Bladder substitution after pelvic evisceration

Abstract

(Reprinted with permission from Surg Clin North Am, 30: 1511-1521, 1950) The problem of developing a suitable substitute for the urinary bladder has been one that has intrigued surgeons intermittently for a good many years. Practically all anatomical possibilities were exhausted at the beginning of this century. Hinman and Weyrauch I have reviewed the various attempts at bladder substitution by ureteroenterostomy. Apparently the first attempt to divert the urinary stream into an isolated segment of ileum and ascending colon was done by Verhoogen 2 in 1908. Such attempts were subsequently discarded because of the prohibitive mortality and the problem of ureteral disposal following cystectomy was solved for many years by the simple implantation of the ureters into the intact sigmoid colon. This procedure is still the one of choice following cystectomy and it will probably remain the procedure of choice in cases in which the sigmoid and rectum can be preserved. However, the recent development of pelvic evisceration as a therapeutic procedure has focused attention again on the problem of what to do with the ureters in cases in which this procedure is used, since the sigmoid colon and rectum are not available as a receptacle. Our interest in carrying forward the radical surgical attack on malignant lesions dates back to 1940 at the Ellis Fischel State Cancer Hospital at Columbia, Missouri. It became evident at that time that in dealing with some lesions, particularly of the colon, we would be limited in our resections only by certain philosophical considerations. The concept of radical amputative surgery could be carried to such a stage that what was left with the patient became a consideration of equal importance to that which was removed. It seemed that if we could not leave a patient in a physiological state compatible with a comfortable existence we were not morally justified in doing some of the extensive procedures. Pelvic evisceration was one of our interests at this time. The procedure was directed at a few advanced lesions of the~Cbladder and prostate. In these cases all pelvic viscera were removed by an abdominoperineal technic. It appeared unnecessary, however, to do a high resection of the sigmoid colon for pathologic lesions of this type. Consequently, we were able to save an isolated segment of sigmoid colon into which the ureters were implanted (Fig. 435, 1, a). Itnever occurred to us at that time to implant the ureters into the intact colon, which was to drain through a colostomy opening, the so-called colostomy. This, of course, was before the days of the Rutzen bag and a wet colostomy would not have fitted in with our ideas of leaving the patient in a physiological state compatible with a comfortable existence. Only two of the four patients operated upon at that time survived the operative procedure; one of these, with carcinoma of the prostate, survived for eighteen months and subsequently died of