Nghien cmi Y hpc '^ Hpc TP. Ho Chi Minh * Tap 18 * Sb 1 * 2014
TAO HINH BANG QUANG TAN TAO TRONG NOI SOI 6 BUNG CAT BANG QUANG TAN GOC
Nguyin Tiai De*, VU Li Chuyen*, Trdn Ngoc Khac Linh*, Trdn Thanh Nhdn*, Chung Tuan Khiem*
T O M T A T
Dat van ^: Plidu thuqt cat bdng quang tan got Id dieu tri diiimi cho nhirng trudng hop ung thu bdng quang te'bdo chuyen tiep xdm Idii lap ca. Phdu thudt de diuyai luu nu&c tiai Id mgt bir&c ketiep hit buoc sau
^mu thuqt cdt bdng qumig tan goc.
Muc tieu nghien ciiu: Ddnh gid kii qud ciia phdu thudt tqo hirdi bang quang tdn tqo sau ph&u thuqt noi soi obung cdt bang quang tdn gm: tqi Binh viin Binh Dm
Dot tugng & pltuong phdp nghien ciiu: Nghiin cuu tiai cieu tren cdc trudng hop co dti diidi ph&u thuqt ngi soi obung cdt bdng quang tdn goi: vd chuyai lieu nuac tiai bang mot tqi Benh vien Binh D&n tie t/imig 10/2007 dat thdng 5-2013.
Kii qud nghiin cdu: Co tong cgng 14 tnecnig hap, trong do da so cdc trudng hgp Id nam, tuoi trung binh Id 56,8 tuoi. Chan dodn trudc ph&u thuqt a giai doqn T2-3a trong 100% trucmg hgp, 50% co dd biit hoa vira vd 35,7% co dg biet hoa kem. Co 6 trudng hgp (42,9%) tqo hinh bdng quang tnec zn qua dudng mo nho 5-6 cm tren vd dudi roh vd 1 trudng hgp bang ngi soi todn bg. Chuyai luu Bricker qua dudng mo nho dugc thuc hien tren 3 tnrdng hgp (21,4%). Thdi gian phdu thuqt tning binh Id 363,2 phut, lugng mdu mdi trong mo Id 607,1 ml. Ti li truyen mdu trong phau diudt Id 42,9%. Thdi gian cdt bdng quang trung binh khodng 148 phut. Benh nhdn bat dau dn lai trung binh vdo ngdy hdu phdu thie 4. Cdc ohg dan luu dugc nit vdo ngdy hdu ph&u trung binh 9,7. Tlidi gian nam mat trung binh Id 10,3 ngdy. Cdc dan lieu rut todn bg sau trung binh 15,3 ngdy. Khong co trudng hgp tac ruot hau ph&u. Trung binh gidm dau tinh mqch trong 4 ngdy hau ph&u dau tien. Bieii chieng hdu ph&u cd 3 tneimg hgp cbn rb nude tieu keo ddi trin 10 ngdy qua dan luu. Ty le ude tinh song khong ung thu sau 5 nam Id 75%.
Kei ludn: Plidu thuqt ngi soi d'bung cdt bdng quang tan goc Id phiecmg phdp lua chgn an todn zm hieu qud tho cdc tnrcmg hop bu&u bdng quang xdm Imi lap ca sdu hoqc budu tdi phdt iihmi lan co do dc cao.
Tii khoa: Tqo hinli bang quang tdn tqo, phdu thuqt cat bdng quang tdn goc, chuyai liru nu&c tieii bang rugt, A B S T R A C T I
NEOBLADDER SUBSTITUTION IN LAPAROSCOPIC RADICAL CYSTECTOMY Vu Le Q i u y e n , N g u y e n Tien De, T r a n N g o c Khac Linh,Tran T h a n h N h a n , C h u n g T u a n Khiem
' Y H o e T P . H o Chi M i n h * Vol. 1 8 - N o 1 - 2014:336 - 339
Introducticm: laparoscopic radical cystectomy is the standard treatmait of muscle-invasive bladder cancer.
Urinary diversion is the next imporiant step in order to re-establish the normally anatomical and physiological fiinction of urinary system.
Aims: to evaluate the results of neobladder substitiitiaii afier laparoscopic radical cystedomy in Binh Dan
Research Methods: zoe seleded tlie patients who have the indication cf radical cystedomy and ileal diversion fiom 10/2007 to 05/2003 in Biidi Dan hospital.
* Khoa Tiet ni?u B^nh vien Binh Dan.
