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History of Urinary Diversion

The history of urinary diversion runs from Simon's ureterosigmoidostomy for bladder exstrophy in 1852 to robotic intracorporeal reconstruction. In 1950 Bricker popularized the ileal conduit, building on Zaayer's 1911 description, and it is still the most common diversion after cystectomy.[1] Kock's detubularized, double-folded ileal reservoir (first used in 1975) set the principles for continent cutaneous reservoirs and for the orthotopic neobladders of Hautmann, Studer and others in the late 1980s.[1][2] The first robotic cystectomy with a completely intracorporeal neobladder was reported in 2003.[3]

Ureterosigmoidostomy (1852 to the 1950s)​

The first reported diversion of urine into bowel was Simon's 1852 ureterosigmoidostomy in a patient with bladder exstrophy. He brought the ureters into the rectum with needles and suture to create a fistula; the patient died of sepsis 12 months later.[1] Ureterosigmoidostomy remained in use, and an antireflux tunneled ureterocolonic anastomosis (Leadbetter, 1951; Goodwin and colleagues, 1953) significantly reduced obstruction and ascending pyelonephritis.[1] Leadbetter and Clarke's combined technique joined Nesbit's refluxing elliptical anastomosis to the submucosal tunnel of Coffey.[4][5]

Long-term follow-up showed hyperchloremic acidosis, ureteral obstruction, pyelonephritis and malignant tumors at the ureteral implantation site.[1] In Ferris and Odel's 1950 report on the blood electrolyte pattern after bilateral ureterosigmoidostomy, severe electrolyte disturbance was a major problem in 112 of 141 patients (80%).[4][6]

The cancer risk emerged later. Kälble and colleagues followed 75 patients who had ureterosigmoidostomy between 1942 and 1987; sigmoidoscopic biopsy in 30 of them found 3 carcinomas at the ureterocolonic junction, an 8.5- to 10.5-fold increase over the general population, and the patients excreted more nitrite and N-nitrosamines than controls.[7] Of 24 evaluable children in a Swedish series who had ureterosigmoidostomy between 1944 and 1961 (25 operated, one early postoperative death), most often for exstrophy-epispadias, invasive colorectal adenocarcinoma developed in 7 at a mean of 38 years (range 23 to 55) after surgery, 42 times the risk in the general Swedish population.[8] Current construction, metabolic care and surveillance are on the Ureterosigmoidostomy and Rectosigmoid Diversion page.

The Ileal Conduit (1911 to the 1970s)​

The intestinal conduit separated urine from the fecal stream. Zaayer described the ileal conduit in 1911, and Eugene Bricker refined and popularized it in 1950 in patients undergoing pelvic evisceration.[1][9] Writing 30 years later, Bricker noted that the conduit had been the most widely practiced form of diversion for 25 years and that the ileal conduit had produced less pyelonephritis and hyperchloremic acidosis than any method of diversion used before 1950, while carrying significant complications and a threat to long-term renal function.[10]

Late conduit complications became apparent in the 1970s: skin and appliance problems, peristomal hernia, stomal stenosis, pyelonephritis, stones, ureteral obstruction and renal deterioration. They were attributed to high-pressure reflux of infected urine, but nonrefluxing colon conduits had similar complications.[1] In the Bern series of 131 patients who survived at least 5 years after ileal conduit diversion (1971 to 1995; median follow-up 98 months), 87 (66%) had conduit-related complications; the proportion rose from 45% within the first 5 years to 94% among patients followed for more than 15 years.[11] See Ileal Conduit, Colon Conduit and Cutaneous Ureterostomy.

