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DOI: 10.1055/s-2001-17286
„Auf der Suche nach dem Heiligen Gral”: Das efferente Segment in der kontinenten kutanen Harnableitung
“The Search for the Holy Grail”: The Efferent Segment in Continent Cutaneous Urinary DiversionPublication History
Publication Date:
12 May 2004 (online)
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Zusammenfassung
Zwanzig Jahre klinisch relevanter kontinenter kutaner Harnableitung haben bezüglich der Reservoirbildung einen breiten Konsensus, im Hinblick auf afferenten und efferenten Schenkel aber ungezählte und erbitterte Kontroversen hervorgebracht: Während die Detubularisierung und sphärische Rekonfiguration von Darm zur Schaffung eines großkapazitären Niederdruckreservoirs (mit dem Vorbehalt der Verwendung unterschiedlicher Darmabschnitte) als Standard unumstößlich etabliert werden konnte, konkurrieren bis in die unmittelbare Gegenwart hinein unterschiedliche Techniken zur Harnleiterimplantation und Konstruktion eines Kontinenzmechanismus miteinander. Liegt bei der ureterointestinalen Anastomose der Akzent der Diskussion auf der Grundsatzfrage nach der Notwendigkeit einer chirurgischen Refluxvermeidung, wird die Auseinandersetzung um das optimale Kontinenzorgan von technisch-operativen Aspekten beherrscht. Auf breiter klinischer und publizistischer Front durchgesetzt hat sich hierbei die Appendix vermiformis, gefolgt von invaginiertem, getapertem oder transversal retubularisiertem Ileum, dem „full thickness”-Darmlappen und dem Ureter als einziger nicht-intestinaler Struktur. Die meisten Optionen basieren im weitesten Sinne auf dem Mitrofanoff-(flap valve)Prinzip, erreichen zuverlässig primäre Kontinenzraten jenseits der 90 % und erfahren eine hohe Akzeptanz von Seiten der Patienten. Während der Einsatz artifizieller Sphinktersysteme erwartungsgemäß zu durchweg enttäuschenden Ergebnissen führte, eröffnet Tissue engineering interessante Perspektiven; praktikable Lösungen fehlen bislang allerdings auch hier.
Abstract
Two decades of clinical experience with continent cutaneous urinary diversion have led to a broad consensus on reservoir formation, but not on the selection of efferent and afferent segments. Whereas detubularization and spherical reconfiguration of small and/or large bowel has become the undisputed standard procedure for creation of a low pressure, high capacity urinary reservoir, uretero-intestinal anastomosis and construction of the continence mechanism remain contentious issues. The argument in ureteral implantation is on whether reflux prevention is at all necessary, while the discussion about the ideal efferent limb centers on technical aspects of construction.
By far the most popular structure for construction of a continence mechanism is the vermiform appendix, followed by tapered, intussuscepted or transversely retubularized ileum, and full thickness bowel flaps. The ureter is the only non-intestinal tube with practical value. Most techniques are based on the so called Mitrofanoff (flap valve) principle which provides reliable continence in more than 90 % of cases and high patient acceptance.
Artificial sphincter systems give disappointing results in the setting of urinary diversion. In the future, the construction of efferent conduits with muscular sphincters by tissue engineering may be possible and is an area of active laboratory research.
