Radical cystectomy is the most effective treatment for muscle-invasive bladder cancer. Uroflow diversion, or reconstruction of the urinary storage organ, has been an important topic after cystectomy and is directly related to the patient’s postoperative quality of life and tumor cure rate. In the past 30 years, there has been a rapid development of urethral rerouting technology, and various urethral rerouting methods have emerged, and there are dozens of controlled urethral rerouting procedures alone. Looking back at the history of surgical development, there are three main forms of urinary diversion: channeled uncontrolled urinary diversion, represented by Bricker’s bladder; controlled urinary diversion with abdominal wall stoma to control urine, represented by Kock’s bladder; and in situ urinary diversion, represented by Studer and Hautmann’s ileal neobladder, etc.
Channeled non-controllable urinary diversion: (1) Ureteral skin stoma: Hages selectively applied ureteral skin stoma, a urinary diversion procedure, in 1811, which is still in use today. It is suitable for people with short life expectancy, distant metastases, or systemic conditions that do not tolerate other procedures. This procedure is prone to retrograde infection and requires the wearing of an ostomy bag.
(2) Ureterocolic anastomosis: In 1852 simon applied ureterosigmoid anastomosis to treat congenital bladder exstrophy, and later was used to reroute urinary flow after radical cystectomy, which is rarely used today due to complications such as urinary flow infection and electrolyte disturbance caused by urinary-fecal coarctation.
(3) Ileal cystectomy: Bricker proposed ureteral ileal cystectomy in 1950. The operation was performed by taking the terminal ileum 15 cm to 20 cm, bilateral ureteral and ileal end-lateral anastomosis, ileal output port in the abdominal wall fistula, and external urinary collector. This procedure overcame a series of shortcomings such as electrolyte imbalance and urinary tract infection, making it once considered the best method for urinary diversion. With advances in surgical techniques, this procedure, once considered the gold standard for urinary diversion, is now being replaced by controlled cystoplasty and in situ bladder reconstruction.
Controlled urinary diversion with abdominal wall stoma control: (1) KOCK bladder. 1982 KOCK published controlled ileal cystectomy, and this procedure was carried out one after another at home and abroad. The operation is basically the same as ileal cystectomy, the difference is that the outflow tract intestine line narrowing, so that the intestine has a certain function of urine storage, without the need to wear a urine collector. However, the anastomosis is prone to stenosis and it is difficult to self-catheterize.
(2) Ileal storage bladder: This controlled bladder surgery has two output tracts, one is the ileal output tract ventral wall fistula and the other is the in situ appendiceal output tract ventral wall fistula, which is a modification of the KOCK bladder.
(3) Rectal cystoplasty: The rectum is used as a urinary storage sac, the sigmoid colon is fistulated ventrally, and the anal sphincter is used for urinary control. The procedure is simple and has few complications, but requires stool diversion, which is not easily accepted by patients.
(4) Sigma rectal cystectomy: controlled urinary diversion utilizes the original urethral orthotropic substitution bladder and rectal controllable bladder within a controlled range, which is in accordance with the physiological situation and easily accepted by patients. Various controllable urinary pouches with abdominal wall insertion have problems of difficult insertion, stone formation in the pouch and degradation of the controllable mechanism over time. This procedure does not require the use of a urinary bag and does not require regular intubation, making it a more desirable way to reroute urinary flow. The Sigma rectal bladder was first reported by Fisch et al. in 1993 and has achieved good results in both domestic and international clinical applications. The Sigma rectal bladder was first reported in 1993 by Fisch et al.
In situ urinary diversion i.e., in situ cystectomy: Traditional urinary diversion surgery with its output end mostly in the abdominal wall stoma requires wearing a urine collection bag or intubation for urination, which brings great inconvenience to the patient’s life and social life. In contrast, orthotopic cystectomy can achieve close to normal physiological voiding, and some male patients do not affect the erectile function after surgery due to the preservation of the erectile neurovascular bundle, which greatly improves the survival and quality of life of patients and is easily accepted by patients.
The first case of in situ ileal neobladder was reported by Camey in 1979. Currently, the common in situ urinary diversions include Studer, Hautmann, Camey II, W-shaped ileal neobladder, S-shaped ileal neobladder, low-pressure ileal neobladder, half-Kock bladder, Mainz bladder, Le-Bag bladder, right hemi-colonic bladder, sigmoid neobladder, and T-shaped bladder. Most of the procedures are performed with a low bowel storage bladder anastomosed to the posterior urethra to achieve in situ voiding. In those with well preserved external sphincter function, postoperative daytime voiding is controllable up to 75%, so whether the external sphincter function is intact is the key to the controllable mechanism. Nocturnal loss of urine is the biggest drawback of orthotopic controllable bladder, because during normal bladder filling, the spinal reflex ensures enhanced contraction of the external sphincter, while in patients with total bladder removal, the above reflex arc has been interrupted, so incontinence is easily produced at night during the sleep state. Learning to increase abdominal pressure to urinate is the key to urination in patients undergoing this procedure. Follow-up has shown that the residual urine volume can be ideal with proper voiding methods. Dyspareunia is also a common complication of neobladder surgery and is reported in the literature as requiring intermittent catheterization to empty the bladder in 4-25% of patients. The causes are multiple and include: angulation of the urethra, opening of the neobladder not at its lowest point, obstruction of the urethral opening by the wall of the urinary bladder, and inability to void with abdominal pressure and a relaxed pelvic floor. Therefore, in addition to surgical factors, postoperative patient voiding training is very important. Patients must understand that reducing the resistance at the bladder outlet is the key to being able to pass urine, and that it is useless to increase abdominal pressure only if the pelvic floor muscles are not relaxed. Clinically, some patients have been able to pass urine after changing to a squatting position when they have difficulty passing urine in a standing position, which illustrates from one side the importance of relaxing the pelvic floor muscles during voiding.
There are many ways to reroute the urinary stream, and new procedures will continue to emerge as technology and medicine evolve. The more options surgeons and patients are faced with, the more difficult their choices become, but as long as they grasp the basic medical and humanistic principles, put the patient’s interests first, insist on individualized treatment, and perfect and strengthen perioperative treatment and care, they can truly maximize the patient’s interests.