Tdc gid lien lac. ThS.BS. Nguyen Tieii E>e DT: 0903622073 Email nKiivcndeI16@yahooo
Hpi Nghi Khoa Hpc Ky Thuat BV. Binh Dan 2014
Y Hpc TP. Ho Chi Minh * Tap 18 * So 1 * 2014 Nghien cmi Y hpc
Results: in total of 14 cases, 92.8% ivas represaited for male patiaits. The mean age zoas 56.8 years old.
Tlia-e were six cases zohich zoere pafonned cxti-acopa-cal ileal conduct and orthotopic bladder substitution and 1 case fall lap. Tlie mean operatwn time was 148 miniates. The boioel movement was recovered at day 3rd -4th post- operation. The drains were completely ranoved in day 9th post-operation. There were 3 cases with urine leakage, in zohich one needed the re-opration to coned the leakage According to Kaplan Meier suwial model, Biefiee cancer survival rate afier 5 year was approximately 75%.
Conclusion: laparocopic radical qistedomy for bladdei- canca is safe and effictizx technique.
Keywords: neobladder substitution, ileal diversion, radical cystectomy Fhuong phap tien hanh
Tu the benh nhan, vi tri dat trocar va tao khoang:
Chung toi dat tu 4 den 5 trocars (2 trocars 10mm, 2 trocars Smm) a cac \ i tri dudi ron, ho ehau 2 ben tao thanh hinh vong cung giiJa ron va gai chau truoc tren hai ben.
Nao hach ehau 2 ben.
Cat bang quang.
Phau thuat chuyeh luu nuoe tieu: theo 2 each Tai tao luu thong rupt bang Stapler kieu ben -ben.
Trong truong hop chuyeh luu nuoc tieu ra da (Bicker ho^c tiii Kock).
KET QUA D A T V A N D E
Phau thuat cat bang quang tan goc bao gom bang quang tuyen tien liet va tui tinh o nam hoac hi cung va phan phu a uH la dieu tri ehuah cho nhung truong hpp ung thu bang quang te bao chuyen tiep xam IMI iop co^'. C^n day, voi nhimg tien bo ve mat ky thuat lan hieu qua ve mat ung thu hpc trong phau tiiuat noi soi cat tien U?t tuyen, phau thuat npi soi 6 bung cat bang quang da dan dupe thye hi^n pho bien nhi^u noi tren The gidi. Mac dii eon co nhung hgn che ve thoi gian phau thu^t keo dai ciing nhu yeu cau ve kinh nghi?m phlu thuat vien, nhung ket qua ban dau da cho thay phau thuat npi soi nhiing uu diem nhu giam lupng mau mat trong phau thuat, giam dau h^u phau, hi?u qua tham my va thoi gian tro lai sinh hoat binh thudng sdm.
Chung toi thuc hien nghien cuu nham budc dau danh gia ket qua ciia phau thuat tao hinh bang quang tan tao sau phau thuat npi soi 6 bung cat bang quang tan goc tai Benh vi?n Binh Dan.
Doi tupng - phirong phap nghien cmx Thiei ki'nghien ahi
Mo ta hang loat truong hpp - tien cuu Thai gian thuc hien
Thang 10-2007 den 5-2013, Dot tuang nghien cuu
Benh iihan dupe chan doan budu bang quang xam lan Idp co {T2) tid len, chua cd dau hi^u xam lah ra ngoai bang quang hen ehah doan lam sang va giai phau benh trudc khi phau thuat cat bang quang tan goc.
Tu thang 10-2007 den 5-2013, cd 14 tirrdng hpp dupe phau thuat cat bang quang tan goc do ung thu bang quang tai khoa Nieu C benh vien Binh Dan.