The ureterointestinal anastomosis​

Wallace's 1970 technique sews the ureters, usually joined to each other, to the end of the bowel segment. It is refluxing and has the lowest complication rate of the ureterointestinal techniques, with stricture in about 3%.[4][12] Antireflux implantation into small bowel followed with the reservoirs. Le Duc and Camey (1979) buried half of a 4 cm ureteral stump between the mucosa and muscle of the ileum and left the other half free in the lumen, and reported no stenosis or reflux in 10 implantations in 6 patients.[13] Abol-Enein and Ghoneim (1994) described serous-lined extramural tunnels in a detubularized ileal W-bladder in 12 patients.[14]

Continent Cutaneous Reservoirs (1950 to the 1990s)​

Gilchrist and colleagues described one of the earliest continent cutaneous diversions in 1950, using the ileocecal valve for continence and the distal ileum as a catheterizable stoma; it attracted little attention at the time.[1][15]

Nils Kock performed the first continent cutaneous ileal reservoir for urinary diversion in 1975 at Sahlgrenska University Hospital in Göteborg.[2] The reservoir used the technique he had developed for the continent ileostomy, with the ureters implanted into an afferent segment protected by a nipple valve. In his 1982 report of 12 patients, nipple-valve malfunction occurred in 8 and was corrected surgically; the 10 surviving patients were continent without reflux, with reservoir capacity above 500 mL, and emptied the pouch by self-catheterization 3 to 6 times a day.[16] Kock's animal and clinical work established complete detubularization and double folding into the most spherical shape possible, the principles behind later cutaneous and orthotopic reservoirs.[1]

Donald Skinner began performing the Kock pouch at the University of Southern California in 1982. Between August 1982 and August 1985, 250 patients had the operation; early complications occurred in 16% and operative mortality was 2%, and 77 patients (31%) needed 85 revisions for late complications.[17] See Kock Pouch.

Ileocecal reservoirs followed. The Indiana pouch evolved from the Gilchrist procedure.[18] In Rowland and colleagues' 1987 report of 29 cecoileal reservoirs, continence came from the ileocecal valve with plication or tapering of the terminal ileum, the ureters were tunneled along the tenia, and the cecum was detubularized with an ileal or sigmoid patch or reconfigured with a Heineke-Mikulicz closure; 93% reported satisfactory continence.[19] With full detubularization, stapled tapering of the efferent limb and plication of the ileocecal valve, the first 69 patients treated with the evolved technique had 97% day and night continence by 1 year.[18] Joachim Thüroff, Rudolf Hohenfellner and colleagues built the Mainz pouch from the cecum and two opened ileal loops, with submucosal-tunnel ureteral implantation and continence from an ileoileal intussusception valve or an alloplastic stomal prosthesis.[20] See Indiana Pouch and Mainz Pouch I.

Mitrofanoff's 1980 transappendicular continent cystostomy, devised for children with neurogenic bladder, used the appendix as a catheterizable channel between the skin and the bladder, its tip opening into the bladder through an antireflux submucosal tunnel. He performed it in 16 children between October 1976 and January 1979.[21] See Catheterizable Channels.

The difficulty across all continent cutaneous designs has been a durable efferent continence mechanism that is easy to catheterize. Stones, difficult catheterization, peristomal hernia and stomal leakage often lead to revision.[1]

Orthotopic Neobladders (1888 to the 1990s)​

Orthotopic substitution predates Kock's continent cutaneous reservoir. In 1888 Tizzoni and Poggi interposed an isolated ileal loop between the ureters and the urethra in a dog, which was reportedly continent and had three pregnancies before dying 30 months later. Lemoine performed the first human orthotopic reconstruction in 1913, converting a ureterosigmoidostomy by transposing sigmoid colon to the urethral stump.[1]

In 1979 Camey and Le Duc reported their clinical experience with orthotopic substitution to the urethra in men with bladder cancer.[1] Lilien and Camey later reviewed 84 men treated with the Camey enterocystoplasty after cystoprostatectomy for carcinoma over a 25-year interval.[22] The original Camey reservoir used an intact ileal segment, which produced a high-pressure reservoir and unacceptable continence.[1]

