Kock pouch bladder replacement

Between May 1986 and February 1990, 126 consecutive male patients have undergone lower urinary-tract reconstruction by means of Kock bladder replacement at our institution. The early and late complication rates have been minimal. Good continence has been achieved in 94% of patients during the day and in 84% at night. Our experience with bladder replacement has yielded extraordinary results in terms of patients acceptance. It is anticipated that our experience as well as the experience of others with this surgery will encourage patients afflicted with high-grade bladder cancer and their physicians toward an earlier decision for aggressive therapy by cystectomy while cure is still possible.     

The Kock continent urinary diversion

The continent ileal reservoir as conceived by Kock produces a low-pressure, high-capacity reservoir with continent and nonrefluxing valves constructed from ileum. From August 1982 through March 1988, 531 patients underwent continent urinary diversion via a Kock reservoir at our institution. Of these, 39 males had a Kock bladder substitution, while the rest underwent cutaneous Kock diversion. Early complications occurred in 16% of all patients, and there was an operative mortality rate of 1.9%. Surgical modifications of nipple fixation, which are discussed in detail in this paper, help to reduce late complications to less than 10%. Patient satisfaction with both procedures remains excellent.     

The S-bladder--a complete continent antireflux functional replacement of the bladder sphincter muscle function

The S-bladder, developed on the basis of the Parks S-pouch, is a continent ileourethrostomy with antireflux implantation of the ureters via a nipple valve. It provides a low-pressure reservoir with a large capacity and allows voiding in the natural way by means of abdominal straining. Reflux is reliably prevented by use of the antireflux nipple valve already familiar from the Kock pouch. If continence during day and night cannot be achieved with the distal sphincter mechanism alone an artificial sphincter can be implanted at the bulbous urethra in men and around the urethral stump in women. Since 1986 16 patients have received S bladders following cystectomy, and implantation of an artificial urinary sphincter has been necessary in 7. All patients are continent by both day and night. The overall complication rate has been low. For 15 patients it is possible to empty the bladder solely by abdominal straining, while in 4 cases additional self-catheterization is necessary. In most cases the urine remains sterile, and gross electrolyte disturbances and acidosis have never been observed. Our indications were: bladder carcinoma in men (T1-2NoMo) with carcinoma-free prostatic urethra, nonfunctional neurogenic bladder, and shrunken bladder following infection or radiation. Psychological acceptance of the procedure, which allows natural voiding with no kind of abdominal wall stoma even after cystectomy, has been excellent.     

Computed tomography of Kock and modified Kock continent ileal reservoir

Kock or modified (Javadpour) ureteroiliostomy was performed in 5 patients following cystectomy for bladder carcinoma or exstrophy. Computed tomography was utilized to demonstrate alterations in pelvic anatomy after construction of the ileal reservoirs. Detailed evaluation of the inlet and outlet antireflux arms of the continent reservoir was possible. Appreciation of the expected alterations in pelvic anatomy accompanying the Kock or modified Kock procedure will be necessary to detect postoperative complications and to achieve early recognition of recurrent carcinoma. Potential advantages of the modified Kock ileal reservoir, as developed by Javadpour, are presented.     

Kock continent ileostomy in Indian patients

Reservoir (continent) ileostomy was performed in 16 of our cases who had undergone total proctocolectomy. The basic pathology in these cases was chronic ulcerative colitis. Four cases (25%) had to be re-operated for partial or complete extrusion of the nipple valve causing incontinence. Two of these cases needed a second revision. By improving the valve formation technique, the incidence of sliding of the exit-valve was reduced. Other postoperative complications also responded well to this treatment. The patients were followed for three to five years. Three cases need frequent evacuation, but the remaining 13 cases, including some who had undergone revisional surgery, are fully continent. This procedure is accepted well by our patients.     

The Kock continent ileostomy: a preliminary report.

A review is presented of seven patients who have undergone a continent type of ileostomy, as described by Professor Kock. There has been no mortality. Two of the early patients had considerable difficulty with the functioning of the valve and required re-operation. No patient in the series now wears an external appliance. Six of the seven are fully continent; the seventh reports occasional leakage, but is satisfied with the operation. The operation is considered to be still under trial, but is regarded as having great potential and likely to be much more widely practised in the future.     

A trial of the bladder assist device (BLADMAN) on Kock continent ileal urinary reservoir

A patient, who underwent total cystectomy and urinary diversion with the Kock pouch, was trained to use the Bladder Assist Device (BLADMAN) to augment the Kock continent ileal urinary reservoir. BLADMAN is a device to provide an intermittent drainage system, which simulates the normal periodic filling and emptying of the bladder of a patient with indwelling catheter. On the 16th day after starting the pouch augmentation with BLADMAN, the pouchgram of the patient revealed a pouch capacity of 450 ml. BLADMAN is considered to be a useful device for the augmentation of Kock continent ileal reservoir.     

