T A O H I N H L A M R O N G B A N G Q U A N G Q U A N Q I S O I O B U N G T R O N G BANG Q U A N G C O N H O D O L A O : B A O C A O 3 TRU'CfNG H Q P BAU TIEN
Nguven Phiic Cam Hoang'. Le Van Hieu Nhan , Tnin Ngpc Khac Linh', Vu Le Chuyen*, Nguyin Viet C u d n g "
TOM LU^gfC
Muc tieu: Danh gia tfnh kha thi ciia phiu thuat lam rdng bang quang bang hdi trang qua noi soi d bung trong bang quang co nhd do lao qua 3 trudng hgp dau tien.
TIT lieu va phinmg phap nghien cuu: Tac gia trinh bay 3 rudng hgp phlu thuat ngi soi lam rpng bang quang bang hoi trang trong bang quang co nhd do lao nieu vira mdi dugc thuc hien dau tien tai Khoa-Phan mdn Nieu benh vien Binh Dan trong thdi gian qua.
Ket qua: Mdt benh nhan nam va hai benh nhan nir, tudi trung binh: 58 (54-61). Dung tich bang quang trudc md: 43,33 mL (40-50). T6n thuang di kem: mgt benh nhan nir cd hep nieu quan trai chau, ngugc ddng bang quang nieu quan (VUR) 2 ben; mdt benh nhan nii khac cd hep meu quan phai, than trai mSt chirc nang va VUR 2 ben; benh nhan nam c6 san than trii, hep va VUR 2 ben va giam nhe chiic nang than (creatinin mau=122 ^mol/L). Hai benh nhki dugc nong nieu quan Uai, mdt benh nhan dugc nong nieu quan phai, dat thdng JJ trudc. Ky thuat mo: dung 4 trocar, dat d viing ha vi. Lam rgng bang quang bang hdi trang: co lap mgt doan hoi trang dai 15-20cm, keo ra ngoai co th^ qua dudng md rgng trocar ron 4-5 cm, xe dng va xip mpt kiSu Goodwin, khau ndi hdi trang-bang quang trong ca the. Thdi gian mo: 430 phut (330-480). LTdc lugng mau mit: 500 mL (400-600). Hau phau: Cd nhu ddng rudt trd lai:
4 ngay; NSm vien sau md: 14 ngay (9-20). Benh nhan nam bi bi^n chiing ban tac rudt sau mo ngay hau phau 14, dieu tri bao tdn. Theo doi sau mo 3-4 thang (2 benh nhan): Co nang: mpt b?nh nhan nu" tieu ngay 1 gid 1 ldn, ti6u dem 4-5 Ian; benh nhan nam tieu ngky 4-5 lan, tieu dim 4-5 ikn. Khdng cd sdn ti6u ngay va dem. MSCT sau md (2 benh nhin): hinh dang va dung tich bkng quang cai thien. Benh nhan nii cd chiic nang than va ion dd mSu binh thudng.
Chup bang quang sau md d benh nhan nay thay dung tfch bang quang = 160 mL, hit ngugc ddng, nude tieu ton luu rat ft.
Ket luan: Qua 3 trudng hgp dau tien ciia chiing tdi cho thiy npi soi 6 bung l^m rdng bang quang bang hdi trang trong bang quang co nhd do lao la kha thi, an tdan, cd ket qua gan rat kha quan ve ca chiic nang va Mnh the dudng tieu ddng thdi da mang lai cho benh nhSn lgi fch cua phau thuat ft xam iin.
Tir khod: Ldm rgng bdng quang bdng hoi trdng qua NSOB; Bdng quang co nhd do lao;
Ngugc dong bdng quang niiu qudn
LAPAROSCOPIC AUGMENTATION ILEOCYSTOPLASTY FOR TUBERCULOUS CONTRACTED BLADDER: REPORT O F 3 INITIAL CASES ABSTRACT
Objective: Assess the feasibility and the safety of laparoscopic augmentation ileocystoplasty for tuberculous (TB) contracted bladder by our first 3 cases.
Materials and method: We present 3 cases of laparoscopic augmentation ileocystoplasty for TB contracted bladder initially performed in our centre.
