Study of antireflux nipple valves of Kock ileal urinary reservoir. Experimental investigation in dogs

To better assess the construction, maintenance, and function of the Kock ileal urinary reservoir with its continent antirefluxing nipple valves, laboratory investigations in dogs were done simultaneously with clinical trials in humans in 1983. Fifteen dogs underwent creation of hemi-Kock ileal reservoirs (without the efferent valve and limb) that were anastomosed to their bladders as enterocystoplasties. The afferent antirefluxing nipple valves were intussuscepted after 7 cm of underlying mesentery had been removed. The nipples were further stabilized with metal and absorbable (Polysorb) staples and Marlex collars. The right ureters were anastomosed to the afferent limb of the reservoirs with the contralateral systems left intact as controls. Ten dogs were able to be followed at the vivaria for twelve to thirty-six months and then studied. All nipple valves remained intact, viable, and nonrefluxing without revision. All kidneys remained histologically normal except those in dogs with dilated ureters secondary to ureteroileal stenosis with concurrent calculi formation. Calculi formed on exposed metal staples and Marlex. The absorbable staples were found to promote appropriate healing and were never the nidus for stone formation. It appears that the intussuscepted nipple valve (with its mesentery removed) is reproducible and functionally reliable in preventing reflux. It also appears these valves can histologically preserve diverted kidneys if the upper urinary tract drainage is normal and calculi are minimized. The proper placement of staples and the elimination of Marlex-anchoring collars are indicated to minimize calculi.     

A new technique for ileal nipple fixation: preliminary report

A new technique for ileal nipple fixation is described in 6 post-cystectomy patients (4 with an ileal bladder substitute and 2 with an ileal reservoir) for the prevention of reflux. Nipple formation is helped by deperitonealization and defatting of the nipple mesentery. A full circumferential incision is made, except for the mesenteric border, and through both nipple layers down to the mucosa of the inner layer. The seromuscular layers on each side of the incision are closed together with continuous 3-zero polyglycolic acid suture. The overlying outer mucosa of both edges then is closed. Endoscopic and radiographic study 6 to 12 months postoperatively showed a stable nipple without reflux. The anatomical and physiological rationale of the technique is discussed.     

Nipple reduction �C An adjunct to augmentation mammaplasty

Nipple hypertrophy is an occasional deformity in Asians and a rare one in Caucasians. Lately, it has been showing up more often in plastic surgeons’ offices across North America and elsewhere, owing to the influx of Asian immigration worldwide, as well as to the rising interest in esthetic surgery among Asian communities.A simplified technique for nipple reduction is described herein. It is very easy to execute, delivers accurate results and is extremely safe. It tackles both the excessive ‘projection’ and the less frequent excessive ‘width’ of the nipple. It may be used separately or incorporated as an adjunct to mammary augmentation or mastopexy. Excellent esthetic results are obtained, while both the nipple innervation and its lactiferous ducts are preserved. The patient’s and surgeon’s satisfaction is high.     

Mucosal function after ileal mucosal fenestration and colonic autotransplantation.

A method of small bowel mucosal augmentation called ileal mucosal fenestration and colonic autotransplantation (IMFCA) was devised and tested in pigs. In this technique, a vascularized mucosal graft was harvested from a 12-cm ileal loop, fenestrated by serial incision and then expanded to 20 cm. A 20-cm colonic loop was isolated and surgical mucosectomy was carried out. The fenestrated ileal mucosal graft was then autotransplanted into the prepared colon and the resulting composite structure was exteriorized as a Thiry-Vella loop. With this technique, ileal mucosal fenestrations healed by lateral epithelial in-growth, giving a new mucosal continuum within the recipient colon. At 60 days after surgery, the surface area of transplanted mucosa exceeded that within the original ileal loop by approximately 85 per cent. At this time, the transplanted mucosa had morphology and capacity for Na(+)-dependent glucose transport which were indistinguishable from those of control ileal mucosa.     

Urethral controlled bladder substitution: a comparison between the intussuscepted nipple valve and the technique of Le Duc as antireflux procedures.

A urethral controlled bladder substitute was constructed from a detubularized, double folded ileal segment in 40 male patients following cystoprostatectomy for bladder cancer. For reflux prevention patients were prospectively randomized to receive either an intussuscepted nipple valve or the ureters were implanted by the Le Duc mucosal trough technique. All patients had normal upper tracts preoperatively. Mean patient age, performance status and stage of cancer were comparable in both groups. Patients were evaluated 6 to 18 months postoperatively. In addition to history taking, assessment included excretory urography, ascending cystography and voiding cystourethrography. During the observation period all patients with nipple valves had normal radiographic appearance of the upper tracts without evidence of reflux. On the other hand, following the Le Duc procedure 12 of 38 renal units (31%) showed evidence of radiographic dilatation. Of the 12 units 11 had stenotic ureters and 1 had reflux. We conclude that nipple valves are more effective in reflux prevention and protection of the upper urinary tract in patients for whom an ileal neobladder is indicated.     

Mucosal ultrastructure of continent cecal reservoir for urine and its ileal nipple valve 2-9 years after construction

Biopsy specimens from continent cecal reservoir for urine and from its ileal nipple valve were studied with electron microscopy after two to nine years of function in ten patients. In the colonic mucosa from the reservoir there was shortening of microvilli, in some cases with random orientation and numerical reduction-changes unrelated to the time from reservoir construction. Filamentous core rootlets were also randomly oriented and numerically diminished. Glycocalyceal bodies were present in most cases. Mucosal edema and reduced numbers of goblet cells were found in six cases and increased amount of collagen in two. In the ileal nipple valve mucosa there were no microvillous changes, but metaplastic formation of glycocalyceal bodies was interpreted as adaptation to physiologic conditions comparable with those in the reservoir's colonic mucosa. Collagen increase was found in two of the nipple valves. Neurogenic processes, enterochromaffin cells and Paneth cells were always well preserved in normal amounts in the cecal as well as the ileal mucosa.     

