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Pelvic exenteration was first described by Alexander Brunschwig in 1948 in New York as a palliative procedure for recurrent carcinoma of the cervix. Because of initially high rates of morbidity and mortality, the practice of this ultraradical operation was largely confined to a small number of American centers for most of the 20 century. The post-World War II era saw advances in anaesthesia, blood transfusion, and intensive care medicine that would facilitate the evolution of more radical and heroic abdominal and pelvic surgery. In the last 3 decades, pelvic exenteration has continued to evolve into one of the most important treatments for locally advanced and recurrent rectal cancer. This review aimed to explore the evolution of pelvic exenteration surgery and to identify the pioneering surgeons, seminal articles, and novel techniques that have led to its current status as the procedure of choice for locally advanced and recurrent rectal cancer.

Continent urinary diversion requires the creation of a reservoir, ureteric implantation and establishment of a continence mechanism in the efferent segment. This review is a short overview on the history of different techniques in current use. Reservoirs with high volume and low pressure can be fashioned by antimesenteric opening and spherical reconfiguration of the bowel. Previously, techniques for ureteric implantation were simply transferred to continent urinary diversion. Currently the need for antirefluxive ureteric implantation techniques is questioned and there is a trend towards refluxive implantation. To create a continence mechanism, simple and reproducible procedures. e.g. the incorporation of the efferent segment into the pouch wall (e.g. appendix stoma, flap valve T mechanism, serosal-lined extramural tunnel) have been developed. Long-term data for different surgical techniques show excellent continence and acceptable complication rates.

Congenital anomalies like bladder exstrophy were the indication in 1821 to implant the ureters into the sigmoid colon for the first time. In 1894 the Maydl technique was used more frequently with a postoperative mortality rate of 31%. The most important impact for ureterosigmoidostomy came from Robert Coffey in 1911. Obstruction at the ureterocolic anastomosis, inflammatory complications together with severe acidosis, renal insufficiency, and high mortality rates however gave way in 1950 to the worldwide success of Bricker's ileal conduit although at the same time the technique of ureterosigmoidostomy was perfected by Leadbetter, Goodwin, and Hohenfellner. About 25 years later, when the high late complication rate of ileal conduits was obvious, the advantages of ureterosigmoidostomy were reconsidered and the technique was refined using valuable principles of pouch surgery. Today modified ureterosigmoidostomy has a strong place among the possibilities of urinary diversion.

The history of urinary diversion in general began in 1852 and started right away with continent diversion, i.e., ureterosigmoidostomy. Anastomosing an intestinal reservoir to the urethra was proposed by Tizzoni and Foggi in 1888. They replaced the bladder by an isoperistaltic ileal segment which was interposed between ureters and urethra in a female dog. In 1951 Couvelaire reactivated this idea of an ileal bladder substitute. Retrospectively many disappointing results of urinary diversion were often not caused by insufficient competence of the outlet mechanism, but because the intestinal reservoir maintained its peristaltic properties causing high pressure peaks. The decisive advance in ensuring continence, and thus an improvement in patient comfort, was achieved with the so-called low pressure reservoir. The main characteristics of this reservoir compared to those from intact intestinal segments are the larger diameter, the greater capacity with significantly low pressures, and the uncoordinated contraction of its wall. Transsection of the circular intestinal musculature when performing bladder augmentation had already been published by Rutkowski in 1899, Tasker in 1953, and Giertz in 1957. In 1969, Kock published the first results obtained with an ileal continent fecal reservoir in patients after total proctocolectomy. The significant advantages of interrupting the tubular structure of a reservoir obtained from intestine had been described much earlier. The need for reflux prevention is not the same as in ureterosigmoidostomy conduit or continent diversion. Reflux prevention in neobladders is even less important than in a normal bladder. When using nonrefluxing techniques, the risk of obstruction is at least twice that after direct anastomosis. Kidney function is not impaired by diversion if stenosis is recognized and managed. Patient health status is influenced more by underlying disease than by diversion. Orthotopic reconstruction has passed the test of time. In these patients life is similar to that in individuals with a native lower urinary tract. Until a better solution is devised orthotopic bladder reconstruction remains the best option for patients requiring cystectomy.

