Continent cutaneous diversion.

Continent urinary diversion requires the creation of a reservoir, ureteric implantation and establishment of a continence mechanism in the efferent segment. This review is a short overview on the history of different techniques in current use. Reservoirs with high volume and low pressure can be fashioned by antimesenteric opening and spherical reconfiguration of the bowel. Previously, techniques for ureteric implantation were simply transferred to continent urinary diversion. Currently the need for antirefluxive ureteric implantation techniques is questioned and there is a trend towards refluxive implantation. To create a continence mechanism, simple and reproducible procedures. e.g. the incorporation of the efferent segment into the pouch wall (e.g. appendix stoma, flap valve T mechanism, serosal-lined extramural tunnel) have been developed. Long-term data for different surgical techniques show excellent continence and acceptable complication rates.

[Ileal bladder substitute]. / Ileale Ersatzblasen.

The history of urinary diversion in general began in 1852 and started right away with continent diversion, i.e., ureterosigmoidostomy. Anastomosing an intestinal reservoir to the urethra was proposed by Tizzoni and Foggi in 1888. They replaced the bladder by an isoperistaltic ileal segment which was interposed between ureters and urethra in a female dog. In 1951 Couvelaire reactivated this idea of an ileal bladder substitute. Retrospectively many disappointing results of urinary diversion were often not caused by insufficient competence of the outlet mechanism, but because the intestinal reservoir maintained its peristaltic properties causing high pressure peaks. The decisive advance in ensuring continence, and thus an improvement in patient comfort, was achieved with the so-called low pressure reservoir. The main characteristics of this reservoir compared to those from intact intestinal segments are the larger diameter, the greater capacity with significantly low pressures, and the uncoordinated contraction of its wall. Transsection of the circular intestinal musculature when performing bladder augmentation had already been published by Rutkowski in 1899, Tasker in 1953, and Giertz in 1957. In 1969, Kock published the first results obtained with an ileal continent fecal reservoir in patients after total proctocolectomy. The significant advantages of interrupting the tubular structure of a reservoir obtained from intestine had been described much earlier. The need for reflux prevention is not the same as in ureterosigmoidostomy conduit or continent diversion. Reflux prevention in neobladders is even less important than in a normal bladder. When using nonrefluxing techniques, the risk of obstruction is at least twice that after direct anastomosis. Kidney function is not impaired by diversion if stenosis is recognized and managed. Patient health status is influenced more by underlying disease than by diversion. Orthotopic reconstruction has passed the test of time. In these patients life is similar to that in individuals with a native lower urinary tract. Until a better solution is devised orthotopic bladder reconstruction remains the best option for patients requiring cystectomy.

Historical perspective of the use of bowel in urology.

The use of bowel has been used in urinary tract reconstruction for more than a century. In the past 20 years, however, indications and methods for bowel utilization have multiplied enormously. This article outlines some of these exciting developments.

[Historic evolution of the use of the intestine in urology]. / Evolución histórica del uso del intestino en Urología.

Knowing the history of Urology has allowed urologists to recover techniques which had been abandoned for different reasons, yet when modified or utilized with current technological advancements, have proved to be very useful. A brief review of the history of urinary diversion clearly shows that it has evolved in parallel with the important diseases; i.e., vesical exstrophy, urinary tuberculosis and bladder cancer. Time tests all new, and thus controversial, concepts or procedures. They become either well established or are condemned to oblivion. All the experience, both successes and failures, that make up the history of Urology undoubtedly contribute towards finding new therapeutic alternatives.

The Mitrofanoff principle. Technique and application in continent urinary diversion.

The Mitrofanoff procedure (appendicovesicostomy and creation of a low-pressure urinary reservoir) is a technically innovative way of providing patients with a form of continent diversion. The principles behind the procedure are use of a narrow, supple conduit, which, when brought out to the skin as a catheterizable stoma, will provide continence by acting as a flap-valve and attachment of the conduit to a low-pressure urine storage reservoir by an antireflux mechanism. Upper-tract contamination is prevented by an antireflux mechanism at the level of the distal ureters. Strict attention to every step of the procedure is mandatory. Emptying of the reservoir is achieved by clean intermittent catheterization. Long-term results are good in a majority of patients with careful selection and education. Life-long follow-up of patients is mandatory.