1 T VN U bng quang l mt bnh thng gp cỏc loi u ca h tit niu Tn sut bnh gp nam gii nhiu hn n gii, bnh gp nhiu cỏc nc cụng nghip phỏt trin nh cỏc nc Tõy u, M M nm 1995, theo Boring v cng ss ngi mc mi mi nm l 50.500 ngi, cht 11.200 ngi (nam: 7.500 ngi, n: 3.700 ngi) Nm 1998, cú 54.000 ngi mc bnh u bng quang v 12.500 ngi ó cht, n nm 2005 cú 63.210 ngi mi mc bnh UBQ v 13.000 ngi cht vỡ bnh ny[1][2] a s ung th bng quang xut phỏt t t bo biu mụ chuyn tip (98%), ú 90% l biu mụ chuyn tip ng bi tit, 6% biu mụ vy, 2% t bo biu mụ tuyn 2% cũn li l ung th ca t chc liờn kt[3] Vit Nam, s ngi b mc bnh u bng quang cú xu hng tng cao theo mc phỏt trin ca cụng nghip nht l cụng nghip hoỏ cht, ch bin cao su U bng quang phỏt trin theo cỏc giai on khỏc Khi u cũn giai on (Tis-Ta-T1), t bo u cha phỏt trin qua lp mng ỏy (Lamina propria), vic iu tr u n gin, mang li hiu qu cao qua phng phỏp ct ni soi qua niu o, hoc phi hp vi bm BCG vo bng quang hoc hoỏ cht Nhng u ó phỏt trin qua lp mng ỏy, sang giai on T2-T3thỡ vic iu tr phc hn nhiu v kt qu iu tr cng kộm u cng phỏt trin sõu vo cỏc giai on T3-T4 Trong cỏc giai on ny, phu thut ct bng quang rng rói v trit c coi l chun vng, c thc hin mt cỏch thng qui ti nhiu trung tõm trờn th gii Phu thut ct bng quang ton b l mt phu thut ln: bao gm ct b bng quang, tuyn tin lit, tỳi tinh nam gii, hoc ct ht lp m quanhbng quang v cung mch, cựng vi no vột hch chu, bng quang, niu o, t cung, bung trng, vũi trng v mt phn õm o n gii vi lyht lp m quanh bng quang v cung mch, cựng vi no vột hch chu Sau ct b bng quang, vic chuyn lu dũng nc tiu ó c nhiu tỏc gi trờn th gii nghiờn cu v phỏt trin theo hng: to mt bng quang thay th bng rut hoc chuyn lu dũng nc tiu ngoi giỏn tip hay trc tip, theo cỏc phu thut Bricker, a niu qun ngoi da [4] Ct bng quang ton b l mt phu thut phc cú nhiu bin chng, (khong 35%) T l t vong khong 5% giai on u, vo nhng thp k 60-70 th k XX; dn dn nh nhng tin b v phu thut v gõy mờ hi sc, nờn ngy t l bin chng gim cũn 10% v t l t vong 2% Ti bnh vin Vit - c s lng bnh nhõn iu tr u bng quang ngy cng tng,trong 10 nm (1982-1991) cú 211 trng hp u bng quang c iu tr, thỡ nm sau (1992-1996) ó cú 255 trng hp mc mi v nm (2000-2002) ó iu tr phu thut cho 427 bnh nhõn u bng quang, ú 51,75% l u tỏi phỏt v 48,25% l u mi phỏt hin, chim t l cao nht cỏc loi ung th ng tit niu, ú phu thut ct bng quang ton b v to hỡnh bng quang bng rut ó c ỏp dng v mang li kt qu tt cho nhiu bnh nhõn Tuy nhiờn cha cú nghiờn cu no i sõu nghiờn cu ỏnh giỏ kt qu c th, lõu di ca phu thut ny [5] Xut phỏt t thc t nghiờn cu iu tr nc cng nh trờn th gii, chỳng tụi nghiờn