Continent urinary diversion using a pre-peritoneal ileal graft and Benchekroun's hydraulic valve

The authors describe the creation of a continent pre-peritoneal ileal urinary reservoir with Benchekroun's valve. This system, performed on 10 occasions with no postoperative complications and currently perfect results, has the following advantages: decreased risk of distension of the reservoir because of its pre-peritoneal position, protection of Benchekroun's valve due to its distance from the reservoir at the end of the antiperistaltic loop, the great ease of creation of the diversion and the superficial situation facilitating any subsequent surgical revisions.     

The continent ileal reservoir (kock pouch) for urinary diversion

Summary Urinary diversion via a continent ileal reservoir was performed in 31 patients. The diversion was a primary procedure in 11 patients, while in 18 it was performed to convert an existing urinary diversion to a continent diversion. In two patients, malfunctioning cecocystoplasties were converted to continent ileum reservoirs. There were no operative mortalities and few early complications. Late complications causing malfunction of the nipple valves required revisional surgery in 15 patients. Postoperative follow-up presently is between 6 months and 10 years. Two patients have died: one in an accident and one of metastatic bladder carcinoma. The remaining 29 patients are continent and without reflux to the upper urinary tract. The reservoir is emptied by catheterization 4–5 times daily, not at night. The volume capacity of the reservoir is around 700 ml. One-third of our patients had constantly negative quantitative urine cultures, whereas two-thirds either had intermittent or constant bacteriuria. Dilatation of the upper urinary tract, progressive renal deterioration or metabolic disturbances have not been encountered. All patients are very satisfied with this type of urinary diversion.Urinary diversion is performed in non-malignant as well as malignant bladder diseases; the majority because of bladder carcinoma. However, long-term studies of conventional urinary diversion procedures have shown that there is a high incidence of late complications with progressive deterioration of renal function [11, 13]. As a result, indications for urinary diversion have been critically reconsidered and alternatives have been sought. Bladder replacement is one method which has been suggested. In non-malignant disease, intermittent catheterization and/or uropharmacological manipulation may be auspicious alternatives. The trend against diversion has also led to reconstruction of the urinary tract in cases previously regarded as suitable only for diversion. In this era of critical reappraisal of conventional urinary diversion procedures a new method for continent urinary diversion was elaborated and introduced for clinical use in 1982 [8]. The low-pressure ileal reservoir originally devised for urinary bladder augmentation or replacement [4] and later used for rendering the ileostomy continent in patients after proctocolectomy [7] has, since 1975, been used in our institution for continent supra-vesical urinary diversion. In this paper the operative method is described and our results and experience obtained during a 10-year period are reported.Supported by grants from the Medical Research Council (Project No 577)     

Bellevue pouch: Ileocolonic continent urinary reservoir

The technique for the Bellevue Pouch, another continent intestinal reservoir, is described. A large-capacity low-pressure reservoir is created from detubularized ascending colon, cecum, and terminal ileum. Continence is achieved by means of an intussuscepted segment of ileum and a modulating colonic pressure cuff wrapped around it. The operation has been performed on 19 patients, all of whom achieved satisfactory continence. Two patients were converted to free drainage systems at a later date. Average follow-up was twenty-five months.     

Absorbable staples in continent ileal urinary pouch

Continent ileal urinary reservoirs were created in dogs to study absorbable surgical staples. Within each pouch, certain controlled observations were possible. The staples and chemically similar polyglactin absorbable sutures caused almost identical tissue reactions. The staples outlasted the sutures, probably because of greater size. Inverted and everted staple closures worked equally well. It appears feasible to consider clinical urinary diversion with absorbable staples, a time-saving method.     

改良低压可控性回肠代膀胱术

目的建立一种更接近生理的回肠代膀胱术。方法１９９１～１９９８年实施５例全膀胱切除,回肠膀胱与尿道吻合,由外括约肌控制,经尿道排尿的新手术方法。结果术后随访３～８４个月,平均２８．６个月。至随访日,５例无吻合口狭窄,排尿通畅。３个月后４例完全控制排尿,１例仍有不完全性尿失禁。结论该术式具有贮尿囊内压低（２０～３０ｃｍＨ２Ｏ）,容量略小（２５０～３００ｍｌ）,可控性和原位排尿的优点,且无电解质紊乱和肾功能损害。     

