Hautmann R E
Klinik für Urologie und Kinderurologie, Urologische Universitätsklinik, Ulm, Deutschland.
Urologe A. 2008 Jan;47(1):33-4, 36-40. doi: 10.1007/s00120-007-1606-0.
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.
一般来说,尿流改道的历史始于1852年,一开始就是可控性尿流改道,即输尿管乙状结肠吻合术。1888年,蒂佐尼和福吉提出将肠道储尿囊与尿道吻合。他们用一段等蠕动的回肠段替代膀胱,该回肠段置于一只雌性犬的输尿管和尿道之间。1951年,库韦拉尔重新启用了回肠膀胱替代的想法。回顾来看,尿流改道的许多令人失望的结果往往不是由于出口机制功能不足,而是因为肠道储尿囊保持其蠕动特性,导致压力峰值过高。确保控尿从而改善患者舒适度方面的决定性进展是通过所谓的低压储尿囊实现的。与完整肠段的储尿囊相比,这种储尿囊的主要特点是直径更大、容量更大且压力显著较低,以及其壁的不协调收缩。1899年鲁特科夫斯基、1953年塔斯克和1957年吉尔茨已发表了在进行膀胱扩大术时横断环形肠肌层的相关内容。1969年,科克发表了全直肠结肠切除术后患者使用回肠可控性粪便储尿囊获得的首批结果。更早之前就已描述了中断从肠道获取的储尿囊管状结构的显著优势。预防反流的需求与输尿管乙状结肠吻合术导管或可控性尿流改道中的情况不同。新膀胱中预防反流甚至比正常膀胱中更不重要。使用抗反流技术时,梗阻风险至少是直接吻合后的两倍。如果能识别并处理狭窄,尿流改道不会损害肾功能。患者的健康状况受基础疾病的影响大于尿流改道。原位重建经受住了时间的考验。在这些患者中,生活与天然下尿路的个体相似。在设计出更好的解决方案之前,原位膀胱重建仍然是需要膀胱切除术的患者的最佳选择。