Dac diem dich te va chan doan tnrac phau thuat
B^c d i e m i n=14) Tu6i trung binh (nam)
BMI trung binh Giffi Giai do^n Bi^t hoa (TCC)
Nam Ni>
T2 T3a Tot Tnjng binh
Kem
T m n g b i n h ± die S d c a 1 T y l # ( % )
56,8 ± 6,4 22,4 ± 1 , 0 13 1 11 3 2 7 5
92,9 7,1 78,6 21,4 14,3 50 35,7
Hgi Nghi Khoa Hpc Ky Thual BV. Binh Dan 2014
'Nghien cuu Y hpc \ Hpc TP. Hb Chi Minh * Tap 18 * So 1 * 2014
'hmmgphap p h l u thuat
P h i K u n g
>hap {n=14)
^ u y S n t i n i n u o c t i l u
Stapler qua flironq m6 nho S t a p l e r - n a soi loan bo Bang quang tan tao - qua
difOTtq mo nho Bang quang tan t a o - d u t m g m o n w c6 ( K n Chtjyen luu Bncker qua d i r o n g mo nho C h u y i n k j u t u Kock qua
d i / 6 n g m 6 n h 6 Bang qua>g tan tao - Ngi
Soi loan t>6 C h u y i n luu B r i c k e r - N p i
S o J t o a n b 6
S d t m v n g h p p
12 2 6 2 3 1 1 1
T y l e 85.7 14.3 42,9 14,3 21,4 7,1 7.1 7.1
C^ qua phau thuat
D i e iOem (n=14)
Thai gian cat banc Thcri gian cat va noi nipt (Stapler)
(phut)
Thai gian tao h i r ^ bang q u v t g tan tao (n=7)(phut)
quang (phut) Qua Noi Soi 6
Bung(n=1) Qua d i r a n g m d nho va c6 dien
(n=13) Qua Npi Soi 6
BMng(n=1) Qua di/cmg mo
nh6(n=6) TTKri gian k h i u n6i co bang quang
t i n tao - nieu flao (n=7) Tong thai gian PT (phiit) {n=14)
Mau mat (ml) Tnjyen mau t n x i g
PT
Co Khong
T n i n g b i n h ± dtc S d c a | T y l & ( %
147,8 ± 2 7 , 5 100 4 5 ± 3 2 , 1
120 88,3 ± 1 4 . 7 51,7 ± 1 3 , 7 363.2 ± 6 3 607,1 ± 373,6
6 8
42.9 57.1
P (95%)
0,05
0 , 0 5
Theo doi ket qua gan trong thai gian hau phau
Thdi qian n i m ICU (ngay) Ngay h | u p h i u nuoi an finh m^ch (ngay)
Thai gian qiam dau finh mach (ngay) Thoi gian njt d i n luu canh v l t mo (ngay)
Then gian njt thong n e u quan (ngay) T h a i gian lut thonq nieu flao (ngay) Thoi gian hit thono banq quang ra da (ngay)
Thcri T n i y e n m a u sau FT
[jian n i m vien (ngay) Co Khong
T m n g b i n h
± d l c S o ca
T y l e
(%)
1.1 ± 0 . 3 4.5 ± Z 5 3,9 ± 1 9.7 ± 5 5 15,5 ± 3 . 8 16.7 ± 3 , 5 26.4 ± 5 . 9 1 5 3 ± 6 . 1 1 11
8,3 91.7
E)ac d i e m {n=14)
Bien Chung hau p h i u
Tac Rjot [36 niicrc tieu tip bang quang
tan tao vao 6 bung XI nuwc t i u keo dai qua d i n
luu (>10 ngay) Tac ong dan luu nieu quan R6 ruot - am dao (benh nhan
nir)
T m n g b i n h i d l e S o ca 0 1 2 4 1
T y i e
(%)
0 7,1 14,3 28.6 7,1
BANLUAN
Cho den nay, phau thuat mo mo cSt bang quang I ^ goc van con la dieu tri chuan cho cac truong hpp buou bang quang xam lah lop co sau, tuy nhien day cung la phlu thuat co nhieu biCTi chiing nhat trong Tiet Nieu cho du voi phSu thuat xien kinh nghiem, mpt phan do nhihig nguyen nhan nhu duong mo dai kem tiioi gian cang keo lau, thoi gian t>pc 16 npi tang keo dai va
&m quan sat cac tang phii tiong vung chau c6 phan han che. Phau thuat npi soi ra doi nham khic phyc nhimg v ^ de tren ma khong anh huong den hieu qua ve mat ung tiiu hoc.
Phlu thuat npi soi cat bang quang kem tao hinh bang quang thay the la mpt phau thuat kho, cac ky thuat van con dang dupe chuah hoa, vi vay viec lua chpn benh tnroc mo dong vai tro rat quan trpng. Buoc dau, chiing toi lua chpn cac tniong hpp CO chan doan gitii doaui tnroc mo la T2b-3aNoMo \'a it benh phoi hpp khac di kem.
Tuy nhien, 6 cac tmng tam Nieu Khoa Ion, cac tac gia da thuc hien phau thuat npi soi cat bang quang tan goc tien cac tmong hpp ung thu xam lah tai di6 hoac di can hach (T3b-4NO-1MO) voi ket qua tuong duong voi mo mo sau 2 naml^.
