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.     

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.     

Colon pouch (Mainz III) for continent urinary diversion

OBJECTIVE: To evaluate the use of a continent cutaneous pouch made exclusively of colon (Mainz pouch III), as excellent results with the Mainz pouch III in irradiated patients suggested that the indication for this type of urinary diversion could be extended. PATIENTS AND METHODS: The outcome of 24 patients with continent cutaneous urinary diversions using colon segments (Mainz pouch III) was investigated retrospectively. Overall, 22 of the patients had a malignant disease and two a benign disease; 16 had a hysterectomy and pelvic exenteration for gynaecological tumours; two men with a rhabdomyosarcoma of the prostate had a radical cystoprostatectomy; one woman had pelvic exenteration for bladder cancer; one man had a simultaneous rectum resection due to infiltrating rectal cancer, and another a left nephrectomy with cystectomy for concomitant kidney and bladder tumour. Benign indications were hyper-reflexive bladder after polytrauma and two cases of neurogenic bladder dysfunction. Eighteen patients had radiotherapy (32-48 Gy) before the urinary diversion. RESULTS: The mean (range) follow-up was 35 (12-65) months. The mean pouch capacity was 293.8 mL. Three patients died during the follow-up (two from disease progression and one suicide); 20 patients were fully continent, four with reduced pouch capacity (<300 mL) had slight incontinence and are wearing a protective pad (band-aid at the umbilicus). All patients use intermittent self-catheterization (mean catheterization frequency 6.8/day, range 6-12). Complications related to the pouch were one outlet stenosis that required revision. Postoperative pouchograms showed asymptomatic reflux in four patients. None of the patients developed metabolic acidosis or diarrhoea. CONCLUSIONS: The Mainz pouch III is an alternative to other types of continent urinary diversion.     

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.     

The Kock continent ileal reservoir for supravesical urinary diversion: An early experience

The most commonly employed urinary diversion operations are associated with a high incidence of complications and the disadvantage of requiring an external appliance to collect urine. The Kock continent ileal reservoir, introduced in 1975, provides an intraabdominal receptacle for storage of urine and two nipple valves which maintain continence and prevent ureteral reflux. The reservoir is emptied by self-catheterization; no external appliance is necessary. This operation provides a more ideal substitute for the lower urinary tract than any other urinary diversion procedure thus far reported.The seven patients reported herein have been followed for up to 3 years and enjoy completely continent ileal reservoirs. Follow-up studies have demonstrated that the kidneys are adequately protected from ureteral reflux and ascending infection. Metabolic acidosis has presented no serious problem. All of the patients enjoy a far better quality of life since discarding their external appliances.     

The continent cecal reservoir for urinary diversion

Summary Urinary diversion was accomplished through a continent cecal reservoir in 27 patients. An intussuscepted ileal nipple valve was used as a continence-providing principle. To achieve continence and ease of catheterization, several constructional modifications of the valve were required. Satisfactory functional results were obtained with a nipple valve protruding into the cecal cavity, mesenteric exclusion from the valve and, for stability, a fascial strip sling around the nipple base. The ureters were implanted into the cecum using an anti-reflux technique. Complications were sliding of the nipple valve, which necessitated revisional procedures in a substantial number of patients, and stricture of the ureterocecal anastomosis. Renal function was well-preserved after long-term follow-up. The continent cecal reservoir offers a better quality of life than conduit diversion, and can be an attractive alternative to other methods for selected patients at centers with a special interest in this field.     

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.     

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.     

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.     

Management of complications after construction of a continent ileal reservoir for urinary diversion

Summary Urinary diversion via a continent ileal reservoir has been performed in our institution for the past 10 years, but has only recently been adopted in several other centers. The technical problems and complications are similar to those encountered with the continent ileostomy, for which considerable experience concerning management of complications has been collected. The nature of the complication is established by patient history, endoscopy, radiological examination or exploration. Early complications include anastomotic leak or necrosis of different parts of the construction due to compromised vascular supply. Late complications were rarely confined to the reservoir itself, but were more often related to the nipple valves. Most complications are corrected by revisional surgery. Due to technical improvements, complications have decreased progressively over the course of time. However, a meticulous technique is instrumental to success, and surgeons performing the continent urostomy should be aware of the complications and their management.     