Literatur
- 1 Abd-el-Gawad G, Abrahamsson K, Hanson E, Norlen L, Sillen U, Sixt R, Hjalmas K. Evaluation of Kock urinary reservoir function in children and adolescents at 3 - 10 years' follow-up. Scand J Urol Nephrol. 1999; 33 149-155
- 2 Arai Y, Kawakita M, Terachi T, Oishi K, Okada Y, Takeuchi H, Yoshida O. Long-term follow-up of the Kock and Indiana pouch procedures. J Urol. 1993; 150 51-55
- 3 Ashken M H. Continent ileocaecal reservoir. J R Soc Med. 1978; 150 357-360
- 4 Bell C RW, Gujral S, Collins G NA, Sibley G NA, Persad R A. The fate of the urethra after definitive treatment of invasive transitional cell carcinoma of the urinary bladder. Br J Urol. 1999; 83 607-612
- 5 Ben-Chaim J, Rodriguez R, Docimo S G. Concealed umbilical stoma: description of a modified technique. J Urol. 1995; 154 1169-1170
- 6 Benchekroun A. Hydraulic valve for continence and antireflux. A 17-year experience of 210 cases. Scand J Urol Nephrol Suppl. 1992; 142 66-70
- 7 Benchekroun A, Lakrissa A, Tazi A, Mikou A. Vessie ileo-caecale continente a propos de 33 cas. Chirurgie. 1980; 106 668-672
- 8 Bihrle R. The Indiana pouch continent urinary reservoir. Urol Clin N Am. 1997; 24 773-779
- 9 Bissada N K. Favorable experience with a simple technique to create a concealed umbilical stoma. J Urol. 1998; 159 1174-1175
- 10 Bricker E M. Bladder substitution after pelvic evisceration. Surg Clin N Am. 1950; 30 1511-1521
- 11 Cain M P, Casale A J, King S J, Rink R C. Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children's Hospital. J Urol. 1999; 162 1749-1752
- 12 Carr L K, Webster G D. Kock versus right colon continent urinary diversion: comparison of outcome and reoperative rate. Urology. 1996; 48 711-714
- 13 Chanturaia Z, Pertia A, Managadze G, Khvadagiani G, Chigogidze L, Managadze L. Right colonic reservoir with submucosally embedded tapered ileum - “Tiflis pouch”. Urol Int. 1997; 59 113-118
- 14 Davidsson T, Hedlund H, Mansson W. Detubularized right colonic reservoir with intussuscepted ileal nipple valve or stapled ileal (“Lundiana”) outlet. Clinical and urodynamic results in a prospective randomized study. World J Urol. 1996; 14 78-84
- 15 Duckett J W, Snyder H M. Continent urinary diversion: variations on the Mitrofanoff principle. J Urol. 1986; 136 58
- 16 Figueroa T E, Sobagol L, Helal M, Lockhart J L. The tapered and reimplanted small bowel as a variation of the Mitrofanoff procedure: preliminary results. J Urol. 1994; 152 73-75
- 17 Gerharz E W, Köhl U, Weingärtner K, Melekos M D, Bonfig R, Riedmiller H. Complications related to different continence mechanisms in ileocecal reservoirs. J Urol. 1997; 158 1709-1713
- 18 Gerharz E W, Tassadaq T, Pickard R S, Shah P J, Woodhouse C RJ, Ransley P G. Transverse retubularized ileum: early clinical experience with a new second line Mitrofanoff tube. J Urol. 1998; 159 525-528
- 19 Gerharz E W, Weingärtner K, Köhl U, Dopatka T, Basler H D, Riedmiller H. Quality of life following cystectomy and urinary diversion - an interdisciplinary retrospective study. J Urol. 1997; 158 778-785
- 20 Gerharz E W, Vik V, Webb G, Woodhouse C RJ. The in situ-appendix in the MACE (Malone antegrade continence enema) - procedure for faecal incontinence. Br J Urol. 1997; 79 985-986
- 21 Gilchrist R K, Merricks J W, Hamlin H H, Rieger I T. Construction of a substitute bladder and urethra. Surg Gynecol Obstet. 1950; 90 752-760
- 22 Hart S, Skinner E C, Meyerowitz B E, Boyd S, Lieskovsky G, Skinner D G. Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, cutaneous or urethral Kock pouch. J Urol. 1999; 162 77-81
- 23 Hautmann R E, de Petriconi R, Gottfried H W, Kleinschmidt K, Mattes R, Paiss T. Ileal Neobladder: complications and functional results in 363 patients after 11 years of follow-up. J Urol. 1999; 161 422-428