Non-stomal continent reservoir: use of detubularized ileal segment for bladder replacement

Summary Total bladder replacement after cystoprostatectomy was performed in 2 patients using a detubularized segment of ileum to construct a continent urinary reservoir. A small part of the segment remained tubular for anastomosis to the urethra. The ureters were implanted into the reservoir using an antireflux technique. There were no complications associated with the procedure. Continence was maintained by the patients' external urethral sphincter. Two bowel configurations in 2 patients are described. The preliminary results with both configurations have been encouraging, with 1 patient achieving total continence. The detubularized ileal reservoir appears to offer technical and functional advantages over other tubular and detubularized bowel segments used for bladder replacement.     

Clinical experience of Kock pouch continent urinary diversion

Kock continent ileal reservoir for urinary diversion was performed in 53 patients with invasive bladder cancer (52) or neurogenic bladder (1). The postoperative follow-up period was from six to thirty-nine months. The clinical results showed no metabolic disturbance of blood electrolytes or acidity. Prolapse of efferent nipple valve developed in 4 patients (7.6%); and 2 underwent revisional surgery with a good result. Another 4 patients (7.6%) suffered from poor continence and relatively frequent catheterization to empty the pouch was necessary to prevent urine leakage through the stoma. Urodynamic study of the Kock pouch in these 4 patients showed a short functional nipple valve length and small pouch capacity. The other 45 patients (84.8%) had good continence. Urodynamic study of the pouch in 20 patients showed low pressure (mean of 13.3 cm H2O) in the pouch and high pressure (mean of 72.1 cm H2O) at the efferent nipple valve. Three patients had unilateral hydronephrosis in the follow-up intravenous urography. Corrective surgery for stenosis at the right ureteroileal anastomosis was done in 1 patient with normalization of the upper urinary tract afterward. The other 2 patients were managed by close observation for the mild hydronephrosis. Symptomatic bacteriuria developed in only 3 patients (5.7%) and responded well to antibiotic management. Reservoirography demonstrated no reflux into the upper urinary tract in all the follow-up patients. There was no significant change of the renal function at twenty-four months after operation detected by radionuclide (131I-Hippuran) renal functional study. All patients were satisfied with Kock urinary diversion.     

Clinical studies on Kock continent urinary reservoir and Indiana continent urinary reservoir]

Recently, the continent urinary reservoir which provides the patient with a better quality of life has become popular. Many types of reservoirs have been reported, but the optimal procedure remains to be established. From July 1987 through November 1988, we performed Kock pouch construction on 11 patients (ages 39 to 76 years). Between July 1989 and March 1991, 9 patients (ages 44 to 66 years) underwent Indiana pouch operation. The first 4 patients underwent ileal patch type, and the subsequent 5 underwent Heineke-Mikulicz type procedure. A one-stage radical cystectomy and continent urinary reservoir construction was performed on 19 patients, and bilateral cutaneous ureterostomy was converted to Kock pouch in one patient. There were no perioperative deaths, but reoperation was required for urinary leakage from the reservoir on one patient in each group. As the late complications in the Kock pouch group, one patient required revisional operation of the continent valve mechanism, 2 patients experienced intermittent prolapse of the nipple valve of the efferent limb, and 2 had malfunction of the afferent nipple valve. In the Indiana pouch group unilateral hydronephrosis was noticed in one patient, and 4 had mild difficulty of catheterization. Although 3 patients in both groups had mild urinary leakage, all patients had good quality of life with capacity of reservoir over 500 ml and with good renal function. We changed the type of operative procedure from Kock pouch to Indiana pouch because of the high complication ratio in the former.(ABSTRACT TRUNCATED AT 250 WORDS)     

Adult female exstrophy of the bladder treated with a Kock continent reservoir. Report of a case

A 24-year-old female with classic exstrophy of the bladder was treated with cystectomy, construction of a Kock continent ileal reservoir, and closure of the abdominal fascial defect using alloplastic material. The Kock ileal reservoir improved the quality of her life not only physically but also mentally by affording her urinary continence.     