Sigmoidorectal (Mainz II) pouch for continent urinary diversion in bladder cancer

BACKGROUND: We aimed to assess the feasibility, safety, and outcome of the sigmoidorectal (Mainz II) pouch for urinary diversion in patients with invasive bladder cancer. METHODS: Twenty-nine patients (25 men and four women), aged 65-76 years, who had undergone radical cystectomy and the sigmoidorectal pouch procedure for invasive bladder cancer were included in this study. Postoperative evaluations included metabolic testing, standard laboratory screening, renal ultrasonography, pouchography, and intravenous urography or pouchoscopy when indicated. RESULTS: The median operative time was 175 min. Urine leakage was encountered in two patients (6.8%), deep vein thrombosis in one (3.4%), and ileus necessitating surgery in another one. Two patients developed pyelonephritis due to ureterocolonic stricture, which was treated with antegrade balloon dilatation. No local relapses of bladder cancer were found. All patients were continent during the day, but one patient was occasionally incontinent during the night. In the long term, six patients (20.6%) developed metastatic disease, and five patients (17.2%) died because of cancer-related causes. Overall survival was 100, 96 and 60% at 1, 2 and 3 years after the operation, respectively. The mean survival was 36.8 +/- 1.9 months, which was statistically significantly associated with the M stage (P < 0.001), but not with the T (P = 0.091) or N (P = 0.081) stages. CONCLUSIONS: The sigmoidorectal (Mainz II) pouch seems to be a feasible, safe and effective method for continent urinary diversion. It is able to provide good quality of life, and ensure good overall survival rates.     

The management of the Kock continent ileal reservoir urinary diversion with single pigtail self-retaining ileal conduit stents

The use of single pigtail soft silicone self-retaining ileal conduit stents appears to have particular value in the perioperative management of patients with a Kock pouch continent urinary diversion. Stenting provides greater assurance of sustained internal urinary diversion, lessening concern regarding anastomotic leaks from the pouch itself. This technique also allows easy sequential radiographic confirmation of healing without losing the capability for continued internal drainage by these stents if necessary. A protocol for the use of such stents is described.     

Volume capacity and pressure characteristics of the continent ileal reservoir used for urinary diversion

The volume capacity and the pressure characteristics of the continent ileal reservoir for urinary diversion were studied at specific intervals postoperatively in 26 patients. The reservoir volume increased during the first year postoperatively from approximately 100 ml. at operation to a mean of 735 ml. and then remained stable during an observation period of up to 7 years. The basal pressure increased during filling from 0 to about 10 cm. water. During physiological conditions, that is when the reservoir was filled by diuresis, the basal pressure was equal to those pressures measured during saline infusion at corresponding reservoir volumes. Calculation of the magnitude of motor activity by 2 different methods showed a significant decrease in activity at 12 months compared to at 2 months after construction of the reservoir. Data from the continent urostomy reservoir were compared to corresponding data from the continent ileostomy and cecal reservoirs for fecal diversion, these being obtained in previous studies in our laboratory. The ileal reservoirs used for fecal or urinary diversion were practically identical with regard to volume capacity, basal pressure and motor activity. However, the cecal reservoir had a significantly lower volume capacity and higher basal pressure at corresponding reservoir volumes, while the motor activity was approximately 10 times greater than in the ileal reservoir. The results indicate that with regard to volume capacity and pressure characteristics the ileal reservoir is superior to the cecal reservoir as a receptacle for urine.     

Continuing experience with the continent ileal reservoir (Kock pouch) as an alternative to cutaneous urinary diversion: an update after 250 cases

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 August 1985, 250 patients underwent this type of surgery at our institution. Of these patients 171 underwent simultaneous radical cystectomy for cancer, 60 had had a previous urinary diversion of another type and 19 had a neurogenic bladder. Our experience represents a series of expected complications and ongoing modification to the surgical technique. A total of 42 patients (16 per cent) suffered early complication resulting in an operative mortality rate of 2 per cent (5 of 250). One or more late complications necessitating 85 revisions occurred in 77 patients (31 per cent). The end result has been an overwhelming success tempered only by the need for reoperation. It is believed that the surgical modifications described will decrease further the incidence of late complications. The basic surgical premise as conceived by Kock remains a low pressure, high capacity reservoir with continent and nonrefluxing valves that can be constructed from ileum. The concept is sound and offers a genuine alternative to the patient who requires cutaneous urinary diversion.     

Renal function and upper urinary tract configuration following urinary diversion to a continent ileal reservoir (Kock pouch): a prospective 5 to 11-year followup after reservoir construction

We followed 17 patients who underwent urinary diversion via a continent ileal reservoir (Kock pouch) with yearly examinations for 5 to 11 years postoperatively. The examinations involved control of renal function and configuration of the upper urinary tract. In 5 patients the upper urinary tract had become dilated during followup and in 2 of these renal scarring also had developed. All 5 patients had endured temporary outflow obstruction or reflux (stricture, overdistension of the reservoir or a defective antireflux valve). Of the patients 1 had a marked decrease in renal function before the outflow obstruction was corrected by an operation. Routine blood chemistry study was normal and hyperchloremic acidosis was not noted in any patient. After peroral loading of 6 patients with ammonium chloride significant excretion of titratable acid was found in the urine. Substitution with vitamin B12 was given to 6 patients due to subnormal values in 2 and borderline values in 4.