cuthc hin ti: ỏnh giỏ kt qu tohỡnh bng quang bng rut non sau ct bng quang ton b ung th ti Bnh Vin Vit c nhm cỏc mc tiờu sau: ỏnh giỏ kt qu phu thut to hỡnh bng quang bng rut sau ct bng quang ton b ung th ti Bnh Vin Vit c t 2009-2015 ỏnh giỏ kt qu phc hi chc nng bng quang rut sau phu thut to hỡnh bng quang bng hi trng ti Bnh Vin Vit c Chng TNG QUAN 1.1 S LC GII PHU BNG QUANG 1.1.1 Gii phu bng quang[6], [7] Bng quang l mt tng rng nm ngoi phỳc mc. ngi trng thnh v khụng cú nc tiu, bng quang nm hon ton phn trc ca vựng chu hụng, phớa trc bng quang l xng mu, phớa sau l trc trng, cỏc tng sinh dc, phớa di l honh chu, phớa trờn l cỏc tng rng phỳc mc Hỡnh th bờn ngoi ca bng quang thay i ph thuc vo s lng nc tiu c cha bờn Khi cha mt lng nc va phi, bng quang cú hỡnh t din vi mt: mt trờn, mt sau v mt di - bờn Khi cng y, bng quang cú hỡnh cu Hỡnh 1.1:Thit ct dc chu hụng n[7] Hỡnh 1.2:Thit ct dc chu hụng nam[7] Bỡnh thng, dung tớch bng quang khong 250ml - 350ml Trong mt s trng hp bnh lý, dung tớch bng quang cú th tng ti hng lớt hay gim ch cũn vi chc mililit Lũng bng quang c che ph bi mt lp niờm mc cú mu hng nht Bng quang c ni thụng vi b thn bi niu qun Hai l niu qun to vi c bng quang mt tam giỏc, gi l tam giỏc bng quang (trigone) ng g cao ni l niu qun l g liờn niu qun, mt mc gii phu quan trng tỡm l niu qun phớa di, bng quang c m thụng ngoi bng niu o nam gii, niờm mc niu o tuyn tin lit v niờm mc bng quang cú cựng bn cht * Liờn quan: + Vi phỳc mc: Mt trờn v phn trờn ỏy bng quang c phỳc mc che ph phớa sau Phỳc mc sau ph lờn bng quang s ph lờn t cung ( n) hoc tỳi tinh ( nam) to nờn tỳi bt bng quang sinh dc + Vi cỏc tng lõn cn: Mt trờn: Liờn quan vi rut non v i trng sigma, n cũn liờn quan vi thõn t cung bng quang trng thỏi rng Trong ct u bng quang ni soi qua niu o, nu thng bng quang ti v trớ ny s thụng bng quang vo bng v cú th lm tn thng rut Mt sau: Bng quang liờn quan vi tỳi tinh, ng dn tinh v trc trng (nam gii), vi thnh trc õm o, c t cung (n gii) Tn thng thng bng quang ti v trớ ny cú th tn thng trc trng, bin chng him gp ct ni soi u bng quang qua niu o Hai mt di - bờn: Liờn quan vi xng mu, khp mu v ỏm ri tnh mch bng quang m ch yu l khoang sau xng mu bờn, liờn quan ti h bt v dõy thn kinh bt Khi ct u bng quang ni soi v trớ mt bờn, nht l phớa di rt hay kớch thớch dõy thn kinh ny v gõy hin tng git chõn m 1.1.2 Mụ hc bng quang[6] Cu to bng quang c chia lm lp: + Lp ngoi cựng l lp t chc liờn kt (Tunica adventila) + Lp gia l c (Tunica muscularis), gm c dc ngoi, c vũng gia v c ri Na ca lp c cũn c gi l lp nụng, na ngoi l lp c sõu Lp mng ỏy l mc rt quan