“J. Simon published the first attempt at continent urinary drainage in 1852, which was a case of ureterosigmoidostomy for ectopia vesicae. In the following years, this technique of simple implantation of the ureter into the intestines was used in several cases, but the patients died relatively early after the operation because of anastomotic incompetence and/or the serious consequences of the reflux of fecal material from the intestine into the upper urinary tract. An alternative attempt of reducing septic complications in the preantibiotic era was by separating the faeces from urine completely. Others, such as Verhoogen (1908), Makkas (1910), Lengemann (1912) used the excluded ileocecal segment as a reservoir and the appendix as an outlet valve. After the first attempts of continent urinary diversion with the use of the ileocecal segment at the beginning of this century, Gilchrist and Merricks reintroduced in 1950 the concept of the continent pouch. It was simple because only intact anatomical structures were used: the caecum as reservoir, and, instead of the appendix, the ileocecal valve and the terminal anisoperistaltic segment of the ileum as antireflux mechanism. This had been prompted by studies published in Argentina by Gallo in 1946, by Santander in 1952 and by Mann and Bollmann in 1931. The original good results in respect of continence could not be confirmed subsequently by other authors for reasons which will be discusses later. However, the idea of the “continent skin stoma” remained. The technique which was most frequently used to assure continence is invagination or intussusception of a segment of the small intestine. The technique was first described in 1949 by Perl for a continent alimentary jejunostomy. The principle was used by Ashken (1974) and Mansson (1977) among others with a cecal reservoir. The “hydraulic valve” with inversion of an ileal segment, described in 1974 by Benchekroun, is based on the same principle: compression of the nipple valve by the surrounding fluid which transmits the intra luminal pressure to the outlet valve. Retrospectively, many disappointing results with various forms of continent suprapubic diversion were often not caused by insufficient competence of the outlet valve, but because the intestinal reservoir maintained its peristaltic properties causing high pressure peaks.

The decisive advance in ensuring continence, and thus an improvement in the comfort of the patient, was achieved through the combination of the continent stoma and a so-called low-pressure reservoir. The main characteristics of this reservoir compared with those from intact segments of intestine are the larger diameter, the greater capacity with significantly lower internal pressures, and the uncoordinated contraction of its wall. The direct consequence of this, theoretically at least, is that the demands made on the anti-efflux and antireflux mechanisms are significantly reduced. Transsection of the circular intestinal musculature when performing bladder augmentation has already been puplished [sic] by Rutkowski in 1899. Tasker (1953) and Giertz (1957) plicated detubularized ileum, whereas Goodwin (1959) double folded it.

Please log-in or register in order to submit comments.

Powered by AkoComment!