"Perspectives in Urinary Diversion" was the title of a presentation held during the opening session of the 56th annual meeting of the German Urological Association in Hamburg on September 21, 2006. It focused on the balance between obstruction and reflux of ureters implanted in diverted intestinal segments, the choice of intestinal segments for orthotopic pouches, orthotopic diversion in the female, the status of rectal diversions, and alternatives to the use of intestinal segments.

The earliest attempt to divert urine flow from the ureters to the intestine, was performed in 1851 by John Simon. In the absence of antibiotics, ureterosigmoidostomy and its modifications during the 19th and early 20th century have been associated with high rate of surgical and metabolic complications. In 1910, Robert Coffey demonstrated a new method for ureterointestinal anastomosis, which renovated primary enthusiasm in ureterosigmoidostomy and it gained broad popularity during the next forty years. In 1950, Ferris and Odel reported 80% incidence of hyperchloremic metabolic acidosis following ureterosigmoidostomy. Based on further investigations by Lapides in 1951, Parsons, Powel and Pyrah in 1952, and Stamey in 1956, which clearly demonstrated that hyperchloremic metabolic acidosis is inevitable complication of ureterosigmoidostomy, this urinary diversion lost its popularity. In 1950's ileal conduit, popularized by Bricker, became the gold standard for the subsequent 35 years. Early attempts for continent urinary diversion occurred form 1888, by Guido Tizzoni and Alfonso Poggi, while the first reservoir-type ileal loop urinary diversion was performed by Cuneo in 1911. By better understanding of principles of detubularization, based on works of Kock and principles of clean intermittent catheterization, established by Lapides, interest in continent urinary diversion has increased. Up to date, various continent cutaneous stomal reservoirs, sigmoidorectal pouches and orthotopic bladder substitutes have been described. Regarding encouraging improvements in biocompatible materials, alloplastic bladder replacement could be the next step for the future in bladder replacement surgery.

Arthur Jacobs (1899-1974) was the father of urology in Glasgow. His extensive experience with genitourinary tuberculosis, ureterosigmoidostomy, and bladder augmentation were far ahead of his time. He became an expert in retropubic prostatectomy and was a pioneer in early imaging techniques.

In 1852, Simon was the first to describe a urinary diversion using intestinal segments. In the late 19th and early 20th century, in the absence of antibiotics, urinary diversion using bowel segments carried a high risk of peritonitis. When Coffey introduced a new method for ureteric implantation in 1911, ureterosigmoidostomy became the most frequently used technique. The ileal conduit, first described by Zaayer in 1911, was established as a standard technique by Bricker in 1950. At the same time, Ferris and Oedel demonstrated a hyperchloremic metabolic acidosis in 80% of the patients with ureterosigmoidostomy, and the ileal conduit became the preferred from of urinary diversion. The first attempts to create a continent urinary diversion were undertaken by Tizzoni and Foggi in 1888. Mauclaire, in 1895, used the isolatec rectum as a urinary reservoir. Two findings were essential for the development of modern continent urinary diversion: Kock established the principle of bowel detubularization to create a low-pressure reservoir, and Lapides popularized the use of clean intermittent catheterization. Utilizing these techniques, a variety of continent reservoirs were introduced. The majority of these used either ileal segments, like the Hautmann neobladder, or ileocecal segments, like 'Le Bag'. Sinaiko was the first to use the stomach for the creation of a urinary reservoir in 1956. Continent urinary diversion is the method of choice in a large number of patients today. Experimental work demonstrated that the creation of a new bladder using cultured urothelial and muscle cells with biodegradable polymers as a scaffold is feasible, and future developments may be vastly influenced by these techniques.

The use of bowel has been used in urinary tract reconstruction for more than a century. In the past 20 years, however, indications and methods for bowel utilization have multiplied enormously. This article outlines some of these exciting developments.

When the need for urinary diversion arises, whether from carcinoma of the urinary tract, malfunction, or malformation, a decision must be made about the type of diversion to be performed. Currently, the patient and surgeon must decide on continent versus noncontinent versus neobladder, and on the type of intestinal segment to be used.