Detubularization changed this. Richard Hautmann and colleagues described the W-shaped ileal neobladder in 1988: a 70 cm ileal segment opened along its antimesenteric border, fashioned into a spherical pouch with Le Duc–Camey ureteral implantation. Filling pressure stayed below 30 cm H₂O without reflux, and 8 of 11 patients were dry day and night.[23] Studer and colleagues reported a low-pressure ileal reservoir in 22 men in 1989; capacity averaged 450 mL at 6 months, and in the subsequent 18 men with the reservoir anastomosed directly to the membranous urethra rather than through a short tubular segment, no notable residual urine or paroxysmal urinary incontinence was reported.[24] The Camey II detubularized reservoir (1990), Skinner's hemi-Kock neobladder (1991), the extraserosal ureteral tunnel of Abol-Enein and Mohamed Ghoneim, the T pouch of John Stein and colleagues (1998) and the Padua pouch (2018) followed.[1] Orthotopic diversion overtook continent cutaneous diversion because it allows voiding per urethra, is simpler to construct and less often needs revision.[1]

The early neobladders were made only in men, because continence in women was thought to depend on an intact bladder neck and the retained urethra was feared as a site of recurrence. In the mid-1990s anatomic dissections and clinical experience showed that women could remain continent with a low-pressure reservoir and preservation of the urethra alone, and that the approach was oncologically safe.[1] Stein and colleagues reported 34 women with orthotopic reconstruction after cystectomy, operated on from June 1990, in 1997.[25] See Hautmann Neobladder, Studer Neobladder, Camey II Neobladder and T-Pouch.

Detubularized rectosigmoid diversion​

The same principle was applied to ureterosigmoidostomy. Margit Fisch, Hohenfellner and colleagues described the Mainz pouch II (sigma rectum pouch) in 1993, splitting the rectosigmoid junction along its antimesenteric border and closing it side to side. All 47 patients were continent by day and all but one were dry at night, with a basal pressure of 24 cm H₂O and a peak of 35 cm H₂O with the reservoir full.[26] See Mainz Pouch II.

Minimally Invasive Reconstruction (2003 to the Present)​

Beecken and colleagues reported the first robot-assisted laparoscopic radical cystectomy with a completely intra-abdominal Hautmann neobladder in 2003; the operation took 8.5 hours with 200 mL of blood loss.[3] In the International Robotic Cystectomy Consortium (2,125 patients from 26 institutions), intracorporeal diversion rose from 9% of diversions after robotic cystectomy in 2005 to 97% in 2015.[27] In the iROC randomized trial, among the 305 patients analyzed for the primary outcome, robotic cystectomy with intracorporeal diversion gave a median of 82 days alive and out of hospital in the first 90 days, against 80 after open surgery; 282 of the 317 operated patients (89%) received an ileal conduit.[28] See Intracorporeal Urinary Diversion.

Continent diversion has become less common. In the United States National Inpatient Sample from 2001 to 2012, 9.2% of cystectomy patients had a continent diversion.[1] In 6,469 patients treated at 23 international referral centers between 2004 and 2024, the ileal conduit remained the most common diversion without significant change over time, cutaneous ureterostomy rose from 2% to 22% and neobladder use fell from 41% to 19%.[29]

Tissue-Engineered Bladder​

Anthony Atala and colleagues implanted autologous engineered bladder tissue in 7 patients with myelomeningocele aged 4 to 19 years. Urothelial and muscle cells from a bladder biopsy were seeded on collagen or collagen–polyglycolic acid scaffolds; over 22 to 61 months of follow-up, the composite scaffolds wrapped in omentum gave the largest gains in capacity and compliance.[30] A systematic review of 25 clinical reports (222 patients) of biomaterials and tissue-engineered bladder found outcomes and safety not good enough to replace enterocystoplasty.[31]

