Studer U E, Spiegel T, Casanova G A, Springer J, Gerber E, Ackermann D K, Gurtner F, Zingg E J
Department of Urology, University of Berne, Switzerland.
Eur Urol. 1991;20(4):315-26. doi: 10.1159/000471724.
Spheroidal bladder substitutes made from double-folded ileal segments, similar to Goodwin's cup-patch technique, are devoid of major coordinated wall contractions. This, together with the reservoir's direct anastomosis to the membranous urethra, prevents major intraluminal pressure peaks and assures a residue-free voiding of sterile urine. In order to determine whether, under these conditions, an afferent tubular isoperistaltic ileal segment of 20-cm length protects the upper urinary tract as efficiently as an antireflux nipple, 60 male patients who were subjected to radical cystectomy were prospectively randomised to groups in which a bladder substitute was formed together with either of these 2 antireflux devices. An analysis of the results obtained in 20 patients from each group who could be followed for more than 1 year (median observation time 30 and 36 months) showed no differences between the groups in metabolic disturbances, kidney size, reservoir capacity, diurnal and nocturnal urinary continence, the incidence of urinary tract infection or episodes of acute pyelonephritis. Later than 1 year postoperatively, intravenous urograms of the renoureteral units of 25% of the patients with antireflux nipples showed persistent but generally slight dilatation of the upper urinary tracts. This observation was significantly more frequent than it was in patients with afferent tubular segments. Urodynamic and radiographic studies showed that the competence of the antireflux nipples was secured by the raised surrounding intravesical pressure. This, however, also resulted in a transient functional obstruction, and a gradual rise of the basal pressure in the upper urinary tracts was recorded. In patients with afferent ileal tubular segments, contrast medium could be forced upwards into the renal pelvis when the bladder substitutes were overfilled. However, despite raised intravesical pressures, peristalsis in the isoperistaltic afferent tubular segment gradually returned contrast medium back to the reservoir. Our results suggest that the combination of an ileal low-pressure reservoir together with an afferent tubular isoperistaltic limb is at least as good as an antireflux nipple valve. Moreover, the use of the afferent ileal limb makes it possible to resect the distal and often diseased ureters together with the paraureteric lymphatics at a safe distance from the bladder tumor. This avoids also distal ischemic ureteric stenosis and makes possible a simple end-to-side ureterointestinal anastomosis with a small complication rate.
由双层回肠段制成的球状膀胱替代物，类似于古德温的杯状补片技术，缺乏主要的协调性壁收缩。这一点，再加上储尿囊与膜性尿道的直接吻合，可防止腔内压力出现大幅峰值，并确保无菌尿液无残余地排空。为了确定在这些条件下，一段20厘米长的传入管状等蠕动回肠段是否能像抗反流乳头一样有效地保护上尿路，对60例行根治性膀胱切除术的男性患者进行了前瞻性随机分组，每组中使用这两种抗反流装置之一构建膀胱替代物。对每组中20例可随访1年以上（中位观察时间为30个月和36个月）患者的结果分析表明，两组在代谢紊乱、肾脏大小、储尿囊容量、日间和夜间尿失禁、尿路感染发生率或急性肾盂肾炎发作方面均无差异。术后1年以后，25%有抗反流乳头的患者的肾输尿管单位静脉肾盂造影显示上尿路持续但一般轻微扩张。这一观察结果在有传入管状段的患者中明显更频繁。尿动力学和影像学研究表明，抗反流乳头的功能通过膀胱内周围压力升高得以保障。然而，这也导致了短暂的功能性梗阻，并记录到上尿路基础压力逐渐升高。在有传入回肠管状段的患者中，当膀胱替代物过度充盈时，造影剂可被迫向上进入肾盂。然而，尽管膀胱内压力升高，等蠕动传入管状段的蠕动逐渐将造影剂回流到储尿囊中。我们的结果表明，回肠低压储尿囊与传入管状等蠕动支的组合至少与抗反流乳头瓣一样好。此外，使用传入回肠支使得能够在距膀胱肿瘤安全距离处切除远端且常患病的输尿管以及输尿管旁淋巴管。这也避免了远端缺血性输尿管狭窄，并使得简单的端侧输尿管肠吻合成为可能，且并发症发生率较低。