This article, describes the evolution of stoma formation from earliest times to current innovative procedures. Surgeons are continually trying to develop new procedures so that they can offer less socially incapacitating alternatives to the abdominal stoma.

Knowing the history of Urology has allowed urologists to recover techniques which had been abandoned for different reasons, yet when modified or utilized with current technological advancements, have proved to be very useful. A brief review of the history of urinary diversion clearly shows that it has evolved in parallel with the important diseases; i.e., vesical exstrophy, urinary tuberculosis and bladder cancer. Time tests all new, and thus controversial, concepts or procedures. They become either well established or are condemned to oblivion. All the experience, both successes and failures, that make up the history of Urology undoubtedly contribute towards finding new therapeutic alternatives.

In spite of the impressive progress in medical science, surgery remains an empirical skill. Surgery of the ureterovesical junction is a permanent challenge for all generations of urologists. Half a century of intensive development of modern surgery evidences the efforts to reestablish function by a perfect copy of natural anatomy.

Gradually, the lifestyle that can be offered to a patient who requires a cystectomy or has a small incontinent bladder is being improved. It is possible to combine sphincter placement with cystoplasty and neobladder formation if the surgery is carried out with care. Further development of the sphincters is required before their use around bowel segments will provide consistently safe results. Concurrently, development of the totally artificial bladder is progressing toward an ideal of a system that is biocompatible and preserves renal function.

An instrument to facilitate the placement of a nephrostomy tube is described. The techniques for performing nephrostomies are historically reviewed.

An understanding of the evolution of intestinal usage in urologic surgery should not only be of academic interest but should also serve as an aid to the urologic surgeon in choosing a procedure most appropriate for the disease. In this manner the pitfalls of repeating errors can perhaps be avoided. It is hoped that this introductory review will provide the urologist with some historical insight into the different procedures that have laid the foundation for the variety of operations that will be described in the following articles.

Some historical aspects of ureterosigmoidostomy are described, and various techniques are discussed and illustrated. Our own satisfaction with the results when the procedure is done through the open sigmoid colon is expressed. Ureterosigmoidostomy, which has in some surgeons' hands fallen into disuse, will continue to be used and probably should be used more than it is at present. When ureterosigmoidostomy is done meticulous care is important in producing a long submucosal tunnel with direct anastomosis of the ureter to the bowel. Preoperative bowel preparation is mandatory. Patients who have undergone ureterosigmoidostomy should remain on a low chloride diet indefinitely with an adequate supplement of sodium potassium citrate to diminish the dangers of electrolyte imbalance and hyperchloremic acidosis. Careful postoperative management and followup care are vital to success.

Eighty-nine patients with bladder exstrophy were seen at our institution over the last fifty years. There were 63 males and 26 females. Cloacal exstrophy constituted 9 per cent of our experience. Twenty-seven patients underwent primary urinary diversion with subsequent genital reconstruction early on in our series. Of the 57 children operated on since 1951, 50 were judged eligible for and underwent a planned multistaged reconstruction. We realized a 50 per cent success rate. The majority of failures were diverted into an ileal conduit for persistent incontinence.

The different methods of treatment of bladder exstrophy are described. Ureterosigmoidostomy and its various modifications are discussed and the longterm result critically reviewed. Urinary diversion by transplanting the ureters into an isolated segment of ileum or colon should, in the authors' opinion, only very rarely be necessary. Cutaneous ureterostomy is used only as a last resort in incontinent patients with severe renal damage. The greatest single advance in the management of the malformation has been the two-stage closure of the exstrophic bladder. The authors' experiences in the two-stage closure of 28 patients with ectopia vesicae are described. No selection of patients was practiced. The results obtained, both clinically and by manometry of the operated bladder, are reviewed. The results are moderately satisfactory.

Public awareness of the alternatives to wet stomas and the patient's concern for body image have significantly increased the demand for continent urinary reservoirs. In the final analysis, preservation of renal function is the standard for judging the success of a diversion, and long-term observations must be made with this point in mind. It seems likely that the continent reservoirs now available will preserve renal function.