Results: One male and two female patients, aged 58 (54-61). Preoperative bladder capacity:
43.33 mL (40-50). Associated urinary deformities: one female patient had left juxtavesical ureteric stricture, bilateral VUR; another female patient had right ureteric stricture, left nonfunctioning kidney and bilateral VUR; the male patient had left renal lithiasis, bilateral juxtavesical ureteric suictures and bilateral VUR. He also presented mild renal insufficiancy (creatinin= 122 ^mol/L). Two patients had previous left ureteral dilatation and one patient had
__Khoa Nieu C. Khu Dieu tri Ky thuat cao benh vien Binh Dan
" Khoa Tiei Nieu, benh vien Quan Y 175
Dia chi lien lac: TS.Nguyen Phiic c4m Hoang Email: [email protected] 500
nght ureteral dilatation with placement of the DJ stent. Operative technique: using 4 trocars, we performed laparoscopic augmentation ileocystoplasty: an ileal segment of 15-20 cm was isolated and extracorporealjzed through an enlarged incision of 4-5 cm at the umbilical port site. The ileal segment detubularized and made into a cup patch according to Goodwin.
Inh^corporeal vesico-ileal anastomosis. Operative time: 430 mins (330-480). Estimated blood loss: 500 mL (400-6(X)). Recovery period: recovery of bowel movements: 4 days;
postoperative hospital stay: 14 days (9-20). The male patient had complication of bowel semi- occlusion in day 14 post-op which was managed conservatively. Follow-up at 3-4 months post-op (2 patients).: Functional: one female patient had micturition every hour in day time, nocturia at 4-5 times; the male patient had 4-5 micturitions in day time and 4-5 micturitions in night time. Both did not have day time and night time incontinence. Postoperative MSCT (2 patients): improved bladder capacity and contour. The female patient had normal renal function and blood electrolytes. Retrograde cystography in this patient revealed a bladder capacity of 160 mL, without VUR, and insignificant RUV.
Conclusion: By our 3 initial cases we realize that laparoscopic augmentation ileocystoplasty for TB contracted bladder is feasible, safe, and have satisfactory short term functional and radiological outcomes. It may help to bring in advantages of MIS to our patients.
Key words: Laparoscopic Augmentation Ileocystoplasty; Tuberculous contracted bladder;
Vesica ureteral reflex (VUR) DAT VAN DE
Bang quang co nhd do lao la di chimg biln the dudng tieu ft gap trong lao nieu-sinh due"" va trong nhihig nam qua da dugc md tao hinh lam rpng bang hdi trang qua md md vdi ket qua trung binh* ' '. Hien nay, trong trao luu phlu thuat ft xam hai trong phlu thuat tao hinh dudng tiiu, mpt so tic gia nude ngdai da b^o cao mdt s6 tnrdng hgp thuc hi?n qua ngi soi d bung'^'^' \ Chiing tdi bao cao lai 3 trudng hgp dau tien tao Wnh iam rgng bang quang bang hdi trang qua ngi soi vira dugc thyc hien trong thdi gian vira qua.
BENH AN B^nh an 1
1. Benh nhan: Dinh Thi Tr., nir, sinh nam 1949 (59 tudi). Sd HS: 208/03923 Dia chi: P.7, Q.8, thanh phd Ho Chf Minh.
Ly do vao vien: dau ltmg trai, tiiu lat nhat
2. Lam sang: khdng cd trieu chiing dac hieu. Tien can: sdi nieu quan, ASA: II 3. Can ISm sang :
Si8u am: than phai va trai u nude dp I, nieu quan, bang quang: binh thudng
UIV: hep nieu quan (T) doanchau gay than (T) li nude dp II, chiic nang than (T) giam nhe; hi than (P) gian nhe, chiic nang tdt, bang quang co ve co nhd.
Chup bang quang co can quang: dung ti'ch bang quang = 40 mL, ngugc dong bang quang-nieu quan 2 ben dp III. (Hinh 3.A)
MSCT: bang quang co nhd, thanh day; than (T) li nude dp II, nieu quan lung gian, hep nieu quan dpan chau, chiic nang than (T) giam (Hinh 2.A).
