Brief History

Living with a Parastomal Hernia

One of the aims of the UA is to promote and co-ordinate research related to urinary conditions and particularly in connection with applicable equipment.

The UA’s National Executive Committee is constantly negotiating the funding of future research projects. Research has enabled great changes to have been made in surgical techniques.

Past

Today, bladder cancer requiring cystectomy (removal of the bladder) is the most frequent indication for a urinary diversion. The first complete radical cystectomy was performed on January 13, 1887 in Cologne, Germany, but the surgery was unsuccessful because of the lack of an adequate method of urinary diversion and the patient died 14 days after surgery due to uraemia and hydronephrosis, but the surgeon had proved the technical feasibility of this operation.

0ld-surgery_1By 1923 the commonest form of urinary diversion was ureterosigmoidoscopy but the operation of cystectomy at that time carried a 59% mortality rate and even by 1939, only 250 cystectomies had been reported.

The incontinent urinary diversion, also known as the Bricker’s loop, ileal loop, or ileal conduit, was developed in the 1950s and rapidly became the gold standard diversion.

It is still the most prevalent procedure, primarily because it is relatively uncomplicated, and is also the urinary diversion procedure most urologists have been trained to perform.

Although the majority work reasonably well, the ileal conduit is far from the perfect solution because of the high incidence of ureter and stoma strictures and urinary reflux to the kidneys. These strictures frequently impair, or even block, urine flow, and may require surgical revision. Additionally, the incidence of ascending bacteria and urinary reflux remains substantial and results in repeat kidney infections and progressive kidney deterioration in up to 30% of the cases.

Present

During the course of the past 20 years, however, we have seen the introduction of alternatives to ileal conduit urinary diversion and these include the continent urinary diversions and the development of orthotopic diversions. Despite these advances, however, in 2012 the ileal conduit diversion still remains the commonest form of urinary diversion performed after a cystectomy, as it is a safe and reliable operation, has a low complication rate and a high patient satisfaction level.

theatre_1The later types of urinary diversion are associated with a much longer operative time, sometimes lasting six hours, and a higher incidence of complications and re-operation rates. There is no doubt, however, that the newer forms of diversion are very popular, especially with younger patients, but the patient’s general condition and other medical problems need to be taken into account when making a decision regarding a particular form of surgery.

There is clear evidence that the age of patients undergoing cystectomy is slowly increasing as the average age of the general population rises and as one gets older, other medical problems develop which may influence the preferred treatment.

Future

New developments in surgical techniques, particularly the introduction of laparoscopic and robotic surgery will further reduce the morbidity and complications related to urinary diversion surgery.

Although there are significant cost implications related to the development of these new surgical techniques, it is certain that they will offer huge advantages to patients undergoing urinary diversion and in the future allow surgeons to undertake more complex procedures in the older patient who has additional medical problems.

For a surgeon trained in conventional techniques laparoscopic procedures can be very taxing and difficult. A simple task like tying sutures suddenly becomes very demanding when performed via a television screen. Try fixing a bow-tie in a mirror to understand the problems. One’s fingers are always moving in the wrong direction.

daVinciRobotRobot-assisted surgery was developed to overcome the limitations of minimally invasive surgery. Instead of directly moving the instruments the surgeon uses a computer console to manipulate the instruments attached to multiple robot arms. The computer translates the surgeon’s movements, which are then carried out on the patient by the robot.

Other features of the robotic system include, for example, an integrated tremor filter and the ability for scaling of movements (changing of the ratio between the extent of movements at the master console to the internal movements of the instruments attached to the robot). The console is located in the same operating room as the patient, but is physically separated from the operative workspace.

Since the surgeon does not need to be in the immediate location of the patient while the operation is being performed, it is possible for specialists to perform remote surgery on patients.

With the cost of the robot at £1million and disposable surgical material costs of £1,500 per operation, the cost of the procedure is much higher. Numerous feasibility studies have been done to determine whether it is really worth a hospital’s while to purchase such a system and opinions differ dramatically.

Surgeons report that, although the manufacturers of the systems provide training on this new technology, the learning phase is intensive and surgeons must operate on twelve to eighteen patients before they feel comfortable with the system. During the training phase, minimally invasive operations can take up to twice as long as traditional surgery, which ties up operating room and surgical staff time and keeps patients under anaesthesia longer.

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