Evolution of outcomes with the ileal hydraulic valve continent diversion: reevaluation of the Benchekroun catheterizable stoma

Summary Initial reports with limited follow-up suggested that the ileal hydraulic valve was a satisfactory approach to continent urinary diversion that was associated with acceptable early complication rates and uniform efficacy in achieving continence. We sought to evaluate the later outcomes of patients with this form of continent urinary diversion. An average extended follow-up of 5 years was available on 11 patients who had undergone ileal hydraulic valve diversion. Although only 13% of patients had complications requiring surgical revision at 18 months of follow-up, at the 5-year follow-up, 91% had developed complications requiring surgical revision. Of these, 64% entailed major revision of the urinary diversion. The most common late complication was stomal stenosis (73%); calculus formation (36%) and devagination (36%) were also common. Although in some cases, stomal stenosis was successfully managed by superficial revision with skin flaps and grafts, most cases required complete replacement of the efferent limb. Use of the devaginated or stenosed ileal hydraulic valve to construct a flap-valve efferent limb based on the Mitrofanoff principal succeeded in salvaging the continent urinary diversions in these patients. Novel forms of urinary diversion require extended follow-up for accurate assessment of their feasibility and efficacy. Attentive surveillance with surgical revision as necessary in such cases is mandatory for the preservation of continence and renal function.     

A continent colonic urinary reservoir: the Florida pouch

A total of 92 patients underwent continent urinary diversion with an extended, detubularized right colonic segment as the urinary reservoir and the distal ileum as a continent catheterizable efferent system. In this series 65 patients were followed for 6 to 46 months (average 17 months). Our reservoir allows the accommodation of a large volume of urine; urodynamic studies in 28 patients demonstrated a maximum reservoir capacity varying between 550 and 1,200 cc (average 747 cc). Maximal reservoir pressures ranged from 10 to 58 cm. water (average 35 cm. water). Of the 127 ureterocolonic reimplantations 4 ureters were initially reimplanted with a modified Le Duc procedure, 26 ureters were managed subsequently with the Goodwin transcolonic approach and 91 reimplantations were done with a direct (nontunneled) mucosa-to-mucosa anastomosis. The overall success rates with each of the 3 techniques (absence of reflux and obstruction) were 75, 88.6 and 90.1%, respectively. Six megaureters underwent imbrication and direct reimplantation, and 3 of these (50%) became obstructed. Two converted ileal conduits were opened at the antimesenteric edge and were patched to the reservoir while the ureteroileal anastomosis was left undisturbed. One patient (1.5%) died of pulmonary embolism. Medical and surgical complications occurred only in the group who underwent simultaneous cystectomy and the over-all rate of complication was comparable to previous series with ileal conduits. The double row plication of the distal ileum and ileocecal valve allows for easy catheterization every 4 to 6 hours and 63 patients (97%) remain continent between catheterization. Four patients (6%) required reoperation for correction of incontinence or other complications. Our satisfactory experience with these patients makes this technique an excellent approach to achieving continent urinary diversion.     

改良可控性回肠膀胱控尿机制的临床研究

目的探讨改良可控性回肠膀胱临床应用的效果。方法膀胱癌行根治性膀胱切除尿流改道患者12例,采用改良的回肠乳头瓣作为输出道,外口与脐孔作皮瓣嵌入防狭窄吻合,去管化回肠浆膜下隧道抗返流技术。结果12例随访14~50个月,昼夜控尿满意,尿动力学显示:储尿囊容量350~720(435±88)m l,充盈时内压15~32(20±5)cm H2O,储尿囊充盈时输出道最大闭合压力74~142(98±23)cm H2O,空虚时为49~105(68±20)cm H2O,2者差异有统计学意义(t=8.82,P<0.01);充盈过程中无收缩波出现。结论改良回肠乳头瓣输出道及去管化回肠浆膜下隧道抗返流技术是比较理想的可控技术改进。     

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)     

Technique of creation of a continent internal ileal reservoir (Kock pouch) for urinary diversion

Kock and associates have made a major contribution to the urologic surgical armamentarium by developing a method to create a continent internal urinary reservoir out of ileum. This innovative procedure now offers patients requiring cystectomy for bladder cancer or cutaneous urinary diversion for any reason a real alternative to the standard ileal conduit, which requires wearing an external appliance. Operative technique, including some modifications developed by the authors, is presented.     