•Rm vi khuan lao trong nude tiiu: CSy nude tieu tim BK: duang tfnh sau 60 ngay Phan irng PCR / nude ti6u (-)
Chiic nang than: US = 6,7 mmol/L ; Creatinin = 100 |imoI / L 4. Chin doan: Hep nieu quan chau (T), bang quang co nhd do lao 5. Dieu In
Nong nieu quan (T) bang may soi nieu quan, dat JJ Dimg thudc khang lao: 2SRHZ/ 6HE
Phlu thuat ngay 28/10/2008 (5 thang sau khi bat diu diiu uj thuoc lao)
Phuong phap phau thuat: Tao hinh Iam rgng bang quang bang hdi trang qua npi soi d bung.
Tu the benh nhan: nim ngiia diu thip (Trendelenburg)
Sd uocar: 4 (Hinh l.A.); ndi soi d bung trong phtic mac
Ky thuat mo: lam rgng bang quang bing hdi Uang (15 cm). Khau ndi rudt ngoai co thk qua dudng md rdng trocar dudi rdn 4-5 cm. Xe dng va glp rudt kilu "cup patch". Khong d m l?i 2 nieu quan. Khau ndi rudt-bang quang trong ca thi bang mdi khdu vdt
Thdi gian md: 480 phiit; Uac lugng mau mat: 400 mL Hau phau: Cd nhu dgng mgt: hau phau 4
Ngi soi bang quang dat JJ (T) ngay hau phlu 8
Riit dng thdng tieu ngay hau phau 9, nam vien sau mo: 9 ngay.
Hinh l.A. Npi soi o bung diing 4 trocar Hinh l.B. Phau thuait hoan th^nh Tdi khim sau md 4 thang: Tieu ngay 1 gid / 1 Ian ; tieu dem: 4 - 5 Ian / dim Khdng sdn tieu ngay va dem.
Chup bang quang cd can quang: dung tfch bang quang =160 mL, khdng cd ngugc ddng bang quang-nieu quan 2 ben, nude tieu tdn luu khdng dang ke. (Hinh 3.B)
MSCT sau md (cdn mang JJ Uai): 2 than cai thien rd vk chiic nang va Mnh the, bang quang tao hinh cd hinh dang bau due (Hinh 2.B).
Chiic nang than: US = 6,4 mmoI/L, creatinin = 106 (jmol / L
,Ion dd mdu: Na+ = 137 mmol/L ; K+ = 4 mmol/L ; CI- = 104 mmol/L; Ca ++ = 1,32 mmol/L; RA = 23,3mEq/L
TPTNT: 500 BC ; 50 HC
Vi khuan lao trong nude tilu am hda qua xet nghiem nhupm Ziehl
Hinh 2.A. MSCT cua BN Tr. tnrfrc mS Hinh 2.B. MSCT sau mo
ffinh 3.A. Chup bang quang cua BN Tr.truoc m6 Hinh 3.B. Chup bang quang sau m6 502
Benh an 2
1. Benh nhan: Luang Thai S., nam, sinh nam 1947 (61 tudi); So HS; 208/ 03890 Dia chi: Ham Tan, tinh Binh Thuan.
Ly do vao vien: dau lung (T) / sdi"th|in (T) 2. Lam sang: khdng co trieu chirng dac hieu. ASA : n 3. Can Iam sang :
Sieu Sm: than trai ir nude dp I, nieu quan, bang quang: binh thudng
UIV: hep nieu quan (T) doan chau gay than (T) ir nude do H, chiic nang than (T) giam nhe;
san thin (T) nhd, bang quang co ve co nhd.
Chup bang quang cd can quang: dung tfch bang quang = 50 mL, ngugc ddng bang quang-nieu quan 2 ben dp Il-in.
MSCT: bang quang co nhd; than (T) cam, nieu quan limg gian, hep nieu quan dgan chau, hep nieu quan chau (P) gay li nude than (P) do II (Hinh 4.A)
Tim vi khuln lao trong nude tilu: Tim BK true tilp (Ziehl): duang ti'nh 3/3 lln Chuc nang than: US = 5,6 mmol/L ; Creatimn = 122 jimol / L
ffinh 4.A. MSCT cua BN S. truwc mo EBnh 4.B. MSCT sau mo 4. Chan doan: San than (T), hep nieu quan chau (T) va (P), bang quang co nhd do lao, than (T) k^m chuc nang
5. Dieu tri:
Nong nieu quan (T) bing may soi nieu quan, dat JJ Diing thudc khang lao: 2SRHZ/ 6HE
Phlu thuat ngay 25/12/2008 (sau khi diit dilu tri lao I thang)
Phuang phap phlu thuat; Tao hinh iam rdng bang quang bang hdi trang qua npi soi 6 bung.
