The Rectal Bladder: An Insight into the History of a Urinary Bladder Substitution

Abstract

Introduction

The history of urinary diversions is long and complex. Urologists have engaged their creativity and skill in creating an alternative to the bladder that could contain urine, prevent reflux nephropathy, and allow for easy and regular voiding. The purpose of an ideal urinary diversion is to comply with all these functions though never comparable with the native bladder and at the cost of a radical re-conformation of the anatomy and physiology of the urinary and intestinal tracts. The rectal bladder (RB) has been described for a century and was an attempt to avoid an abdominal stoma and allow for perineal voiding. Italian urologist Ulrico Bracci and many others possessed significant expertise in developing the RB, in all its variations, between the 1950s and 1980s. Our objective was to delineate the history, evolution, and demise of the RB technique in the context of the surgical challenges its pioneers faced.

Sources and Methods

We conducted a survey of the existing medical literature on rectal bladder construction, utilizing the resources available at the Medical Area Library of the University of Naples Federico II, PubMed, Internet Archives, and the National Library of France for contemporary and historical medical literature on the topic. The terms used to search the literature for rectal bladder were: “rectal bladder”, “bladder exstrophy”, urinary diversions, and various historical figures in the history of RB construction.

Results

The use of isolated rectum to serve as a urinary reservoir was first described by Placide Mauclaire (1863-1940) as an alternative to the then standard method of urinary diversion in bladder exstrophy, the ureterosigmoidostomy (USS). Many innovators worked to avoid the cutaneous stoma of urinary or fecal diversion owing to the absence of satisfactory stoma appliances and its social impact. We found that two general uses of RB were described: orthotopic and pararectal intersphincteric.
The former was described by Gil Antonio Gil-Vernet (1904-1990) and the latter by a number of individuals including MH Boyer, A Hovelacqu and others. All techniques required significant surgical experience with bowel, placed vascular mesenteric pedicles at risk, and potentially compromised the anal sphincter which, in the case of bladder exstrophy, is congenitally functional.

Conclusions

The rectal bladder (RB) is no longer a commonly used option for internal urinary diversions, originating and being utilized before the advent of modern stoma appliances and detubularized bowel techniques for an orthotopic neobladder. Still, RB proved to be a viable method of internal diversion in cases like bladder exstrophy (BE) or radical cystectomy (BE). The pioneers who described RB aimed to help patients without a functional bladder by providing a functional substitute that preserved the upper tracts and avoided the stigmata of cutaneous urinary diversion.

Key Words

Urinary bladder, Bladder exstrophy, Urinary diversion, Rectal bladder