Long-time experience with the Kock ileal reservoir for continent urinary diversion.

OBJECTIVES: N.G. Kock performed the first continent cutaneous ileal reservoir for urinary diversion in 1975 at the Sahlgrenska University Hospital, G?teborg, Sweden. We have investigated the fate of the patients operated during the following 25 years at this hospital and analyzed their health-related quality of life (SF-36) as well as their psychological adjustment to a life with a continent urinary reservoir (OAS). MATERIAL AND METHODS: Between 1975 and 1999, 176 patients underwent continent urinary diversion using a Kock reservoir. At the end of 1999, 126 patients were known to be alive. Their reservoir function was estimated from their journals as well as from a questionnaire answered by the patients. RESULTS: Almost 90% of the survivors had a well-functioning reservoir at the time of follow-up. The need for reoperation has been high, mainly due to nipple problems. Kidney function is not influenced by the continent diversion per se. The health status of the patients is more influenced by the underlying disease than by their reservoirs. Patients with benign functional or inflammatory diseases experience comparatively more problems with their reservoirs. CONCLUSIONS: The functional end results as well as patient acceptance of continent urinary diversion with a Kock reservoir are excellent.     

Clinical experience of laparoscopic-assisted radical cystectomy with continent ileal reservoir

INTRODUCTION: Laparoscopic-assisted radical cystectomy with continent ileal reservoir reconstruction is a challenging procedure. We report our experience learned from a hand-assisted laparoscopic technique in our transition to a pure laparoscopic approach. MATERIALS AND METHODS: Eighteen consecutive patients underwent laparoscopic-assisted radical cystectomy with continent ileal reservoir. Hand-assisted laparoscopy was used for the first 11 patients and pure laparoscopy was performed for the subsequent 7 patients in radical cystectomy. Continent ileal reservoir reconstruction was performed extracorporeally via the hand port wound or trocar extension wound. Surgical outcome was analyzed in a retrospective review of the medical records. RESULTS: In the hand-assisted and pure laparoscopic groups, the mean operative time for cystectomy was 2.5 and 2.3 h, for continent ileal reservoir reconstruction it was 4.0 and 3.7 h, and for bilateral lymph node dissection it was 0.8 and 0.6 h, respectively. Mean intraoperative blood loss was 286 ml for the hand-assisted and 179 ml for the pure laparoscopic group. There were no major intraoperative complications nor need for conversion in any of the procedures. Bowel movement was regained in a mean of 3 days and the mean length of postoperative hospital stay was 7 days. CONCLUSIONS: The hand-assisted laparoscopic experience of radical cystectomy learned from the initial 11 patients effectively helped us in the transition to a pure laparoscopic approach. A comparable surgical outcome was found in both groups of patients.     

Urinary diversion with the Kock continent ileal reservoir: report of 13 cases

We tried the new method of urinary diversion via a continent ileal reservoir, reported by Kock in 1982, and now being accepted with great enthusiasm and satisfaction not only by doctors, but also by patients in Europe and in the United States. With this method, continency with storage of urine under low pressure is well maintained so that no external appliances are necessary. Ileorenal reflux is also prevented with this nipple valve forming technique, minimizing impairment of renal function. We report for the first time in Japan 13 cases, in which this method of innovative urinary diversion was used, with special attention paid to its demanding surgical technique and early results with its complications. From November, 1984 to August, 1985, we performed urinary diversion via the Kock pouch in 13 cases: 10 males and 3 females, from 35 to 67 years old (mean age 49 years), 11 bladder cancer patients, and 2 rectal cancer patients. The 2 patients with rectal cancer died from cancer and 1 bladder cancer patient with psychosis died from mental crisis 4 months after the operation. Of the 10 cases followed up long enough, 7 cases were in excellent condition with complete continence, 2 cases were in good condition with minor leak due to intermittent prolapse of the nipple valve, and in one case with failure, due to the postoperative ileus and eversion of the nipple valve, which made it difficult to catheterize into the pouch. Excision of the pouch and conversion to the standard ileal conduit was performed by reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ongoing experience with the kock continent ileal reservoir for urinary diversion