trng phõn chia giai on UTBQ xõm ln (invasive) hay cha (noninvasive), ung th cha xõm ln c BQ gi l ung th BQ nụng, ung th ó xõm ln c BQ gi l ung th BQ sõu + Lp cựng l niờm mc (Tunica mucosa): Niờm mc BQ c gi l biu mụ chuyn tip ng tit niu Gia lp niờm mc v lp c l t chc liờn kt di niờm mc - Lp mng ỏy (Lammina propria) + Biu mụ bng quang bỡnh thng(Normal Urothelial):Theo WHO biu mụ BQ l mt biu mụ t bo chuyn tip ng tit niu (Urothelial transition cells) cú khong 3-7 lp t bo gm: mt lp t bo nn (lp ỏy), trờn lp ny l mt hoc nhiu lp t bo trung gian, trờn b mt l cỏc t bo hỡnh ụ phng Cỏc t bo biu mụ BQ cú hng cựng vi trc dc ovan ca nhõn v vuụng gúc vi lp ỏy to cho lp biu mụ tớnh phõn cc rừ Ton b lp biu mụ nm da trờn mng Lamina propria (mng ỏy) Hỡnh 1.3: Biu mụ bỡnh thng ca bng quang (WHO/ISUP, 1998) 1.1.3 Mch mỏu, bch huyt v thn kinh[6], [7] Hỡnh 1.4: ng mch cp mỏu cho bng quang[7] ng mch: Bng quang c cp mỏu bi cỏc mch mỏu xut phỏt t ng mch chu trong, chia nhỏnh cp mỏu cho BQ bao gm: - ng mch bng quang trờn cp mỏu cho mt trờn v mt phn mt di - bờn bng quang - ng mch bng quang di cp mỏu cho phn sau mt di - bờn ca bng quang v tuyn tin lit - Nhỏnh ng mch trc trng gia cp mỏu cho phn ỏy bng quang n gii, ỏy bng quang cũn c cp mỏu bi nhỏnh ca ng mch õm o Ngoi ra, cp mỏu cho bng quang cũn cú cỏc nhỏnh ca ng mch thn v ng mch bt Tnh mch: Cỏc tnh mch bng quang trung to thnh mt ỏm ri tnh mch bng quang (Santorini), ri t ú vo tnh mch chu Bch huyt: Cỏc mch bch huyt i dc theo cỏc tnh mch v vo cỏc hch bch huyt dc ng mch chu Thn kinh: c tỏch t ỏm ri h v v thn kinh cựng II, III, chi phi ng c bng quang v cm giỏc (nh cng y, au rỏt) 1.2 DCH T HC U BNG QUANG U bng quang phỏt trin nhiu cỏc nc k ngh phỏt trin M nm 1995 cú 50.500 ngi mc bnh u bng quang, cht khong 11.200 ngi Nm 1998 cú 54.000 mc bnh u bng quang, cht 12.500 ngi Nhng ngi tui ngoi 40 mc bnh u bng quang chim 20/100.000 dõn Tui mc bnh cú th t 30 tui tr lờn, ngi cao tui t l mc cao hn nhng ngi tr tui Theo William J Catalona (1998), thỡ t l cao nht tui 60 n 70 tui T l sng ph thuc vo tin trin ca bnh, theo y vn, t l sng quỏ nm ca giai on u nụng l 51% - 79%, t l tỏi phỏt khong 52% - 73%, t - 15 nm sau phu thut[8] Cng nh cỏc loi ung th khỏc, u bng quang phỏt trin nhiu yu t gõy nờn, yu t gõy bnh nhiu nht (20 - 25%), thng liờn quan n ngh nghip v mụi trng ngh nghip Ung th bng quang thng gp nhng ngi m ngh nghip v mụi trng phi tip xỳc vi húa cht T cui th k XIX ngi ta ó nhn thy mt s húa cht cú th gõy ung th ng tit niu Bng thc nghim trờn ng vt v quan sỏt ung th xut hin nhng ngi cụng nhõn tip xỳc vi húa cht (aniline v