Sd trocar : 4 ; ndi soi d bung trong phuc mac
Ky thuat mo: Iam rpng bang quang bing hdi trang (20 cm) (Hinh 5.B), Khau ndi rupt ngoai ca thi qua dudng md rpng uocar dudi rdn 4-5 cm (Hinh 6.A). Xe dng va khau gap rudt kieu
"cup patch" (Hinh 6.B). Clm lai niiu quan (P) vao phin bang quang hdi trang (LeDuc) (ngoai ca tfie, cd dat thdng JJ). Khau ndi nigt-bang quang trong ca the bang mQi khdu vdt (Hinh 7) Thdi gian mo; 480 phiit ; Ude lugng mau mat: 600 mL
Hau phlu: Cd nhu ddng rudt: hau phlu 4.
Biln chung hap phau: ban tac rugt ngay hSu phau 14, dilu tri bao tdn
Riit dng thdng tieu ngay hau phau 18, nim vien sau md: 20 ngay.
Tai kham sau md 3 thang: Tieu ngay: 4 -5 Ian ; tieu dem: 4 - 5 lln / dem Khdng sdn tieu
MSCT sau md: than (P) cai thien ro ve chirc nang va hinh the (giam do ir nude), than (T) vln cam, bang quang tao hinh cd hinh dang trdn (Hinh 4.B).
Vi khuan lao uong nude tieu am hoa qua nhugm Ziehl va phan iing PCR
Smm ' Smm
l /
ffinh 5.A. Cach dat 4 trocar
ffinh 5.B. Doan hdi trang 15 cm dirge keo ra ngoai qua dirong md*
rgng trocar ron '^^
ffinh 6.A. Doan hoi trang duwc c6 lap va xe ong Chii y khong lam xoay, xo^n mac treo rugt' ^
Hinh 6.B. Khau gap ru^t thanh
"patch" hinh chir U™
Mnh 7: Khau noi ru9t-bang quang trong ca thS bang miii lihau vdt, "full thickness" " "
Benb an 3
l.Benhnhan: LeThi M... nil, sinlinam 1955 (54tu6i); S6 HS: 208/22525 Dja chi: P.3, Q.4, thanh ph6 H6 CM Minh.
Ly do vao vien: dau ha vi, tieu lat nhat
2. Lam sang: Idiong co trieu chirng dac hieu. TiSn can: ngi soi nieu quan (P), dat th6ng JJ vi hep nieu quan do lao, mo vo bang quang trong phuc mac, mo bang quang ra da, ASA: II 3. Can lam sang :
Sieu am: than (?) u nuoc do H, than (T) vt nuac do III, than (T) mAt cSu true chu m6.
Chup bang quang co can quang: dung tich bang quang = 40mL, ngugc dong bang quang-nieu quan 2 ben do IU. (Hinh 8A.)
504
MSCT: bang quang co nhd, thanh day; than (?) ir nude dd U, than (T) ir nude do III, than (T) cam (Hinh 8B.)
Tim vi khuan lao trong nude tilu: Cly nude tilu tim BK: duang tfnh sau 30 ngay Phan img PCR / nuac tilu (+)
Chirc nang than: US = 3,6 mmol/L ; Creatinine 105 p n i o l / L
Hinh 8.A. Chup bang quang cua BN M. trudc m l Hinh 8.B. MSCT ciia BN M. trudc md 4. Chan doan: Hep nieu quan chau (P), than (T) mit chiic nang, bang quang co nhd do lao 5. Dilu tri
Diing thudc khdng lao; 2SRHZ/ 6HE
Nong nieu quan (P) bang mdy soi nieu quan, dat JJ 6 tuin Phlu thuat ngay 5/8/2009 (sau khi dirt dieu tri lao 2 thang)
Phuang phap phlu thuat: Tao hinh Iam rdng bang quang bang hdi trang qua ngi soi 6 bung, elm lai nieu quan (P) vao phan bang quang hoi trang
Sd uocar: 4 ; ndi soi d bung trong phiic mac tien hanh gd dfnh rudt va gd dfnh bang quang vdi thanh bung (do md vd bang quang va md bang quang ra da)
Ky thuat md: lam rpng bang quang bing hdi uang (20 cm). Khau ndi rugt ngoai ca the qua dudng md rgng uocar dudi rdn 4-5cm. Xe dng va gap rudt kieu "cup patch" cdi bien.. Cam Iai nieu quan (P) vao phin bang quang hoi trang (ngoai ca the, dat JJ). Khau ndi ruOt-bang quang trong ca thi bang mHi khdu roi
Thdi gian md: 330 phut ; Ude lugng mau mat: 500 mL Hau phau: Cd nhu dgng rudt: hau phau 4
Rut dng thdng tieu ngay hau phlu 12, nim vien sau mo: 13 ngay.
