肠代膀胱的尿动力学表现ppt课件.ppt

Urodynamic Urodynamic S Studytudy of of Enterocystoplasty andEnterocystoplasty and NeobladderNeobladder 沈沈 华华南京医科大学附属明基医院南京医科大学附属明基医院泌尿外科泌尿外科OverviewOverview2020世纪世纪8080年代中期前，很少采用肠道膀胱成形术，新膀胱术也年代中期前，很少采用肠道膀胱成形术，新膀胱术也没有成型。没有成型。临床上还没有意识到低的膀胱并发症的重要性，在晚期膀胱癌临床上还没有意识到低的膀胱并发症的重要性，在晚期膀胱癌的治疗中回肠膀胱仍然是的治疗中回肠膀胱仍然是“金标准金标准”方法，但回肠膀胱却显示方法，但回肠膀胱却显示存在较高的后期并发症。存在较高的后期并发症。从社会心理学观点来看，采用外部集尿器会影响患者获得满意从社会心理学观点来看，采用外部集尿器会影响患者获得满意的生活质量。的生活质量。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logo从从2020世纪世纪8080年代开始，神经原性膀胱已经成为肠道膀胱成形术年代开始，神经原性膀胱已经成为肠道膀胱成形术的相对适应证，而如今主要由于采用间断自家导尿来排空膀胱的相对适应证，而如今主要由于采用间断自家导尿来排空膀胱的方法被广泛接受，神经原性膀胱患者成为施行膀胱成形术的的方法被广泛接受，神经原性膀胱患者成为施行膀胱成形术的最重要人群。最重要人群。肠道膀胱成形术在难治性逼尿肌过度活动及低顺应性膀胱患者肠道膀胱成形术在难治性逼尿肌过度活动及低顺应性膀胱患者中是一种安全有效的方法，但对难治性间质性膀胱炎患者效果中是一种安全有效的方法，但对难治性间质性膀胱炎患者效果不佳。不佳。可控尿流改道和新膀胱已经成为膀胱癌膀胱全切后的一种经典可控尿流改道和新膀胱已经成为膀胱癌膀胱全切后的一种经典的改道方式，在高危的膀胱癌患者中回肠膀胱仍是主要的改道的改道方式，在高危的膀胱癌患者中回肠膀胱仍是主要的改道方式。方式。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logo肠道成行手术和新膀胱的目的在于形成一个低压、高容量的储肠道成行手术和新膀胱的目的在于形成一个低压、高容量的储尿囊，储尿囊的排空或依靠间断自家导尿尿囊，储尿囊的排空或依靠间断自家导尿(intermittent(intermittent catheterization)catheterization)，或排尿反射，或排尿反射(activation of the(activation of the micturition reflex)micturition reflex)，或腹压排尿，或腹压排尿(straining)(straining)。(Case 1(Case 1、2 2、3)3)新膀胱的手术方法很多。偶尔情况下，当膀胱癌患者施行较大新膀胱的手术方法很多。偶尔情况下，当膀胱癌患者施行较大范围的膀胱部分切除术时可进行膀胱扩大成形。范围的膀胱部分切除术时可进行膀胱扩大成形。(Case 6)(Case 6)当不能通过尿道间断导尿时，带可控的能导尿的输出道的尿流当不能通过尿道间断导尿时，带可控的能导尿的输出道的尿流改道方式是一种选择，但有时合并症较明显。施行膀胱扩大手改道方式是一种选择，但有时合并症较明显。施行膀胱扩大手术的患者若不能经尿道导尿时也可做可控的输出道。术的患者若不能经尿道导尿时也可做可控的输出道。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoUrodynamic Findings in Orthotopic Ileocecal and Ileal Urodynamic Findings in Orthotopic Ileocecal and Ileal NeobladderNeobladder南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoComparison of Clinical and Urodynamic Outcome in Comparison of Clinical and Urodynamic Outcome in Orthotopic Ileocecal and Ileal Neobladder.Orthotopic Ileocecal and Ileal Neobladder.Europeon Urology,2003,43(3):258-262.Europeon Urology,2003,43(3):258-262.Case 1 Case 1 3535岁女性脊髓多发性硬化患者，岁女性脊髓多发性硬化患者，7 7年前因难治性逼尿肌年前因难治性逼尿肌-外括约外括约肌协同失调肌协同失调(DESD)(DESD)施行回肠膀胱扩大成形术。施行回肠膀胱扩大成形术。她每日导尿她每日导尿4 4次，并且能控尿。次，并且能控尿。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogovAugmentationAugmentation enterocystoplasty in a 35-year-oldenterocystoplasty in a 35-year-old woman woman with exacerbating,with exacerbating,remittingremitting multiple sclerosis who multiple sclerosis who underwentunderwent the operation 7 years earlier becausethe operation 7 years earlier because of of refractory detrusor-externalrefractory detrusor-external sphincter dyssynergia sphincter dyssynergia(DESD).(DESD).vSheShe is on intermittent catheterizationis on intermittent catheterization 4 times a day 4 times a day and remainsand remains continent.continent.南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoUrodynamic tracing shows and acontractile Urodynamic tracing shows and acontractile bladder with a capacity of over 750ml,FSFbladder with a capacity of over 750ml,FSF435ml,1435ml,1stst urge urge650ml,severe urge650ml,severe urge750ml.750ml.南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoX-ray obtained at X-ray obtained at 550ml.550ml.Case 2 Case 2 4343岁女性，难治性特发性膀胱过度活动症岁女性，难治性特发性膀胱过度活动症(OAB)(OAB)。患者于患者于1818个月前施行回肠膀胱扩大术。个月前施行回肠膀胱扩大术。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogovUrodynamic study in a 43-year-old woman who Urodynamic study in a 43-year-old woman who underwent ileal augmentation cystoplasty 18 months underwent ileal augmentation cystoplasty 18 months earlierearlier because of refractory idiopathic overactive because of refractory idiopathic overactive bladder(OAB).bladder(OAB).