Key Landmarks​

YearLandmark
1852Simon: first ureterosigmoidostomy, for bladder exstrophy[1]
1888Tizzoni and Poggi: ileal bladder substitute in a dog[1]
1911Zaayer: ileal conduit described[1]
1913Lemoine: first human orthotopic reconstruction (sigmoid)[1]
1950Bricker: ileal conduit after pelvic evisceration; Gilchrist: ileocecal continent reservoir; Ferris and Odel: electrolyte disturbance after ureterosigmoidostomy[1][6][9][15]
1955Leadbetter and Clarke: five-year experience with the combined tunneled ureterointestinal technique[5]
1970Wallace: conjoined uretero-ileal anastomosis[12]
1975Kock: first continent cutaneous ileal reservoir[2]
1979Le Duc and Camey: antireflux ureteroileal implantation[13]
1980Mitrofanoff: transappendicular continent cystostomy[21]
1982Kock: 12-patient report of the continent ileal reservoir; Skinner begins the Kock pouch at USC[16][17]
1986Thüroff: Mainz pouch[20]
1987Rowland: Indiana pouch, 29 patients[19]
1988Hautmann: W-shaped ileal neobladder[23]
1989Studer: ileal low-pressure bladder substitute[24]
1993Fisch: Mainz pouch II[26]
2003Beecken: robotic cystectomy with intracorporeal neobladder[3]
2006Atala: tissue-engineered bladder augmentation[30]
2022iROC trial of robotic cystectomy with intracorporeal diversion[28]

See Also​

References​

1. Ghodoussipour S, Daneshmand S. Continent Urinary Diversion. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Elsevier; 2025:2812-2842.

2. Jonsson O, Olofsson G, Lindholm E, Törnqvist H. "Long-time experience with the Kock ileal reservoir for continent urinary diversion." Eur Urol. 2001;40(6):632-640. doi:10.1159/000049849

3. Beecken WD, Wolfram M, Engl T, et al. "Robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic ileal neobladder." Eur Urol. 2003;44(3):337-339. doi:10.1016/s0302-2838(03)00301-4

4. Preston MA, Dahl DM. Use of Intestinal Segments in Urinary Diversion. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Elsevier; 2025:2784-2811.

5. Leadbetter WF, Clarke BG. "Five years' experience with uretero-enterostomy by the combined technique." J Urol. 1955;73(1):67-82. doi:10.1016/S0022-5347(17)67368-3

6. Ferris DO, Odel HM. "Electrolyte pattern of the blood after bilateral ureterosigmoidostomy." J Am Med Assoc. 1950;142(9):634-641. doi:10.1001/jama.1950.02910270024006

7. Kälble T, Tricker AR, Friedl P, et al. "Ureterosigmoidostomy: long-term results, risk of carcinoma and etiological factors for carcinogenesis." J Urol. 1990;144(5):1110-1114. doi:10.1016/s0022-5347(17)39670-2

8. Pettersson L, Tranberg J, Abrahamsson K, et al. "Half century of followup after ureterosigmoidostomy performed in early childhood." J Urol. 2013;189(5):1870-1875. doi:10.1016/j.juro.2012.11.179

9. Bricker EM. "Bladder substitution after pelvic evisceration." Surg Clin North Am. 1950;30(5):1511-1521. doi:10.1016/s0039-6109(16)33147-4

10. Bricker EM. "Current status of urinary diversion." Cancer. 1980;45(12):2986-2991. doi:10.1002/1097-0142(19800615)45:12<2986::aid-cncr2820451217>3.0.co;2-5

11. Madersbacher S, Schmidt J, Eberle JM, et al. "Long-term outcome of ileal conduit diversion." J Urol. 2003;169(3):985-990. doi:10.1097/01.ju.0000051462.45388.14

12. Wallace DM. "Uretero-ileostomy." Br J Urol. 1970;42(5):529-534. doi:10.1111/j.1464-410x.1970.tb04498.x

13. Le Duc A, Camey M. "[A procedure for avoiding reflux in uretero-ileal implantations during enterocystoplasty]." J Urol Nephrol (Paris). 1979;85(7-8):449-454. PMID 529367

