Hautmann Richard E, Abol-Enein Hassan, Hafez Khaled, Haro Isao, Mansson Wiking, Mills Robert D, Montie James D, Sagalowsky Arthur I, Stein John P, Stenzl Arnulf, Studer Urs E, Volkmer Bjoern G
Department of Urology, Faculty of Medicine, University of Ulm, Ulm, Germany.
Urology. 2007 Jan;69(1 Suppl):17-49. doi: 10.1016/j.urology.2006.05.058.
A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review reports of urinary diversion. The world literature on urinary diversion was identified through a Medline search. Evidence-based recommendations for urinary diversion were prepared with reference to a 4-point scale. Many level 3 and 4 citations, but very few level 2 and no level 1, were noted. This outcome supported the clinical practice pattern. Findings of >300 reviewed citations are summarized. Published reports on urinary diversion rely heavily on expert opinion and single-institution retrospective case series: (1) The frequency distribution of urinary diversions performed by the authors of this report in >7000 patients with cystectomy reflects the current status of urinary diversion after cystectomy for bladder cancer: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous diversion, 8%; incontinent cutaneous diversion, 2%; and others, 0.1%. (2) No randomized controlled studies have investigated quality of life (QOL) after radical cystectomy. Such studies are desirable but are probably difficult to conduct. Published evidence does not support an advantage of one type of reconstruction over the others with regard to QOL. An important proposed reason for this is that patients are subjected preoperatively to method-to-patient matching, and thus are prepared for disadvantages associated with different methods. (3) Simple end-to-side, freely refluxing ureterointestinal anastomosis to an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure that results in the lowest overall complication rate. The potential benefit of "conventional" antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and reoperation rates. The need to prevent reflux in a continent cutaneous reservoir is not significantly debated, and this should be done. (4) Most reconstructive surgeons have abandoned the continent Kock ileal reservoir largely because of the significant complication rate associated with the intussuscepted nipple valve.
世界卫生组织（WHO）和国际泌尿外科学会（SIU）召开了一次共识会议，对尿流改道的报告进行严格审查。通过医学文献数据库检索确定了关于尿流改道的世界文献。参照四点量表制定了基于证据的尿流改道建议。发现许多3级和4级引用文献，但2级文献很少，1级文献则没有，这一结果支持了临床实践模式。总结了300多篇经审查的引用文献的研究结果。关于尿流改道的已发表报告严重依赖专家意见和单机构回顾性病例系列：（1）本报告作者对7000多名膀胱癌膀胱切除患者进行的尿流改道频率分布反映了膀胱癌膀胱切除术后尿流改道的现状：新膀胱，47%；输尿管皮肤造口术，33%；肛门改道，10%；可控性皮肤造口术，8%；不可控性皮肤造口术，2%；其他，0.1%。（2） 没有随机对照研究调查根治性膀胱切除术后的生活质量（QOL）。此类研究是可取的，但可能难以开展。已发表的证据并不支持一种重建方式在生活质量方面优于其他方式。一个重要的原因是患者在术前进行了方法与患者的匹配，因此对不同方法的缺点有了心理准备。（3） 简单的端侧、自由反流的输尿管肠吻合术与低压原位重建的输入袢相结合，同时定期排尿并密切随访，是总体并发症发生率最低的手术方式。“传统”抗反流手术与原位重建相结合的潜在益处似乎被更高的并发症和再次手术率所抵消。对于可控性皮肤贮尿囊预防反流的必要性没有显著争议，应该这样做。（4） 大多数重建外科医生已基本放弃了可控性Kock回肠贮尿囊，主要是因为套叠乳头瓣相关的并发症发生率较高。
