Clinic and Polyclinic for Urology, University Hospital Mainz, Germany.
Dtsch Arztebl Int. 2012 Sep;109(38):617-22. doi: 10.3238/arztebl.2012.0617. Epub 2012 Sep 21.
Bladder cancer is not a rare disease: In 2010, there were more than 70 000 affected patients in the United States. Radical cystectomy for the treatment of muscle invasive bladder cancer necessitates urinary diversion.
We present the current options for urinary diversion and their different indications on the basis of a selective search for pertinent literature in PubMed and our own clinical experience.
When bladder cancer is treated with curative intent, continence-preserving orthotopic urinary bladder replacement is preferred. For heterotopic urinary bladder replacement, a reservoir is fashioned from an ileal or ileocecal segment. Urine is diverted to the rectum by way of the sigmoid colon. When bladder cancer is treated with palliative intent, non-continence-preserving cutaneous urinary diversion is usually performed: The creation either of a renal-cutaneous fistula or a self-retaining ureteral stent is a purely palliative procedure. In these interventions, the resorptive surface of the bowel segment used can no longer play its original physiological role in the gastrointestinal tract, even though its absorptive and secretory functions are still intact. This has metabolic consequences, because the diverted urine here comes into contact with a large area of bowel epithelium. Early preventive treatment must be provided against potentially serious complications such as metabolic acidosis and loss of bone density. The resection of ileal segments can also lead to malabsorption. The risk of secondary malignancy is elevated after either continence-preserving anal urinary diversion (>2%) or bladder augmentation (>1%).
There are four options for urinary diversion after cystectomy that can be performed when surgery is performed with either curative or palliative intent. There are also a number of purely palliative interventions.
膀胱癌并不罕见：2010 年，美国有超过 70000 名患者。根治性膀胱切除术治疗肌层浸润性膀胱癌需要尿路改道。
我们根据在 PubMed 上对相关文献的选择性搜索和我们自己的临床经验，介绍了目前尿路改道的选择及其不同适应证。
当膀胱癌以治愈为目的治疗时，首选保留控尿功能的原位膀胱替代。对于异位膀胱替代，使用回肠或回盲肠段制作储尿器。尿液通过乙状结肠引流至直肠。当膀胱癌以姑息为目的治疗时，通常进行非保留控尿功能的皮肤性尿路改道：建立肾-皮肤瘘或自维持输尿管支架是纯粹的姑息性手术。在这些干预措施中，使用的肠段的吸收表面在胃肠道中不能再发挥其原有的生理作用，尽管其吸收和分泌功能仍然完整。这会产生代谢后果，因为这里的引流尿液与大面积的肠上皮接触。必须早期预防性治疗，以防止代谢性酸中毒和骨密度丧失等潜在严重并发症。回肠段的切除也可导致吸收不良。无论是保留控尿功能的肛门性尿路改道（>2%）还是膀胱扩大术（>1%），继发恶性肿瘤的风险都会增加。
根治性膀胱切除术后有四种尿路改道选择，可以在以治愈或姑息为目的的手术中进行。还有一些纯粹的姑息性干预措施。