Clinical experience with the Kock continent ileal urinary reservoir

From May 1985 through July 1987, 22 patients underwent Kock continent ileal reservoir for urinary diversion. There were 19 males and 3 females, between 38 and 82 years old (mean age 63.1 years). A one-stage radical cystectomy and Kock pouch construction were performed in 21 patients. One patients was converted from standard ileal conduit to this new reservoir. The keys to success of the Kock pouch are creation and maintenance of the nipple valve to prevent reflux and to ensure continence. Mesenteric fat is removed with CUSA for 8 cm along the afferent-efferent limbs of the pouch and exclusion of mesentery is limited for only 3-4 cm. This important modification will ensure adequate ileal intussusception and vascular supply to the valves. To prevent eversion and prolapse, the nipple valve is anchored to the wall of reservoir. A strip of sauvage filamentous Dacron serves as a collar to fix the afferent-efferent limbs to the pouch. There were 2 postoperative deaths and two major early complication: 1 acute renal failure and 1 intestinal fistula, both of which were treated conservatively. Late complications occurred in 6 patients. Of these 6 patients, 1 required reoperation and revision of the continence valve mechanism and 1 required hospitalization for entero-pouch fistula. Serum electrolytes and vitamin B12 remained normal in all patients. Patients perform self-catheterization every 4-6 hours during the day and once at night for volumes ranging up to 1,000 ml. The end result in 19 of 20 patients was excellent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bladder replacement by entero-cystoplasty after radical cystectomy for bladder cancer--the urethral Kock pouch

From September 1989 to March 1990, 6 male patients with invasive bladder cancer, 49 to 70 years old in age, underwent bladder replacement with the ileum (the urethral Kock pouch) after radical cystectomy. Follow up ranged between 3 and 9 months. Urodynamic evaluation showed the ileal bladder to be a low pressure reservoir with a capacity that increased to more than 250 ml. The ileal bladder was emptied by straining without significant residual urine in all patients except one who was performing intermittent self-catheterization. All patients were continent in the daytime. However, all patients required pads at night because of occasional loss of a little urine. Excretory urograms revealed excellent upper tract function. The procedure is suitable whenever the urethra can be preserved after cystectomy for cancer.     

Total replacement of bladder and urethra by cecum and appendix in bladder exstrophy

The first case of total bladder and urethral replacement by cecoappendiceal unit was achieved in a five-year-old boy born with bladder exstrophy. Residual vesical and prostatic tissue was utilized to provide continence successfully.     

The Kock continent ileal urinary reservoir: surgical technic and clinical results

From July 1985 through January 1986, 43 patients underwent urinary diversion that included creation of a continent reservoir from an ileal segment, according to the method described originally by Kock. An important modification included removal of a narrow strip of mesentery for 8 cm along the afferent and efferent limbs of the pouch to allow adequate ileal intussusception and fixation of the nipple valves to prevent reflux and to ensure continence. A strip of PGA mesh serves as a collar to fix the afferent-efferent limb to the pouch once the intussusception technique has been accomplished. The use of a narrow Marlex strip allows fixation to the abdominal wall both lateral and medial to the stoma site (insert). This strip is important in preventing a parastomal hernia and helps fix the continence valve mechanism to the posterior abdominal wall. Previous urinary diversion was by ureterosigmoidostomy in 2 patients, standard ileal conduit in 8 and chronic dialysis after nephrectomy of solitary kidney and cystectomy in 1. A total of 32 patients underwent simultaneous anterior exenteration or radical cystectomy for pelvic malignancy. There were 4 postoperative deaths and early complications occurred in one patient. Late complications occurred in only 3 patients: they required reoperation and revision of the continence valve mechanism. The end result in 39 of 43 patients has been an overwhelming success. Patients perform self-catheterization every 4 to 6 hours during the day and once at night for volumes ranging up to 1,400 cc. Serum electolytes have remained normal in all patients. X-ray of the Kock pouch have shown no evidence of reflux, and all excretory urograms have demonstrated either normal upper tracts without obstruction or improvement in patients with preoperative hydronephrosis. Although preliminary, this clinical trial suggests that the quality of life for patients considered previously to be candidates for cutaneous diversion can be improved markedly by a modified Kock continent ileal reservoir. During the same time, 21 patients out of 278 patients who underwent creation of a Kock continent ileal urinary reservoir since August 1982, underwent revision of Kock pouch. Two of those required subsequent reoperation and revision of the continence valve mechanism. The end result in all patients has been an overwhelming success.     

Incontinence cured by replacement of the urethra with a bladder flap

Referring to the experimental work of Lapides the author describes three successful cases of substituting the urethra with a tube made from the anterior wall of the bladder. The lack of urethra and the incontinence in the three female children were due to malformation. The paper also deals with the conditions of the operation. According to the author there is no lower age limit to using this operative method.