Tdi kham sau md 1 thang: Tieu ngay 2 gid / 1 lan ; tieu dem: 3-4 lan / dem Khdng sdn tieu ngay va dim.
BAN LUAN
Bang quang co nhd do lao la di chiing it gap uong lao nieu sinh duc"^', nd cd the gap sau khi da ngung dieu tri thudc khang lao dudi dang di chiing ciia benh hoac uong thdi ky dieu tri lao tin cdng dudi dang xa hda do lanh seo (healing fibrosis) diln tien nhanh do tac dgng cua thudc khdng lao'^' . Trong nhieu nam qua chiing tdi da xii tri bang phlu thuat tao hinh lam rgng bang quang bing hdi uang qua md md'^^'"*'.
Chi dinh tao hinh lam rgng bang quang khi dung tfch bang quang < 100 mL*''^'^'^l Gupta'^' chu trucmg iam rdng bang quang khi dung tfch bang quang 30-150 raL, lam bang quang thay the thing (orthotopic neobladder) khi dung tfch bang quang < 30 mL va dung manh ghep da day khi cd suy than, dung dai uang sigma va hdi manh Uang khi cin elm Iai nieu quan vao bang quang tan tao.
Kinh nghiem cua chiing tdi Uong tao hinh bang quang bang rupt chi dilng hdi trang vi ky thuat kha de dang va quen thugc, sau md khdng thiy cd bien chiing rli loan nude dien giai*^'^'.
505
Ung dung trong phau thuat ndi soi dung hdi trang cung thuan tien khi chgn doan rudt va keo rupt ra ngoai ca thi. Trong 3 trudng hgp nay kh^u ndi rugt chiing tdi dung stapler nin khS nhanh chdng va thuan tien. Chiing tdi chu uuong khdng khau ndi rudt hoan toan bing npi soi''** vi ky thuat phirc tap va thay khdng cin thiet.
Trong uudng hgp diu chiing tdi khdng d m lai nieu quan vao bang quang vi ca diu tien lam phlu thuat ngi soi tao hinh bang quang. Thdi ky hau phlu chting tdi ndi soi bang quang dat JJ (T) vi cd hep nieu quan (T). Kit qua chup bang quang sau md khdng con ngugc ddng bang quang-nieu quan ca 2 ben. Trudng hgp thii hai than (T) da kem chuc nang, cd ngugc ddng va hep nieu quan chau (P) nen chiing tdi chi cam Iai nieu quan (P) vao bang quang tan tao. Cim lai nieu quan chiing toi diang ky thuat LeDuc vi da cd kinh nghiem trong loat tao hinh bang quang thay thl'^'. Ket qua MSCT sau md thiy than (P) cd cai thien ve hinh the va chiic nang.
Trudng hgp thii ba cd kha nhilu thach thiic vl ky thuSt: benh nhan da cd md viem phiic mac do vd bang quang trong phiic mac do dat thdng tieu, mang thdng md bang quang ra da, npi soi o bung phai tdch dinh rudt va tach dfnh bang quang vdi thanh bung truac. Trong md nhan thay bang quang chi cdn Iai phin tam giac nen phai ding ky thuat khau gap rudt "cup patch"
cai bien de phan rudt ndi vdi tam gidc bang quang thuc hien dugc (ndi hdi Uang-bang quang nhu trong bang quang thay the thang). Can biet rang day cdn la trudng hgp xa hda do lanh seo diln tien nhanh: bang quang co nhd chi sau 4 tudn dudi tac dung cua thudc khang lao tan cdng.