Summary The continent ileal reservoir, as introduced by Dr. Nils Kock, presents an intriguing but challenging option in the field of urinary diversion. From August 1982 through December 1984, 157 patients underwent this type of surgery at our institution. Of these patients, 103 underwent simultaneous radical cystectomy for cancer, 42 had a previous urinary diversion of another type, and 12 had neurogenic bladders. Our experience represents a series of expected complications and ongoing modifications to the surgical technique. A total of 24 patients experienced early complications requiring 6 reoperations, and 32 patients were noted to have 41 late complications necessitating 33 further revisional surgeries. There were 3 operative mortalities and 12 late deaths due to nonoperative causes. Three patients required conversion of their Kock pouch to an ileal conduit. The end result leaves 139 patients for chronic follow-up, of whom 134 are doing extremely well and fit all of the criteria for a successful continent diversion. They catheterize every 5–6 h with a mean reservoir capacity of 800–1000 cc and wear only a small pad over their stoma. The long-term results continue to be encouraging and suggest that the continent ileal reservoir is a definite alternative for the patient who requires a cutaneous urinary diversion and who is seeking an improved quality of life.     

Clinical experience with the Kock continent ileal reservoir for urinary diversion

From August 1982 through January 1984, 51 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 to prevent reflux and to ensure continence. Previous urinary diversion was by ureterosigmoidostomy in 3 patients, standard ileal conduit in 7 and suprapubic cystotomy in 1. A total of 39 patients underwent simultaneous anterior exenteration for pelvic malignancy. There was 1 postoperative death and early complications occurred in 10 patients. Of these 10 patients 4 required reoperation: 2 for drainage of a pelvic abscess, 1 for conversion to a standard ileal conduit and 1 for bleeding. Late complications occurred in only 8 patients: 5 required reoperation and revision of the continence valve mechanism, and 3 required hospitalization for brief episodes of pyelonephritis. The end result in 49 of 50 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 electrolytes have remained normal and hyperchloremic acidosis has been encountered in only 1 patient who had had compromised renal function preoperatively with hyperchloremic acidosis as a result of previous ureterosigmoidostomy. X-rays of the Kock pouch have shown evidence of reflux in only 1 patient, 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.     

Continent ileal urinary reservoir (Kock pouch)

The Kock pouch has three major limitations at the present time: The efferent nipple valve remains by far the weakest link in the procedure. A 10 to 20 per cent failure rate is too high, and it remains to be seen whether further modifications will be successful in the long run. The long-term function is unproven, and it is possible that deleterious effects may be seen as additional follow-up is obtained. Theoretically, the low-pressure system afforded by the Kock pouch may be superior in long-term safety to that provided by reservoirs made from other bowel segments. A stoma is still necessary. In spite of the above, there is a need for this type of procedure. We cannot remain content with the ileal conduit and should continue to search for better functional diversions. It is a debatable issue relative to the superiority of an internal functional reservoir to the urethra, which may lead to night-time incontinence, versus a Kock pouch with a stoma, which must be intubated. Improvement in overall survival from bladder cancer may be hard to come by, unless effective systemic chemotherapy is available; one means is to perform the surgery without delay in patients with potentially lethal cancers. To do this on a large scale, we must make the surgery as safe as possible and provide the least disruption of lifestyle. In some patients an internal intestinal reservoir attached to the urethra will be possible. Other patients may elect for a Kock pouch, whereas others may even be best served by standard ileal conduit. The growth pains of the Kock pouch have been significant but not without a reward.     

Serous lined extramural ileal valve: a new continent urinary outlet

PURPOSE: We report the functional results following the use of serous lined extramural valve as an antireflux technique and urinary outlet for continent urinary diversion. MATERIALS AND METHODS: The procedure was performed in 18 men and 5 women. The technique entails fashioning 2 serous lined extramural troughs in a detubularized W-shape ileal reservoir. A tapered ileal segment is embedded in 1 trough as an antireflux valve and the ureters are anastomosed to its proximal end. Another tapered ileal segment or the appendix is embedded in the second trough and acts as a continent cutaneous outlet. RESULTS: No operative or postoperative mortality was observed. One patient had prolonged ileus which was treated conservatively. All patients were evaluable with a mean followup of 19 months. All patients but 1 were continent day and night. No catheterization difficulties were reported. Evacuation intervals were 4 to 5 hours. Radiographic evaluation demonstrated a continent compliant reservoir, stable and straight outlet, and absence of pouch and ureteral reflux. CONCLUSIONS: This procedure is technically feasible, surgically versatile, applicable for urinary diversion or conversion and associated with satisfactory outcome.