南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoUrodynamic study:FSF=415ml,1Urodynamic study:FSF=415ml,1stst urge=574ml,and severe urge=574ml,and severe urge=600ml.urge=600ml.Pressure flow study:Qmax=8ml/s,PdetQmax=43cmHPressure flow study:Qmax=8ml/s,PdetQmax=43cmH2 2O,O,Pdetmax=54cmHPdetmax=54cmH2 2O,voided volume=216ml,PVR=975ml.O,voided volume=216ml,PVR=975ml.After the catheter was removed,in the privacy of After the catheter was removed,in the privacy of the bathroom,she voided to completion with a bell the bathroom,she voided to completion with a bell shaped curve and Qmax=25ml/s.shaped curve and Qmax=25ml/s.VOID:25/462/200.VOID:25/462/200.This corresponds to a mild grade 1 urethral This corresponds to a mild grade 1 urethral obstruction on the Blaivas-Groutz nomogram.obstruction on the Blaivas-Groutz nomogram.南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoCase 3 Case 3 5454岁男性患者，岁男性患者，2 2年前因浸润性膀胱癌行年前因浸润性膀胱癌行StuderStuder回肠新膀胱回肠新膀胱术。术。患者白天每患者白天每4 46 6小时用腹压排尿小时用腹压排尿1 1次，夜间不排尿，有时有次，夜间不排尿，有时有遗尿，但否认其他的下尿路症状遗尿，但否认其他的下尿路症状(LUTS)(LUTS)。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogovIleal neobladder.This is a 54-year-old man 2 years Ileal neobladder.This is a 54-year-old man 2 years status post ileal(studer)neobladder for invasive status post ileal(studer)neobladder for invasive bladderbladder cancer.cancer.vHe voids by,straining,about every 4He voids by,straining,about every 4 6 hours during 6 hours during the day and does not have nocturia.He has the day and does not have nocturia.He has occasionaloccasional enuresis,but denies any other lower enuresis,but denies any other lower urinary tract symptoms(LUTS).urinary tract symptoms(LUTS).南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoUrodynamic Urodynamic tracing.tracing.FSF=559ml,FSF=559ml,1 1stst urge=1028ml,urge=1028ml,severe severe urge=1297ml,and bladder capacity=1311ml.urge=1297ml,and bladder capacity=1311ml.The The electromyography electromyography(EMG)(EMG)channel channel was was not not working working properly during this study.properly during this study.南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoUroflow without the catheter shows Uroflow without the catheter shows a straining pattern.a straining pattern.南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoStraining to Straining to void.void.Case 4 Case 4 6262岁男性患者，施行保留神经的膀胱前列腺切除术，采用岁男性患者，施行保留神经的膀胱前列腺切除术，采用StuderStuder方法重建回肠新膀胱。方法重建回肠新膀胱。患者按计划大约每天排尿患者按计划大约每天排尿6 6次，从来没有排尿感。次，从来没有排尿感。白天及夜间均无尿失禁。白天及夜间均无尿失禁。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogovStuder neobladder:62-year-old man status post nerve Studer neobladder:62-year-old man status post nerve sparing cystoprostatectomy and construction of ileal sparing cystoprostatectomy and construction of ileal neobladder with Studer limb.neobladder with Studer limb.vHe voids about 6 times a day,by design,but never He voids about 6 times a day,by design,but never senses an urge to void.senses an urge to void.vHe is never incontinent,day or night.He is never incontinent,day or night.南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoCystogram obtained 3 weeks Cystogram obtained 3 weeks postoperatively with 100ml postoperatively with 100ml in the bladder.in the bladder.Straining to Straining to void.void.Case 5 Case 5 南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logov另一新膀胱患者另一新膀胱患者3 3年后尿动力学检查图：年后尿动力学检查图：In the filling phase of the study,he did not perceive In the filling phase of the study,he did not perceive the urge to void,but felt a vague fullness beginning the urge to void,but felt a vague fullness beginning at about 900ml.He voided voluntarily by marked at about 900ml.He voided voluntarily by marked abdominal straining at a bladder volume of about 1l.abdominal straining at a bladder volume of about 1l.Qmax=11ml/s,voided volume=492ml,and PVR=510ml.Qmax=11ml/s,voided volume=492ml,and PVR=510ml.