14. Abol-Enein H, Ghoneim MA. "A novel uretero-ileal reimplantation technique: the serous lined extramural tunnel. A preliminary report." J Urol. 1994;151(5):1193-1197. doi:10.1016/s0022-5347(17)35211-4

15. Gilchrist RK, Merricks JW, Hamlin HH, Rieger IT. "Construction of a substitute bladder and urethra." Surg Gynecol Obstet. 1950;90(6):752-760. PMID 14782131

16. Kock NG, Nilson AE, Nilsson LO, et al. "Urinary diversion via a continent ileal reservoir: clinical results in 12 patients." J Urol. 1982;128(3):469-475. doi:10.1016/s0022-5347(17)53001-3

17. Skinner DG, Lieskovsky G, Boyd SD. "Continuing experience with the continent ileal reservoir (Kock pouch) as an alternative to cutaneous urinary diversion: an update after 250 cases." J Urol. 1987;137(6):1140-1145. doi:10.1016/s0022-5347(17)44429-6

18. Rowland RG, Kropp BP. "Evolution of the Indiana continent urinary reservoir." J Urol. 1994;152(6 Pt 2):2247-2251. doi:10.1016/s0022-5347(17)31651-8

19. Rowland RG, Mitchell ME, Bihrle R, et al. "Indiana continent urinary reservoir." J Urol. 1987;137(6):1136-1139. doi:10.1016/s0022-5347(17)44428-4

20. Thüroff JW, Alken P, Riedmiller H, et al. "The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion." J Urol. 1986;136(1):17-26. doi:10.1016/s0022-5347(17)44714-8

21. Mitrofanoff P. "[Trans-appendicular continent cystostomy in the management of the neurogenic bladder]." Chir Pediatr. 1980;21(4):297-305. PMID 7408090

22. Lilien OM, Camey M. "25-year experience with replacement of the human bladder (Camey procedure)." J Urol. 1984;132(5):886-891. doi:10.1016/s0022-5347(17)49934-4

23. Hautmann RE, Egghart G, Frohneberg D, Miller K. "The ileal neobladder." J Urol. 1988;139(1):39-42. doi:10.1016/s0022-5347(17)42283-x

24. Studer UE, Ackermann D, Casanova GA, Zingg EJ. "Three years' experience with an ileal low pressure bladder substitute." Br J Urol. 1989;63(1):43-52. doi:10.1111/j.1464-410x.1989.tb05122.x

25. Stein JP, Grossfeld GD, Freeman JA, et al. "Orthotopic lower urinary tract reconstruction in women using the Kock ileal neobladder: updated experience in 34 patients." J Urol. 1997;158(2):400-405. PMID 9224311

26. Fisch M, Wammack R, Müller SC, Hohenfellner R. "The Mainz pouch II (sigma rectum pouch)." J Urol. 1993;149(2):258-263. doi:10.1016/s0022-5347(17)36050-0

27. Hussein AA, May PR, Jing Z, et al. "Outcomes of intracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium." J Urol. 2018;199(5):1302-1311. doi:10.1016/j.juro.2017.12.045

28. Catto JWF, Khetrapal P, Ricciardi F, et al. "Effect of robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy on 90-day morbidity and mortality among patients with bladder cancer: a randomized clinical trial." JAMA. 2022;327(21):2092-2103. doi:10.1001/jama.2022.7393

29. Pellegrino F, de Angelis M, Scilipoti P, et al. "Temporal trends and clinical determinants of urinary diversion after radical cystectomy." BJU Int. 2026;137(2):323-331. doi:10.1111/bju.70018

30. Atala A, Bauer SB, Soker S, Yoo JJ, Retik AB. "Tissue-engineered autologous bladders for patients needing cystoplasty." Lancet. 2006;367(9518):1241-1246. doi:10.1016/S0140-6736(06)68438-9

31. Chua ME, Farhat WA, Ming JM, McCammon KA. "Review of clinical experience on biomaterials and tissue engineering of urinary bladder." World J Urol. 2020;38(9):2081-2093. doi:10.1007/s00345-019-02833-4