Vergho D, Kocot A, Bauer C, Riedmiller H
Klinik und Poliklinik für Urologie und Kinderurologie, Julius Maximilians-Universität Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland.
Urologe A. 2012 Apr;51(4):485-93. doi: 10.1007/s00120-012-2813-x.
Besides common requirements like universal applicability, reproducibility, and low complication rate, functionality and cosmetic aspects are essential in continent cutaneous diversions. Creation of the continence mechanism certainly represents the major surgical challenge in continent cutaneous diversions. Complete continence and ease of catheterization are mandatory for the patient's quality of life.High surgical competence, creativity, and variability are required in cases of revisional surgery for stomal insufficiency. In addition to accurate preoperative clinical, endoscopic, and radiologic evaluation, extensive expertise in the fields of continent urinary diversion and reconstructive urology allows performance of a surgical solution ideally adapted to the patient's individual situation. Between January 1990 and September 2011 we performed urinary diversion in 1,224 patients (mean follow-up 90.3 months). Continent urinary diversion was performed in 717 patients (59%); in 486 patients an ileocecal reservoir with continent cutaneous diversion, in 186 patients an ileocecal neobladder, and in 45 patients a sigma rectum pouch was created. Incontinence rate and stenosis rate in patients with appendico-umbilical stoma (n=219) were 2.3% and 10% and in patients with intussuscepted ileum nipple (n=267) nipple 5.2% and 2.7%. Stenosis usually can be corrected easily by simple excision of the obstructive scarred tissue or by stomal reconfiguration. Outlet failure may result from simple causes like fistula formation between reservoir and efferent segment or skin and nipple gliding or prolapse which can easily be repaired. More complex situations might require creation of a secondary continence mechanism. In our series of 486 patients having undergone continent cutaneous diversion in our department, 14 patients (appendico-umbilical stoma n=5, ileal nipple n=9) suffered from irreversible damage of the continent outlet. In 11 patients creation of a secondary intussuscepted ileal nipple and in 3 patients a modified Managadze procedure was performed.In case of absence of the ileocecal valve (e.g. in primary ileal reservoirs, ileocolonic reservoirs without integrated ileocecal valve) and in case of a preexisting pouch of small capacity we prefer augmentation of the primary reservoirs with an ileocecal cup patch plasty in combination with the submucosally embedded appendix or intussuscepted ileal nipple serving as continent outlet. In our institution this was done in four patients who had undergone primary surgery elsewhere.
除了普遍适用性、可重复性和低并发症率等常见要求外，控尿功能和外观方面在可控性皮肤改道中至关重要。建立控尿机制无疑是可控性皮肤改道手术的主要挑战。完全控尿和易于导尿对患者的生活质量至关重要。对于造口功能不全的翻修手术，需要高超的手术技能、创造力和灵活性。除了准确的术前临床、内镜和放射学评估外，在可控性尿流改道和重建泌尿外科领域的广泛专业知识有助于实施最适合患者个体情况的手术解决方案。1990年1月至2011年9月，我们对1224例患者进行了尿流改道手术（平均随访90.3个月）。717例患者（59%）进行了可控性尿流改道；486例患者采用回盲部贮尿囊行可控性皮肤改道，186例患者采用回盲部新膀胱，45例患者制作了乙状结肠直肠袋。阑尾脐部造口患者（n = 219）的尿失禁率和狭窄率分别为2.3%和10%，套叠回肠乳头患者（n = 267）的尿失禁率和狭窄率分别为5.2%和2.7%。狭窄通常可通过简单切除阻塞性瘢痕组织或造口重新塑形轻松纠正。出口功能障碍可能由贮尿囊与输出段之间形成瘘管、皮肤与乳头滑动或脱垂等简单原因引起，这些情况很容易修复。更复杂的情况可能需要建立二级控尿机制。在我们科室接受可控性皮肤改道的486例患者系列中，14例患者（阑尾脐部造口n = 5，回肠乳头n = 9）出现了不可逆的可控性出口损伤。11例患者制作了二级套叠回肠乳头，3例患者进行了改良的马纳加泽手术。在回盲瓣缺失的情况下（如原发性回肠贮尿囊、无完整回盲瓣的回结肠贮尿囊）以及存在小容量原有贮尿囊的情况下，我们更倾向于采用回盲杯补片成形术扩大原发性贮尿囊，并结合黏膜下包埋阑尾或套叠回肠乳头作为可控性出口。在我们机构，对4例在其他地方接受过初次手术的患者进行了此项操作。