- 24 Henriet M P, Neyra P, Elman B. Kock pouch procedures: continuing experience and evolution in 135 cases. J Urol. 1991; 146 16-20
- 25 Hinman F. Functional classification of conduits for continent diversion. J Urol. 1990; 144 27-30
- 26 Horowitz M, Kuhr C S, Mitchell M E. The Mitrofanoff catheterizable channel: patient acceptance. J Urol. 1995; 153 771-772
- 27 Khoury A E, Van Savage J G, McLourie G A, Churchill B M. Minimizing stomal stenosis in appendicovesicostomy using the modified umbilical stoma. J Urol. 1996; 155 2050-2051
- 28 Kock N G. Intra-abdominal “resevoir” in patients with permanent ileostomy. Arch Surg. 1969; 99 223-231
- 29 Kock N G, Kock A E, Nilsson L O, Norlen L J, Philipson B M. Urinary diversion via a continent ileal reservoir: clinical results in twelve patients. J Urol. 1982; 128 469-475
- 30 Könyves J, Davidsson T, Wullt B, Mansson W. Continent cutaneous urinary diversion with the Lundiana pouch - the first 72 cases. Eur Urol. 1999; 35 (supplement) 30
- 31 Lampel A, Fisch M, Stein R, Schultz-Lampel D, Hohenfellner M, Eggersmann C, Hohenfellner R, Thüroff J W. Continent diversion with the Mainz pouch. World J Urol. 1996; 14 85-91
- 32 Lampel A, Hohenfellner M, Schultz-Lampel D, Thüroff J W. In situ tunneled bowel flap tubes: 2 new techniques of a continent outlet for Mainz pouch cutaneous diversion. J Urol. 1995; 153 308-315
- 33 Lampel A, Thüroff J W. Bowel-flap tubes for continent cutaneous urinary diversion. World J Urol. 1998; 16 235-241
- 34 Lampel A, Thüroff J W, Roth S. Modified seromuscular tube: serosa lined bowel wall imbrication as a continent outlet for continent cutaneous urinary diversion. J Urol. 2000; 163 201-204
- 35 Lebret T, Herve J M, Barre P. Urethral recurrence of transitional cell carcinoma of the bladder. Predictive values of preoperative latero-montanal biopsies and urethral frozen sections during prostatocystectomy. Eur Urol. 1998; 33 170-174
- 36 Leissner J, Black P, Fisch M, Hockel M, Hohenfellner R. Colon pouch (Mainz pouch III) for continent urinary diversion after pelvic irradiation. Urology. 2000; 56 798-802
- 37 Lengemann P. Ersatz der extirpierten Harnblase durch das Coecum. Zentralbl Chir. 1913; 40 14-15
- 38 Leonard M P, Quinlan D M. The Benchekroun ileal valve. Partial and total bladder reconstruction. Urol Clin N Am. 1991; 18 717-724
- 39 Light J K. Use of the artificial urinary sphincter around bowel. In: Webster GD, Goldwasser B (Hrsg.). Urinary Diversion. Oxford: Isis Medical Media 1995: 244-251
- 40 Makkas M. Zur Behandlung der Blasenektopie. Umwandlung des ausgeschalteten Coecum zur Blase und der Appendix zur Urethra. Zentralbl Chir. 1910; 37 1073-1076
- 41 Mansson A, Mansson W. When the bladder is gone - quality of life with different forms of urinary diversion. World J Urol. 1999; 17 211-218
- 42 Marshall I Y, Bissada N K. Study of the unaltered in situ appendix as a native continence mechanism: cadaveric and clinical correlation. J Invest Surg. 1995; 8 147-152
- 43 McGuire M S, Grimaldi G, Grotas J, Russo P. The type of urinary diversion after radical cystectomy significantly impacts on the patient's quality of life. Ann Surg Oncol. 2000; 7 4-8
- 44 Mitrofanoff P. Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques. Chir Ped. 1980; 21 297-305
- 45 Monti P R, Lara R C, Dutra M A, de Carvalho J R. New techniques for construction of efferent conduits based on the Mitrofanoff principle. Urology. 1997; 49 112-115
- 46 Mouriquand P D, Boddy S. Salvage procedures for failed Benchekroun hydraulic valves: experiences in four patients. Br J Urol. 1996; 77 740-744
- 47 Mundy A R. The future of Urology. Vorgetragen anlässlich der Jahrestagung der British Association of Urological Surgeons. Dublin 25. - 28. Juni 2001
