HISTORICAL PERSPECTIVE OF THE USE OF BOWEL IN UROLOGY

In relatively recent years bowel has become an important part of the urologic surgeon's armamentarium for dealing with a wide variety of reconstructive problems in both pediatric and adult patients. Historically, use of bowel as a substitute in the urinary tract was described a century ago. 75 These early efforts have been described in a scholarly fashion by Goodwin, 30 who did much to advance the art of incorporating bowel into the urinary tract during his own brilliant and innovative career. Only relatively recently, however, has use of bowel in the urinary tract been so commonplace that most recent graduates in urology have experience with surgery of the small bowel, colon, and stomach in constructing conduits, reservoirs, and augmentations, or using bowel to prevent reflux or provide continence. There has been a virtual revolution in recent years in what the urologic surgeon can do when faced with a severe anomaly in a child, such as cloacal exstrophy or in reconstructing an adult after cystectomy for cancer. Improved anesthesia has been one of the most important keys in these advances because many of the reconstructive cases using bowel are lengthy and cannot be done hurriedly. The expertise of our anesthesiology colleagues today is far ahead of what was available just 30 to 40 years ago. Modern intraoperative monitoring of blood pressure, electrocardiogram, blood gases, and electrolyte concentrations allows physiologic homeostasis during prolonged surgery during which there are enormous shifts of body fluids. Better anesthesia and modern day intensive postoperative care have made it possible to manage complex cases that could not be accomplished previously. This is particularly true for infants and children. I can recall many instances of intraoperative cardiac arrest early in my own career when there were very few anesthesiologists who concentrated their efforts in the pediatric age group. Newer radiographic imaging techniques have contributed enormously to our understanding of urologic physiology, function, and anatomy, and secondarily to development of reconstructive technique using bowel. Radiographic screening in 1960 consisted of an intravenous pyelogram, a static cystogram through an indwelling catheter, and a retrograde pyelogram to visualize the ureter. Modern dynamic imaging with radionucleide techniques, CT scan, MR imaging, and so forth did not exist. Intermittent catheterization, popularized by Lapides et al, 57 was an essential step to the development of much of the surgery we do today in both children and adults. It was recognized 40 years ago that inlying tubes are associated with chronic urosepsis, stones, and gradual deterioration of the urinary tract. Therefore, when Lapides et al 57 introduced the idea of catheterizing the urinary tract to empty it, there was much skepticism about it. It soon became apparent, however, that passing a clean catheter after hand washing can effectively empty the urinary tract without creating the risks posed by an inlying tube. This opened the door for bladder augmentation, which often depends on intermittent catheterization, and construction of the internal urinary reservoir to be emptied by catheterization (continent diversion). As so often happens in surgery, one advance often spawns another. The concept increased greatly the use of bowel in the urinary tract. Improved surgery to create a continent bladder outlet, including the use of an artificial sphincter, has also increased the use of bowel in the urinary tract to augment the small bladder with inadequate volume. Modern endoscopy equipment and simultaneous videoscopy have contributed greatly to modern reconstructive urology. Senior surgeons remember endoscopes illuminated by an incandescent light bulb. The surgeon's view was poor by today's standards and teaching was frustrating to pupil and teacher alike.