„Auf der Suche nach dem Heiligen Gral”: Das efferente Segment in der kontinenten kutanen Harnableitung

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.

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