The efferent segment in continent cutaneous urinary diversion: a comprehensive review of the literature
Authors: Ardelt Peter U. , Woodhouse Christopher R.J. , Riedmiller Hubertus , Gerharz Elmar W. 
Published: June 2011

Study Type – Prognosis (case series)

Level of Evidence 4

What’s known on the subject? and What does the study add?

While the ileal conduit and orthotopic neobladder are the most commonly used diversions today, continent cutaneous reservoirs remain an invaluable treatment option for a well‐defined subset of indications. After several decades of surgical experience a continuous optimisation process, especially for the continence mechanism, is still ongoing. The continence mechanism largely determines the treatment success in terms of patient satisfaction and quality of life. At present, no consensus has been reached regarding an optimal technique. Common problems include stomal stenosis with impaired catheterisation, urinary incontinence, and nipple gliding.

This review critically examines published reports on the various efferent segments used in continent catheterisable urinary reservoirs. It compares data regarding the complications as well as clinical performance. Hence, it provides a valuable comparison and insight into some of the biophysical properties, shortcomings and complications of the different outlets. Also, this view clearly demonstrates that literature evidence for each technique remains poor.

OBJECTIVE

• To critically assess the biophysical properties and current status of outlet formation in heterotopic intestinal urinary diversion. As despite three decades of clinical experience with continent cutaneous urinary diversion through bowel segments, no consensus has been reached for the optimal efferent segment although its function largely determines patient satisfaction.

METHODS

• A comprehensive Medline literature search using the Medical Subject Headings database (search terms: continent urinary diversion followed by either efferent segment, nipple, Mitrofanoff, Yang‐Monti, Benchekroun, tapered ileum, intussuscepted ileum, Kock pouch, T‐valve, or Ghonheim) was conducted to identify all full‐length original articles addressing the various principles and techniques of outlet formation as well as their outcomes and complications.

• Examined series were published in English between 1966 and 2010.

• All studies were systematically evaluated using a checklist (study design, number of patients, etc.) and rated according to the Oxford Centre for Evidence‐Based Medicine Levels of Evidence (LoE).

RESULTS

• While there was a continuous flow of publications over the last three decades, the vast majority of studies were retrospective case series with numerous confounding factors and poorly defined, non‐standardized outcomes (LoE, 3). Only a few investigations compare different efferent segments (LoE, 2a).

• No randomized studies exist.

• The major biophysical principles are based on the use of flap, nipple, and hydraulic valves.

• Vermiform appendix, intussuscepted ileal nipple, and the Yang‐Monti tube are the most popular techniques and have well‐established data on outcomes, complications, and failure rates.

• Artificial sphincter systems and tissue engineering have provided disappointing results thus far. Most reconstructive strategies are subject to a process of on‐going improvement.

CONCLUSIONS

• The continuous quest for optimization has not led to a single universally applicable efferent segment in continent cutaneous urinary diversion.

• While all techniques have their unique set of advantages and disadvantages, they will always remain a compromise. Success depends on selecting the optimal strategy for individual patients.

• A major change in principles in the near future is unlikely.