Phmmg phap chuyen lini nuoc tieu Hien nay, chi dinh lua chpn phuong phap chuyeh luu nude tieu con phu tiiupc vao timg truong hpp cu the. Cac yeii to xem xet co the bao
^ m : giai doan va dp biet hoa, tuoi, tong trang benh di kem, gioi, tam li, vi tri ung thu va nieu dao di kem. Co the torn luoc mpt so nhom chinh nhu sau:
Hoi Nghi Khoa Hoc Ky Thuat BV. Binh Dan 2014
Y Hpc TP. Ho Chi Minh * Tap 18 * So 1 * 2014 Nghien cixu Y hpc
- Mo nieu quan ra da- day la hinh thuc chuyen luu ra da don gian nhat. Mac dii ty le bien ehung lien quan den phau fhuat mo nieu quan ra da thap hon phau thuat chuyen luu ra da bang rupt, nghien cuu cua cac tac gia cho thay phau thuat nay ve lau dai co ty le hep mieng noi nieu quan va nhiem trimg duong Tiet Ni^u tren cao hon so voi chuy§h luu bang rupt.
- Chuyen luu nuoc tieu ra da bang mpt - khong kiem soat: day la ky thuat duoc sir dung nhieu, tham chi la tren nhung b?nh nhan gia yeu va Ion tuoi. Tuy nhien, co den khoang 48% cac truong hpp la co bien ehung nhu: viem dai - be than, ro va hep mieng noi nieu quan - rupt theo ket qua nghien cuu cua Nieuwenhuijzen va cpng s\r. Ngoai ra, bien chimg xa thudng gap tren mieng noi len den 20% va kha nang tao soi ding thuong gap. Nghien cuu ciia chiing toi cho thay bien chiing thuong g|p nhat ciia chuyeh luu Bricker la nhiem trimg ni^u tai di tai lai {2/4 truang hpp).
- Chuyen luu nuoc ti^'u ra da bSng rupt - kiem soat: nhieu doan rupt dupe sir dung nhu da day, hoi manh trang d^ hang signma da dupe nhieu tac gia nghien cuu. Ty le kiem soat nuoc' tieu ngay va dem ciing tien 90% va ty le hep mieng tlii thap duoi 20%'i>.
- Tgo hinh bang quang tan tao true v\: day la ky thuat ngay cang dupe sir dung nhieu hon.
Doan rupt hoi - manh trang va doan cuoi hoi trang dupe sir dung nhieu nhat. Viec di tieu dupe thuc hien nho ap luc 6 bung nhu dpng rupt va su dan no ciia san ehau. Ti le tai bieh - bien ehung ehung o ca giai doan som va mupn vao khoang 22%, ti le tieu khong kiem soat ban ngay khoang 8-10%, tieu khong kiem soat ban
dem khoang 20-30%, hep cho cam nieu quan vao bang quang tir 3-18% va tieu khong het duoi 12%. Hon nira, tiong eung mot gia doan benh, nghien cuu cho thay vi^c lua chpn phuong phap chuyen luu nuoc tieu khong anh huong den ket qua ung thu hpc. Vi vay, phau thuat vien can lua chpn phuong phap chuyen luu nuoc tieu phu hpp nhat, trong do uu tien phuong phap tao hinh bang quang diing v\ tri va chuyen luu nuoc tieu CO kiem soat nham nang cao chat lupng song ciia b^nh nhan.
KETLUAN
Phlu thugt npi soi 6 bung eSt bang quang tan goe la phuong phap l\ra chpn an toan va hieu qua cho cac truong hpp buou bang quang xam lah lop co sau hoae buou tai phat nhieu Ian co dp ac cao. Tgo hinh bang quang tan tao tri^c vi hogc bang quang thay the ehuyen luu ra da theo nga ngoai 6 bung, qua duong m6' nho Ig phuong phap lya chpn an toan va hieu qua, co the ke thiia tot uu diem ciia phau thuat npi soi eSt bang quang.
TAI L l | U THAM KHAO
1 Abol-Enein H & G h o n a m MA (2001) Funchonal resulls of orthotopic ileal neobladder with serous-lined exlramuial ureteral reimplantation: experience with 450 patiaits, J Urol, 165(5), 1427-1432
2 Alonso y Gregorio S, Alvarez Maestro M, Cabrera Castillo PM. Tabemero Gomez A, C a n ^ o Alcaide R, Gsneros Ledo J, De la Pena Barthd J) (2008) Laparoscope urinary dlveraons.
A d a s Urol Esp, 32(9), 908-915.
3 Aitm M Colombo JR, Jr, Haber GP, Campbell SC & Gill IS (2007) Laparoscf^ic radical cystectomy. BJU Inl, 100(2), 455-
Ngdyiibgn bdibdo:
Ngay phdn bien nhdn xet bdibdo:
Ngdy bdi bdo dugc dang-
05/11/2013 02/12/2013 20/02/2014
Hgi Nghi Khoa Hpc Ky Thuat BV. Binh Dan 2014
