Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy

 

Abstract

Background

Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments.

Objectives

To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease.

Search methods

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 19 June 2007) and the reference lists of relevant articles.

Selection criteria

All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract.

Data collection and analysis

Trials were evaluated for appropriateness for inclusion and for methodological quality by the review authors. Three review authors were involved in the data extraction. The data collected was then analysed for statistical significance.

Main results

Four trials met the inclusion criteria with a total of 284 participants. These trials addressed only five of the 14 comparisons pre-specified in the protocol. One trial reported no statistically significant differences in the incidence of upper urinary tract infection, ureterointestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. The confidence intervals were all wide, however, and did not rule out important clinical differences. In a second trial, there was no reported difference in the incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. Similarly, a third trial reported no differences in the incidence of dilatation of upper tract, urinary incontinence or wound infection using different intestinal segments for the bladder replacement. However the data were reported for 'renal units', but not in a form that allowed appropriate patient-based paired analyses. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions and bladder replacement groups. Again, the outcome data were not reported as paired analysis or in form to carry out paired analysis.

Authors' conclusions

The evidence from the included trials was very limited. Only four studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The small amount of usable evidence for this review suggests that collaborative multicentre studies should be organised, using random allocation where possible.

 

Plain language summary

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence following bladder surgery

The normal urinary bladder is a hollow muscular organ that lies deep in the pelvis. It functions through the balanced activity of many inter-related nerves and muscles that contain or empty urine as needed. If the bladder has been damaged by disease, surgery can be performed to divert the urine from the bladder (urinary diversion), to reconstruct the bladder or to replace the bladder with intestinal segments. The review did not find enough evidence from trials to show which surgical options are the most effective. More research is needed to determine the most effective surgical methods for urinary diversion, reconstruction or replacement of the urinary bladder that has been damaged by disease.

 

摘要

背景

利用腸道的尿液分流術與膀胱重建/置換術治療難治性尿失禁或膀胱切除

背景 一個世紀前，對於功能受損的膀胱，已經可以藉由手術改善甚至取代原有膀胱的功能。大部分膀胱受損的原因不外乎:膀胱癌 、神經性膀胱功能障礙、逼尿肌活動亢進(detrusor overactivity)、或膀胱的慢性發炎(例如：間質性膀胱炎、結核病、血吸蟲等感染所引起的發炎。對於最合適的手術治療仍有其不確定性。基本上，現階段可提供的手術有以下，包括：1)通路分流術(conduit diversion：製造從腸道的某一段到皮膚的尿液通路)或者可控式尿流改道(continent diversion：可以藉著經直腸人造膀胱或者禁制性經皮分流術)2)膀胱重建術，以及3)利用腸道片段進行的膀胱置換術。

目標

對於將被移除的膀胱、失去功能或者有留存之疑慮的膀胱，可以找到一個最好的方式：改善或使用某腸段來取代下泌尿道的功能

搜尋策略

我們在實證醫學資料庫┌考科藍實證醫學尿失禁組┘搜尋資料以及其列於參考資料中相關的文章(於2007年六月19日)。

選擇標準

有關在泌尿道中置放腸段的手術的所有隨機或半隨機對照試驗。

資料收集與分析

這些試驗皆被回顧文獻的作者們評估其合適度以及研究方法之品質。其中，有三位回顧文獻的作者參與資料解析的工作。此外，所有收集來的數據皆以有統計意義的方法加以分析。

主要結論

在284個試驗中，有4個試驗符合優良臨床試驗準則。這些試驗提出，十四個對照中只有五個在治療準則中有做提前的明確說明。 其中一個試驗指出，通路分流術以及可控式尿流改道術兩者在於術後併發症的比較中，即：上泌尿道感染、泌尿生殖道狹窄，以及腎臟的惡化三者的發生率，並沒有顯著的統計學差異。信賴區間接呈現寬的狀況，然而，卻無法排除重要的臨床差異。在第二個試驗中，在改良通路分流術：以迴腸或大腸來做人造膀胱的比較中，對於上泌尿道感染、泌尿生殖道狹窄的術後併發症，發生率亦沒有差別。相同的，在第三個試驗中，使用不同腸段來取代膀胱的手術比較結果，上泌尿道的擴張、尿失禁、術後傷口感染三個併發症的比較亦沒有差別。然而這些實驗數據是建立在以腎臟為單位的比較基礎上，而不是以病患為基礎的集對分析。 比較“可控性尿流改道的輸尿管腸管吻合術”與“膀胱置換術”中“的反尿液逆流”及“尿液逆流”兩組比較，腎臟疤痕逆流的發生率沒有顯著的統計學意義。 我們再次重申，實驗數據的結果並不是以集對分析的方法，亦或以實踐集對分析的方法來呈現。

作者結論

符合優良臨床試驗準則的試驗所能提供的訊息實在有限。只有四個臨床試驗符合準則：小量、中等程度或貧乏的研究方法品質，呈現出少量的預先篩選成果指標。這篇回顧文獻沒有找到在因癌症的膀胱切除後，有關膀胱置換術(正位性或可控式尿路分流)優於通路分流術的證據。在良性膀胱病變中，亦沒有證據指出膀胱重建優於通路分流術。這篇文獻只提供少量建議：即眾多研究中心的共同研究必須整合，且應使用隨機分配之形式。

翻譯人

本摘要由中國醫藥大學附設醫院伍貞穎翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

我們需要更多的研究，來幫我們決定何者為尿液分流術、膀胱重建/置換術中最有效的手術方法。 正常的膀胱是一個中空的肌肉器官深藏在骨盆腔內。必須由其內許多的神經、肌肉和諧的相互各司其職，膀胱才能發揮正常功能，例如：儲尿或排尿。若膀胱因病受損，手術可以幫忙尿液改變通路而排出(尿液分流術)，或者重建膀胱．或可以藉由某腸段來取代膀胱功能。但是，回顧文獻並沒有提供足夠的資訊證明哪一種手術最為有效。