Ve CO nang Uong 2 trudng hgp diu cd theo doi xa, nhat la Uudng hgp thii hai, giam ban sd lan di tieu, benh nhan het tieu glp kem tieu dau, khdng sdn tieu. Trudng hgp dau lugng nude tieu tdn luu khdng ddng ke, kiem ua thang bang nude dien giai va kiem toan thay khdng cd roi loan gi. Tuy vay, thdi gian thea doi sau md con ngan han, can theo doi dM ban ve nhihig bien ddi ciia dung tfch bang quang, ngupc ddng bang quang-nieu quan va nhat la lugng nude tieu tdn luu va chiic nang than uong nhilu nara sau''^'.
Trong 8 U-udng hgp ciia Ngd Gia Hy''^* dng cd kit qua trung binh tren 7 trudng hgp (I trudng hgp tir vong do nhiem triing huyet). Ong cho ring phau thuat tao hinh chi Iam dd phin n^o nhirng rdi loan di tieu. Tac gia ky vpng vao phau thuat nay chii yeu Iam giam bdt hoac Ioai bo ngugc dong bang quang-nieu quan vdi ti le thanh cdng la 50%. Trong trudng hgp dau, tuy chiing tdi khdng cam lai nieu quan vao bang quang nhung cung khdng cdn ngugc ddng bang quang-nieu quan sau md.
Kerr va cdng su' Uong 12 trudng hop iam rdng bang quang bang rugt nhan manh phai cit het phan chdp bang quang trudc khi khau ndi vdi rudt de iam giam trieu chumg Ueu nhieu lln va iam giam lugng nude tieu tdn liru. Trong trudng hgp cd ngugc ddng bang quang-nieu quan dng khuyen cao diing hoi trang vdi elm lai nieu quan vao diu gin ciia quai rupt, dau xa quai rupt ndi vdi tam giac-cd bang quang. Kit qua rit tdt: chi 1 trudng hgp cdn di tilu nhilu lln, cac benh nhan khde cd thdi gian di tieu mdi 2-6 gid. Hai trudng hgp cd Iugng nude tilu tin luu ldm sau md, mpt trudng hgp benh nhan cd nhung ccm giam kali mau.
KET LUAN
Qua 3 trudng hgp dau tien ciia chiing tdi cho thay ndi soi I bung Iam rdng bang quang bing hdi uang Uong bang quang co nhd do lao la kha thi, an tdan, cd kit qua gin rit kha quan vl ca chirc nang va hinh the dudng tilu ddng thdi da mang lai cho benh nhan Igi fch ciia phlu thuat ft xam lln.
TAI LIEU THAM KHAO
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2 Cibert J.: La tuberculose renale sous Tangle de la therapeutique, Masson et Cie Ed., Paris, 1946
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company, pp. 729-34, 1998.
9. Johnson W. D., Johnson C. W., Lowe F. C . : Tuberculosis and parasitic diseases of the genitourinary system, Campbell's Urology, 8*ed., Vol.1, 743-63, 2002.
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11. Khader K., Lrhorfi M. H., el Fassi J., Tazi K., Hachimi M., Lakrissa A.: Tuberculose uro-genitale. Experience de 10 ans. Prog Urol, 11 (1), 62-67,2001
12. Ngo Gia Hy, Pham Van Biii, Vo Thi Hong Lien, Nguyen Phuc Cam Hoang: Mot vai sac thai dac biet ciia lao nieu sinh due va phSu thuat tao hinh duong tieu. Th&i sir Y duac hoc, Hgi Y dugc hgc TPHCM (5) 33-35, 1995.
13. Nguyin Phiic Cam Hoang, Dao Quang Oanh, Nguyin Van An; Nhihig thay doi ve sinh h6a va nuac dien giai tiBn benh nlian tao hinh bgng d^ bang rugt non. Sinh hogt KHKT BV Binh Dan (S),193-19S,\995-1996.
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15. jpsihramis K. E. and Donahoe P. K.: Primary genitourinary mberculosis: rapid progression and tissue destruction during treatment, J.Urol,\3S, pp.1033-6,1986.
16. Rackley R.R., Abdelmalak J, and Ross J.: Bladder Augmentation With or Without Urinary Diversion. Operative Urology at the Cleveland Clinic Edited by: A. Novick et al. © Humana Press Inc., Totowa, NJ, 264-272.
