospective randomized trial. BJU Int. 104, 1 5 1 8 - 1 5 2 1 .
9. Camey M. & Botto H. (ig92).The ileal neobladder: development and long-term ex- perience, Camey I and 11. Scand J Urol Nephrol Suppl. 142, 98 - 1 0 0
10. Guven Sevin Sedat Seyupek, Abdul- lah Armagan (2004). Ileal orthotopic neoblad- der (modified Hautmann) via a shorter detubu- larized ileal segment: expenence and results BJU Intemational, 94, 355 - 359.
11. Ramesh Thurairaja, Fiona C.
Burkhard, Urs E. Studer (2008). The or- thotopic neobladder. BJU Intemational, 102, 1 3 0 7 - 1 3 1 3 .
12. George N. Thalmann, John P. Stein (2008). Outcomes of radical cystectomy. BJU international, 102,1279 - 1 2 8 8
Summary
SEROUS - LINED EXTRAMURAL REIIMPLAIVITATION IN PATIENTS UNDERGOING ILEAL ORTHOTOPIC BLADDER:
TENIQUE OF ABOL - ENEIN
The objective of the study was to assess the results of serous - lined extramural ureteral reim- plantation in patients undergoing orthotopic bladder substutation in Vietduc university Hospital from January 1999 to June 2013. The study included 35 patients with bladder cancer (31 men and 4 women). After radical cystectomy, the neobladder was performed by ileum with Abol - Enein technique. Subsequently patients were followed by clinical, biochemical, and radiological assessments. Results: in 35 men and women, there were no perioperative death with 88.6% day-
T f P CHi N G H I S N cO'U Y HQC •
time urinary continence and 82.9% nighttime continence but none required protective pads.
2.85% of patients performed self - intermittent catheterization because of poor reservoir empty- ing. The mean functional bladder capacity was 375 ml (240 - 800 ml). There was 1.42% ureterk;
implantation stenose Reflux was not observed In eonelution. the serous - lined extramural tunnel has proved its efficiency and durability as an antireflux technique.
Key words: antireflux, orthotopic bladder, bladder cancer
TCNCYH 93(1)-2015