- 48 Narayanaswamy B, Wilcox D T, Cuckow P M, Duffy P G, Ransley P G. The Yang-Monti ileovesicostomy: a problematic channel?. BJU Int. 2001; 87 861-865
- 49 Nieh P T. The Kock pouch urinary reservoir. Urol Clin North Am. 1997; 24 755-772
- 50 Okada Y, Shichiri Y, Terai A, Kakehi Y, Terachi T, Arai Y, Yoshida O. Management of late complications of continent urinary diversion using the Kock pouch and the Indiana pouch procedures. Int J Urol. 1996; 3 334-339
- 51 Riedmiller H. Kommentar. Akt Urol. 1998; 29 II
- 52 Riedmiller H, Bürger R, Müller S, Thüroff J W, Hohenfellner R. Continent appendix stoma: a modification of the Mainz pouch technique. J Urol. 1990; 143 1115-1116
- 53 Ronzoni G, De Vecchis M, Raschi R, Cuneo L, Cagossi M. Rome pouch: preperitoneal continent ileal reservoir with hydraulic valve. Br J Urol. 1992; 70 514-518
- 54 Roth S, Weining C, Hertle L. Continent cutaneous urinary diversion using the full-thickness bowel flap tube continence mechanism: a simplified tunneling technique. J Urol. 1996; 156 1922-1925
- 55 Sanda M G, Jeffs R D, Gearhart J P. Evolution of outcomes with the ileal hydraulic valve continent diversion: reevaluation of the Benchekroun catheterizable stoma. World J Urol. 1996; 14 108-111
- 56 Skinner D G, Lieskovsky G, Boyd S D. Continuing experience with the continent ileal reservoir (Kock pouch) as an alternative to cutaneous urinary diverison: an update after 250 cases. J Urol. 1987; 137 1140-1145
- 57 Stein R, Pfitzenmaier J, Behringer M, Hohenfellner R, Thüroff J W. The long-term results (5 - 16 years) of the Mainz pouch I technique at a single institution. J Urol. 2001; 165 (suppl) A360
- 58 Studer U E, Hautmann R E, Hohenfellner M, Mills R D, Okada Y, Rowland R G, Tobisu K, Tsukamoto T. Indications for continent diversion following cystectomy and factors affecting long term results. Vorgetragen anlässlich des 5. International Consensus Meeting on Bladder Cancer, Tokio, Japan. 1997
- 59 Sullivan H, Gilchrist R K, Merricks J W. Ileocecal substitute bladder: long-term follow-up. J Urol. 1973; 109 43-45
- 60 Tasker J H. Ileo-cystoplasty: a new technique: an experimental study with report of a case. Br J Urol. 1953; 25 349-353
- 61 Thüroff J W, Alken P, Riedmiller H, Engelmann U, Jacobi G H, Hohenfellner R. The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion. J Urol. 1986; 136 17-26
- 62 Thüroff J W, Alken P, Riedmiller H, Jacobi G H, Hohenfellner R. 100 cases of Mainz pouch: continuing experience and evolution. J Urol. 1988; 140 283-288
- 63 Verhoogen J. Neostomie uretero-caecale. Formation d'une nouvelle poche vesicale et d'un nouvel uretre. Ass Franc d'Urol. 1908; 12 362-365
- 64 Watson H S, Bauer S B, Peters C A, Mandell J, Colodny A H, Atala A, Retik A B. Comparative urodynamics of appendiceal and ureteral Mitrofanoff conduits in children. J Urol. 1995; 154 878-882
- 65 Weijerman P C, Schurmans J R, Hop W C, Schroder F H, Bosch J L. Morbidity and quality of life in patients with orthotopic and heterotopic continent urinary diversion. Urology. 1998; 51 51-56
- 66 Woodhouse C RJ. Long-term results of the Mitrofanoff-Stoma. Dial Ped Urol. 1999; 22 7-8
- 67 Woodhouse C RJ. Reconstructive Urology (1). In: Gerharz EW, Emberton M, O'Brien T (Hrsg.). Classic Papers in Urology. London: Isis Medical Media 1999: 183-203
- 68 Woodhouse C RJ, MacNeily A E. The Mitrofanoff principle: expanding upon a versatile technique. Br J Urol. 1994; 74 447-453
- 69 Yang W-H. Yang needle tunneling technique in creating antireflux and continent mechanisms. J Urol. 1993; 150 830-834
- 70 Zingg E, Tscholl R. Continent cecoileal conduit: preliminary report. J Urol. 1977; 118 724-728
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