南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoA magnified view during A magnified view during voiding.voiding.南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoX-ray obtained during X-ray obtained during uroflow.uroflow.南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoUroflow obtained prior to the urodynamic Uroflow obtained prior to the urodynamic study show a very different pattern than study show a very different pattern than that seen during the study.VOID:13/333/0.that seen during the study.VOID:13/333/0.Case 6 Case 6 8787岁男性患者，因膀胱移行细胞癌岁男性患者，因膀胱移行细胞癌(T(T2 2N N0 0M M0 0)施行施行“膀胱部分切除膀胱部分切除术术+膀胱扩大术膀胱扩大术”。术后术后6 6个月出现双侧膀胱输尿管反流及无症状性逼尿肌过度活动。个月出现双侧膀胱输尿管反流及无症状性逼尿肌过度活动。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogovBilateral vesicoureteral reflux(VUR)and asymptomatic Bilateral vesicoureteral reflux(VUR)and asymptomatic detrusor overactivity in an 87-year-old man 6 months detrusor overactivity in an 87-year-old man 6 months status post partial cystectomy and augmentation status post partial cystectomy and augmentation cystoplasty for transitional cell carcinoma of the cystoplasty for transitional cell carcinoma of the bladder(T2,N0,M0).bladder(T2,N0,M0).南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoUrodynamic study:There are multiple low Urodynamic study:There are multiple low magnitude involuntary detrusor contractions magnitude involuntary detrusor contractions during bladder filling that do not result in during bladder filling that do not result in incontinence.incontinence.FSF=750ml,1FSF=750ml,1stst urge=950ml,severe urge=1001ml,urge=950ml,severe urge=1001ml,PVR=850mlPVR=850ml。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany LogoCase 7 Case 7 6868岁男性患者，因膀胱癌在本院行岁男性患者，因膀胱癌在本院行“全膀胱切除全膀胱切除+Sigma+Sigma直直肠膀胱术肠膀胱术”。术后半年行尿动力学检查。术后半年行尿动力学检查。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logo南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logo尿动力学检查显示：尿动力学检查显示：FSF=110mlFSF=110ml，1 1stst urge=235ml urge=235ml，severe severe urge=465mlurge=465ml。灌注至。灌注至180ml180ml、220ml220ml、254ml254ml时患者出现少量漏尿。时患者出现少量漏尿。灌注过程中代膀胱压力与腹压同步上升，至灌注过程中代膀胱压力与腹压同步上升，至465ml465ml时嘱其排尿，时嘱其排尿，排出尿量排出尿量=284ml=284ml。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logo排尿期图形：排尿期图形：Qmax=74.2ml/sQmax=74.2ml/s，达峰时间达峰时间=4s=4s。Case 8 Case 8 5959岁女性患者，三年前因膀胱癌在外院行岁女性患者，三年前因膀胱癌在外院行“全膀胱切除全膀胱切除+原位原位新膀胱术新膀胱术(具体不详具体不详)”。因外伤后尿失禁入院，一周后好转，行尿动力学检查。因外伤后尿失禁入院，一周后好转，行尿动力学检查。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logo南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logo尿动力学检查显示：尿动力学检查显示：FSF=362mlFSF=362ml，1 1stst urge=415ml urge=415ml，灌注，灌注至至421ml421ml时患者出现漏尿。时患者出现漏尿。南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logo排尿期图形：排尿期图形：Qmax=19.4ml/sQmax=19.4ml/s，达峰，达峰时间时间=22s=22s。Review Review 南京医科大学附属明南京医科大学附属明基医院泌尿外科基医院泌尿外科Company LogoCompany Logo1 1腹腹压压排排尿尿2 2排排尿尿反反射射3 3自自家家导导尿尿肠代膀胱的排尿方式肠代膀胱的排尿方式肠代膀胱的排尿方式肠代膀胱的排尿方式南京医科大学附属明基医院南京医科大学附属明基医院泌尿外科泌尿外科后面内容直接删除就行后面内容直接删除就行资料可以编辑修改使用资料可以编辑修改使用资料可以编辑修改使用资料可以编辑修改使用主要经营：网络软件设计、图文设计制作、主要经营：网络软件设计、图文设计制作、发布广告等发布广告等公司秉着以优质的服务对待每一位客户，做公司秉着以优质的服务对待每一位客户，做到让客户满意！到让客户满意！致力于数据挖掘，合同简历、论文写作、致力于数据挖掘，合同简历、论文写作、PPTPPT设计、计划书、策划案、学习课件、各设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求类模板等方方面面，打造全网一站式需求The user can demonstrate on a projector The user can demonstrate on a projector or computer,or print the presentation or computer,or print the presentation and make it into a film to be used in a and make it into a film to be used in a wider fieldwider field