dn cht) ó cho phộp xỏc nh hai cht gõy ung th biu mụ ng tit niu ú l: Beta Naphtylamin v Benzidine Cỏc cht gõy ung th c hp thu bng ng tiờu húa v hụ hp c o thi qua ng tit niu (nng ca chỳng ng tit niu cao hn 100 ln mỏu) v t bo biu mụ ng tit niu c bit nhy cm vi s tỏc ng ca chỳng gan, Beta Naphtylamin b oxy hoỏ thnh amin Naphtyl v tip hp vi axit Glucuronic thnh axit amin Naphtyl Glucuronic T gan, cht ny qua thn tr thnh m c v c bi tit qua nc tiu xung bng quang Ti bng quang axit amin naphtyl Glucuronic b cht t Beta Glucuronidase ca nc tiu thu phõn thnh: axit Glucuronic + amin Naphtyl Cht amin Naphtyl l nguyờn nhõn chớnh gõy ung th sau c hp thu qua niờm mc bng quang [9] 1.3 C IM GII PHU BNH HC V S PHN CHIA GIAI ON UTBQ 1.3.1 c im gii phu bnh v mụ bnh hc UTBQ + i th: - Ung th biu mụ chuyn tip th nhỳ: L nhng u nhỳ c to bi nhiu np gp nhỳ trụng nh nhng mỳi thu, mnh v hp nht li - Ung th biu mụ th c: L nhng u c sựi hỡnh sỳp l - Ung th ti ch (Carcinoma in situ): L u nm niờm mc BQ V mt s lng cú th l mt hoc t hai hay nhiu u, thm u dy c c lũng bng quang UTBQ cú khong 70% l u nhỳ, 10% l u ti ch v 20% l u hn hp[9] + Vi th: Cỏc t bo UTBQ u xut phỏt t lp t bo biu mụ bỡnh thng ca BQ gm: Ung th biu mụ chuyn tip (Transition cell carcinoma - TCC): Chim trờn 90% UTBQ, biu hin bng tng s lp t bo biu mụ, cú s ri lon trt t sp xp cỏc t bo v mt tớnh phõn cc Ung th biu mụ vy (Squamous cell carcinoma):L cỏc sng húa, cỏct bo ny hp thnh nhng hỡnh ng tõm ging nh vy ngc trai, cú s bit húa tt him di cn xa Ung thbiu mụ tuyn(Adenocarcinoma): Th ny bit húa kộm v cú nguy c phỏt trin xõm ln c bng quang cao 1.3.2 S phõn chia giai on ung th bng quang Hip hi quc t chng ung th (UICC) v T chc Y t th gii kt hp vi Hip hi cỏc nh gii phu bnh lý tit niu (WHO/ISUP) ó thng nht phõn chia giai on UTBQ da theo mc xõm ln (Staging) v bit hoỏ t bo ca u (Grading) [10] + Phõn chia giai on UTBQ theo mc xõm ln (Staging) Cú hai h thng phõn chia giai on chớnh cho UTBQ: H thng phõn loi ca Jewett Strong-Marshall (1946)ngy ớt s dng v h thng phõn loi theo TNM ca UICC (1987, 1997) Theo ú, giai on UTBQ ph thuc vo sõu xõm ln ca cỏc t bo ung th t niờm mc,xung lp di niờm mc (mng ỏy), ti lp c hay xõm ln ngoi hoc di cn 10 Nm 1997, UICC sa i h thng phõn loi giai on UTBQ nm 1987 cho phự hp vi thc t lõm sng v khoa hc hn H thng ny bao gm: T: U ban u(primary tumor)hoc (U nguyờn phỏt) Tx: Khụng xỏc nh c u To: Khụng cú bng chng ca u ban u Ta: Ung th th nhỳ khụng xõm ln (lp mng ỏy) Tis: Ung th in situ (u phng niờm mc) T1: Khi u xõm ln vo lp mng ỏy (Lammina propria) T2: U xõm ln xung lp c T2a: U xõm ln lp c nụng (na trong) T2b: U xõm ln lp c sõu (na ngoi) T3: U xõm ln t chc quanh bng quang T3a: U nh lp m quanh bng quang T3b: Khi u ln ngoi thnh bng quang T4: U xõm ln cỏc c quan lõn cn T4a: U xõm ln vo TLT, niu qun hoc õm o T4b: U xõm ln vo thnh chu hụng hay thnh bng N: Hch vựng (Regional lymph node) Nx: Khụng xỏc nh c hch vựng No: Khụng cú di cn hch vựng N1: Di cn ti hch vựng ng kớnh < 2cm N2: Di cn ti hch vựng ng kớnh t 2-5cm hoc nhiu hch vựng khụng ln hn 5cm N3: Di cn ti hch vựng ng kớnh > 5cm hoc ti nhiu hch vựng M: Di cn xa (Distant metastases) Mx: Khụng xỏc nh c di cn xa 63 Aboseif SR, Borirakchanyavat S, Lue TF, Carroll PR (1998) Continence mechanism of the ileal neobladder in women: a urodynamics study, World Journal of Urology, 16(6), pp 400 404 64 Ali-El-Dein B, Abdel-Latif M, Mosbah A, Eraky I, Shaaban A, Taha N, Ghoneim M (2004) "Secondary malignant involvement of gynecologic organs in radical cystectomy speciments in women: Is it mandatory to remove these organs routinely?, J Urol, 172, pp 885 65 Ali-El-Dein B, Gohma M, Ghoneim M (2002), Critical evaluation of the problem of urinary retention after orthotopic bladder substitution in women, J Urol, 168, pp 587 66 Anastasiadis AG, Feyerabend S, Kuczyk MA, Stenzl A (2008), Cystectomy in the female, Treatment and management of bladder cancer, Informa Healthcare, pp 91 96 67 Bayraktar Z, Sevin G, Gurbuz G, Tasci AI (2001), Ileal orthotopic neobladder in women: The first experiences from Turkey and our modifications, International Urology and Nephrology, 32(3), pp 371 375 68 Bhatta Dhar N, Kessler TM, Mill RD, Burkhard F, Studer UE (2007), Nerve sparing radical cystectomy and orthotopic bladder replacement in female patient, Eur Urol, 52, pp 1006 1014 69 Arai Yoichi, Okubo Kazutoshi, Konami Teruo, Kin Sojun, v cs(1999) Voiding function of orthotopic ileal neobladder in women Urology, 54(1), 44-49 70 Courtney M.P Hollowell Arthur P Christiano, Gary D Steinberg(2000) Technique of Hautman ileal neobladder with chimney modification: interim results in 50 patients The Journal of urology, 163, 47 - 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ớt Thnh thong Hay t c Thng xuyờn 1/2 s ln nh giao hp > 1/2 s ln nh giao hp Thng xuyờn giao hp c Trong tt c cỏc ln dng vt cng Khụng < 1/2 cng di kớch thớch tỡnh dc ụng thy lm s ln kh nng giao hp (kh nng a c nh dng vt vo õm o) ca ụng t giao mc no sau õy? hp Trong tt c cỏc ln giao hp ụng gi Rt c dng vt cng cng him sut quỏ trỡnh giao hp nh th no sau õy? < 1/2 1/2 s > 1/2 Tt c s ln ln s ln cỏc ln Trong tt c cỏc ln giao hp ụng cú gi Khụng