Objective: To optimize the surgical procedures of laparoscopic radical cystectomy and urinary diversion for the elderly patients with bladder cancer, generalize operating technique, summarize clinical experiences. Methods: From July 2004 to October 2016, laparoscopic radical cystectomy (LRC) and urinary diversion was performed in 68 elderly patients (≥75 years old) diagnosed with bladder cancer in urology department of Beijing Chaoyang Hospital, Capital Medical University, and the relevant clinical and follow-up data were retrospectively reviewed. All the patients were pathologically diagnosed and their perioperative data, postoperative pathological results, postoperative complications and follow-up outcomes were recorded and analyzed. Results: Among 68 elderly patients with bladder cancer, fifty patients were male and 18 were female, the age of whom were (79±4) (range 75 to 91) years old. The Charlson comorbidity index (CCI) score was 6±1 (range 5 to 7). All the 68 operations were successfully performed without conversion to open surgery. There were 26 cases receiving cutaneous ureterostomy, 34 cases receiving ileal conduit (intracorporeal for 16 cases and extracorporeal for 18 cases) and 8 cases receiving orthotopic ileal neobladder (intracorporeal for 4 cases and extracorporeal for 4 cases; Xing's technique for 4 cases, T-Pouch for 2 cases and Studer-Pouch for 2 cases) respectively, and the operation time of these three groups were (221±47) min, (315±70) min and (358±90) min respectively, the estimated blood loss were 100 (87, 200)ml, 300 (250, 500) ml and 250 (113, 725) ml respectively, the time of intake of liquid diet were 3 (2, 4) d, 6 (5, 7) d and 9 (5, 12) d respectively, and the postoperative hospital stay were (12±6) d, (24±11) d, and (27±11) d respectively. Postoperative pathological results showed urothelial carcinoma in 64 patients, squamous cell carcinoma in 2 patients and adenocarcinoma in 2 patients. Sixty patients received laparoscopic pelvic lymphadenectomy and the number of dissected lymph nodes was 17.1±7.0. There were 46 cases with T stage greater than or equal to T2 (46/68, 67.6%), 4 cases of low grade (4/68, 5.9%) and 60 cases of high grade (60/68, 88.2%). All the early postoperative (within 30 days after the operation) complications were grade Ⅰ-Ⅱ mainly manifested as fever, pain and infection that could get better with symptomatic treatment, and the incidence rate were 30.8% for cutaneous ureterostomy, 29.4% for ileal conduit and 37.5% for orthotopic ileal neobladder. The patients were followed up for a median period of 93.5 months without obvious hydronephrosis and impaired renal function. The 5-year cancer specific survival rate and overall survival rate were 57% and 50% respectively. There was significant difference between the preoperative and postoperative QOL (quality of life) score (56.0±10.0 and 47.4±5.8 respectively, P<0.05) which indicated that the patients' postoperative quality of life was greatly improved. Conclusions: Laparoscopic radical cystectomy and urinary diversion for the elderly patients with bladder cancer is safe and feasible, and owns great therapeutic value.
目的： 优化高龄膀胱癌患者行腹腔镜根治性膀胱切除加尿流改道术的手术步骤，归纳手术技巧，总结临床经验。 方法： 回顾性分析2004年7月至2016年10月于首都医科大学附属北京朝阳医院泌尿外科接受腹腔镜下根治性膀胱切除加尿流改道术的68例高龄膀胱癌患者（≥75岁）的临床及随访资料。所有患者术前均经病理学确诊为膀胱癌。记录并分析患者围手术期资料、术后病理、术后并发症及随访结果等。 结果： 68例高龄膀胱癌患者中，男50例，女18例。年龄75~91（79±4）岁。Charlson合并症指数（CCI）评分5~7（6±1）分。手术均顺利完成，无中转开放。输尿管皮肤造口26例，回肠通道术34例（完全腹腔镜16例，小切口辅助18例），原位回肠新膀胱术8例（完全腹腔镜4例，小切口辅助4例；邢氏新膀胱4例、T型回肠新膀胱2例、Studer回肠新膀胱2例），3组手术时间分别为（221±47）min、（315±70）min、（358±90）min；术中出血量分别为100（87，200）ml、300（250，500）ml、250（113，725）ml；恢复进食时间分别为3（2，4）d、6（5，7）d、9（5，12）d；术后住院时间分别为（12±6）d，（24±11）d，（27±11）d。术后病理64例患者为尿路上皮癌，2例鳞癌，2例腺癌。60例患者行盆腔淋巴结清扫，平均清扫（17±7）个。T分期≥T2的患者46例（46/68，67.6%），低级别4例（4/68，5.9%），高级别60例（60/68，88.2%）。术后早期（术后30 d内）并发症均为Ⅰ~Ⅱ级，发生率分别为30.8%（输尿管皮肤造口）、29.4%（回肠通道）、37.5%（原位回肠新膀胱），主要为发热、疼痛、感染，给予对症处理后好转。中位随访时间93.5个月，患者无明显肾积水及肾功能受损，5年肿瘤特异性生存率和总体生存率分别为57%和50%。术前生活质量评分56±10，术后为47±6，差异有统计学意义（P<0.001），患者术后生活质量明显提高。 结论： 腹腔镜根治性膀胱切除加尿流改道术在高龄膀胱癌患者是安全可行的，具有较大的治疗价值。.
Keywords: Age; Cystectomy; Laparoscopes; Urinary bladder neoplasms; Urinary diversion.