Neobubble
Under a Neobladder is understood in the medical , in particular the urology , one from the small intestine started continent urinary bladder replacement.
The formation of a neobladder or ileum conduit is usually necessary after a cystectomy , i.e. removal of the urinary bladder (and prostate ). The neobladder takes over the reservoir function of the previously removed urinary bladder. The reservoir of intestinal loops is constructed using what is known as detubularisation: the small intestine is cut open lengthways and sewn in an N, S or W shape to form an intestinal plate. The intestinal panel is folded and the outer edges are connected to one another. The ureters are connected to the reservoir in different ways, depending on the surgical technique. The goal is a reservoir that can hold a sufficiently large volume of urine without a large increase in pressure. The neobladder is connected to the urethra in place of the urinary bladder or, if that is not possible (see below), connected to the body surface (skin) in another way. The prerequisite is that the urethra is not affected by the cancer. The neobladder is connected to the urethra and the urine is excreted through this as before. In contrast to the other alternatives to urinary diversion, this ensures a much better quality of life and a lower risk of infection. The problem with the small intestinal tissue is its ability to secrete relatively large amounts of mucus , which is then found in the urine. Furthermore, the resorption (re-absorption) of urine components through the small intestinal mucosa can lead to disturbances of the acid-base balance and the "blood salts" ( electrolytes ). After the creation of a neobladder, bothersome urinary incontinence can arise.
History of the artificial urinary diversion
The idea of artificial urinary diversion is as old as that of removing the urinary bladder. Many methods have been developed and tried over time.
The history of artificial urinary diversion began in 1852. The surgeon John Smith made a ureter-intestinal fistula to the rectum with a double-barreled catheter made of silver . The 13-year-old patient died a year later of peritonitis.
The first successful ureteral implantation in the intestine was also performed by Smith in 1878.
As early as 1887, the German surgeon Bernhard Bardenheuer performed the first complete bladder removal. He wanted to implant the ureters in the intestine, but could not find one of the two ureters during the operation. The urine collected in the pelvis and the patient died two weeks after the operation.
The results of full cystectomy (removal of the bladder) were not encouraging: a 1952 study found a five-year survival rate for malignancies of only 9%. The introduction of radical cystectomy by Whitemore and Marshall in 1956 brought a significant improvement in results. With this surgical technique, in contrast to total cystectomy, all surrounding tissue is also removed, i.e. the tumor is incised at a greater safety distance .
Another milestone was the ileum conduit introduced by Bricker in 1950 . In this procedure, a 10 cm long piece is cut out of the small intestine, and the two loose ends of the small intestine are then reconnected with an anastomosis . The two ureters are implanted at one end of the separated section of the intestine and a stoma is implanted in the abdominal wall above the skin level on the other side.
The first neobubble was introduced by Camey in 1958. He switched off a segment of the small intestine and connected the two ureters on one side. The piece of small intestine was retained in its original, tubular shape, not cut open and sewn in a spherical shape as is customary today.
Before 1980, the patient's risk of not surviving such an operation because of anesthesia and subsequent intensive care was still high. Only great advances in anesthesia in the 1980s made such extensive operations possible. In the meantime, efforts have been made to split the operation into two operations in order to reduce the risk for the patient: in the first step, the neobladder was formed from intestinal parts and in a second operation the natural urinary bladder was removed.
Hautmann's neo-bladder
This form of urinary diversion was developed by R. Hautmann and colleagues at Ulm University . It was first described in 1987. In this neobladder, a 65 cm long piece of small intestine is turned off and sewn in a W-shape to form a plate. After sewing in the ureters and connecting them to the urethra , the two ends of the intestinal plate are sewn together.
Neobladder according to Studer
With the neobladder according to U. Studer from Inselspital Bern , a 45 cm long piece of small intestine is eliminated. The intestine is split up to 10–15 cm. This is where the ureters will later be implanted. After connecting to the urethra, the new bladder is closed.
MAINZ Pouch I
The MAINZ-Pouch I (mixed augmentation ileum 'n zecum) consists of 1/3 of the large intestine and 2/3 of the small intestine and can later hold a urine volume of 300–600 ml. Like the neobases according to Hautmann and Studer, it belongs to the low-pressure systems. The replacement bladder is connected to the navel via a piece of small intestine or, if still present, the appendix . The bladder can then be emptied with a catheter . As a rule, the patients are continental.
MAINZ Pouch II
The ureters are implanted in the rectum and urine is passed through the anus along with the stool . The prerequisite for this is that the sphincter muscle works well , which is checked before the operation. This type of urinary diversion has long been the method of choice. Today, however, it is rarely used because of the high complication rates. A big problem is the sphincter function, which declines in the course of life, because it decreases continence. In addition, follow-up complications due to contact of the mucous membrane with urine with electrolyte disturbances up to the not inconsiderable rate of malignancies in the long-term must be taken into account.
Jena urinary bladder
The Jena urinary bladder is similar to the Hautmann and Studer procedures. However, with this method, parts of the prostate are preserved in men , on which the neobladder formed from the small intestine is then placed. The benefits are not only improved continence for the patient, but also the preservation of potency. Furthermore, the operation time is shorter and the perioperative blood loss is lower.