Rt c dng vt cng cng cho n gi khú xut tinh nh th no sau õy? c Trong tt c cỏc ln giao hp, ụng t n Hu cc khoỏi cm nh th no sau õy? nh khụng Tng Khú Hi khú Khụng khú chỳt no < 1/2 1/2 s > 1/2 Tt c s ln ln s ln cỏc ln B GIO DC V O TO TRNG I HC Y H NI B Y T TRNH HONG HNG ĐáNH GIá KếT QUả TạO HìNH BàNG QUANG BằNG RUộT NON SAU CắT BàNG QUANG TOàN Bộ DO UNG THƯ TạI BệNH VIệN VIệT ĐứC Chuyờn ngnh : Ngoi Khoa Mó s : 60720123 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS Trng Thnh H NI 2015 Lời cảm ơn hon thnh lun ny, tụi nhn c s h tr v giỳp ca nhiu cỏ nhõn, th Tụi xin chõn thnh by t lũng bit n ti: - ng y, Ban giỏm hiu, Phũng o to sau i hc, B mụn Ngoi Trng i hc Y H Ni - ng y, Ban Giỏm c, cỏc khoa phũng (c bit Khoa Tit niu, Th vin, Phũng Lu tr h s, Phũng m Tit niu, Khoa 1C) - Bnh vin Vit c - S Y t Thỏi Bỡnh ng y, Ban giỏm c, Khoa Ngoi Tit Niu- Bnh vin a khoa Tnh Thỏi Bỡnh ó quan tõm v to mi iu kin thun li cho tụi quỏ trỡnh hc v nghiờn cu Tụi xin by t lũng kớnh trng v bit n sõu sc ti: - PGS TS Trng Thnh - Ngi thy mu mc, tn tỡnh, trc tip hng dn, úng gúp nhiu ý kin quý bỏu tụi tng bc hon thnh lun Tụi xin by t lũng bit n ti cỏc Thy Hi ng duyt cng: - GS TS Nguyn Ngc Bớch - PGS TS V Nguyn Khi Ca - PGS TS Hong Long ó úng gúp nhng ý kin hay v b ớch ti ca tụi thờm phong phỳ v cht lng Tụi bit n sõu sc ti nhng úng gúp quý bỏu ca: Thy Ch tch Hi ng, cỏc Thy Hi ng chm lun cho ti ca tụi c hon thnh trn Cui cựng tụi vụ cựng bit n n gia ỡnh nh, v, cỏc yờu quý ca tụi v nhng ngi thõn gia ỡnh, ng nghip, bn bố ó luụn ng viờn, to mi iu kin thun li v vt cht v tinh thn tụi hc v phn u t c kt qu nh ngy hụm H Ni, Ngy 10 thỏng 09 nm 2015 Trnh Hong Hựng LI CAM OAN Tụi xin cam oan õy l cụng trỡnh nghiờn cu ca riờng tụi Nhng s liu, kt qu nờu lun l trung thc v cha cú cụng b bt k cụng trỡnh nghiờn cu no khỏc Tụi xin m bo tớnh khỏch quan, trung thc ca cỏc s liu ó thu thp v kt qu x lý s liu nghiờn cu ny H Ni ngy 10 thỏng 09 nm 2015 Tỏc gi Hc viờn Trnh Hong Hựng DANH MC CC CH VIT TT BC : Bch cu BN : Bnh nhõn BQ : Bng quang CLVT : Ct lp vi tớnh GPB : Gii phu bnh HC : Hng cu ISUP : Hip hi cỏc nh gii phu bnh hc tit niu (International society of urologic pathologists) MRI : Cng hng t NKQ : Ni khớ qun TCC : Ung th t bo chuyn tip ng tit niu (Transitionoal cell carcinoma) Tb : T bo TLT : Tin lit tuyn TUR : Phu thut ni soi ct u qua niu o (Trans urethral resection) UICC : Hip hi Quúc t chng Ung th (Union Internationale Contre Cancer) UIV : Chp niu tnh mch UTBQ : Ung th bng quang WHO : T chc Y t th gii (World Health Organization) MC LC DANH MC BNG DANH MC BIU DANH MC HèNH NH