Filler Injection Enhances the Projection of the Reconstructed Nipple:An Original Easy Technique

Background Reduced nipple projection is the main reason for unsatisfactory nipple–areola complex reconstruction, and many techniques have been proposed to maintain projection of the reconstructed nipple.Methods For 70 patients, 90 nipples were reconstructed using either a small wedge from the labia minora (LMW) (n=70) or nipple sharing (NS) (n=20). Two months after reconstruction, each reconstructed nipple was injected with DermaLive. Second and third injections were performed 2 and 5 months later. The injected volume was tailored to the desired projection. Nipple projection was measured at the moment of implant, before and after each injection, and 6 and 12 months after the last injection.Results Nipple projection was satisfactory in all cases and comparable with that of the contralateral nipple. The average nipple projection at 6 months was 5.8 mm in the LMW group and 3.8 mm in the NS group (p < 0.01) and, respectively, 5.6 mm and 3.5 mm at 12 months (p < 0.01). No complications occurred, except for one positron emission tomography (PET) false-positive result.Conclusions The described method is simple and safe. It provides precise projection with no need for intraoperative forecasting of tissue reabsorption. The result was better for the LMW patients, perhaps because of their higher distensibility.     

绕乳头基底乳晕纵切口结合肿胀麻醉隆乳术

目的：探讨绕乳头基底乳晕纵切口结合肿胀麻醉隆乳术的操作技巧及此方法的优点。方法：对我科39例腋下切口、15例乳房皱襞下切口、27例乳晕下缘弧形切口及35例绕乳头基底乳晕纵切口结合肿胀麻醉的116例隆乳患者的疗效及患者满意度进行比较。结果：采用绕乳头基底乳晕纵切口患者的疗效及满意度最高。结论：绕乳头基底乳晕纵切口结合肿胀麻醉是理想的隆乳术式,手术创伤小,切口隐蔽,易于操作,术后患者恢复快,形态好。     

Current status of continent urinary reservoirs for invasive bladder cancer patients undergoing total cystectomy]

Continent urinary reservoirs (CUR) have become one of the major options of urinary diversion for invasive bladder cancer patients who require cystectomy and cutaneous urinary diversion. We have experienced 100 cases of Kock pouch and 30 cases of indiana pouch during the past 5 years which comprise 45% of all cases. Standard ileal conduit and ureterocutaneostomy were performed in 34% and 20%, respectively, and orthotopic urinary reservoir by hemi-Kock pouch was done in only one case during the same years. There were 3 perioperative deaths, 2 had Kock pouch and one Indiana pouch. Early postoperative complications were not substantial. However, significantly high rates of late postoperative complications were seen in Kock pouch, i.e., both efferent (18%) and afferent (13%) nipple valves and stone formation (18%). Uretero-ileal anastomosis by hammock method done in 10 cases resulted in success in 8 cases, abolishing the afferent nipple. Indiana pouch, in which no nipple valves or foreign materials like staples or collars are necessary, has been adopted as a first choice for the past 3 years. Of 29 evaluable cases, Heineke-Mikulicz method was used in 7 cases, and ileal patch method in 22 cases. An hourglass-like deformity was seen in 2 cases in the former method. Severely difficult catheterization, parastomal abscess, and acidosis occurred in one. Overall, 24 cases (83%) have come up with satisfactory results with minimal overflow incontinence in the early postoperative course. Although much longer followup is necessary, CUR's by Kock or Indiana pouch are more acceptable by bladder cancer patients requiring cystectomy.     

100 cases of Mainz pouch: continuing experience and evolution

The surgical technique for creation of the Mainz pouch uses 10 to 15 cm. of cecum and ascending colon and 2 ileal loops of the same length for construction of a urinary reservoir. Initial applications of the Mainz pouch were for bladder augmentation after subtotal cystectomy and for continent urinary diversion. Current indications have been extended to complete bladder substitution after radical cystoprostatectomy with anastomosis of the pouch to the membranous urethra. For cosmetic reasons the umbilicus is used as a stomal site for continent urinary diversion, and the technique of intussuscepting the continence nipple has been modified accordingly. A total of 100 patients underwent a Mainz pouch procedure since 1983: 34 for bladder augmentation, 15 for total bladder substitution after cystoprostatectomy and 51 for continent urinary diversion. In the bladder augmentation group 1 patient underwent conversion to a continent stoma, 1 has urge and frequency, and the remaining 32 are completely dry day and night. These patients empty the bladder at normal intervals spontaneously except for 3 who rely on intermittent catheterization. In the bladder substitution group 1 patient has grade 1 stress incontinence and the remainder are completely dry during the day. However, at night 4 patients have leakage and they use a condom urinal. In the urinary diversion group all but 2 patients are completely dry and are on intermittent catheterization. The main problem of the initial series was prolapse of the continence nipple, which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve.     

The use of a combined technique in reduction mammaplasty (inferior pyramidal and superior glandular techniques)

The management of mammary hypertrophy is a developing process. The common surgical options for reduction mammaplasty include amputation with free nipple graft as well as the bipedicled, inferior pedicle and vertical pedicle techniques. All techniques are used widely. Disadvantages of these procedures include nipple areola necrosis, insensitivity, hypopigmentation, and poor breast projection. Even with the standard modifications of the original techniques, the resultant breast and nipple may be wide and flat. The purpose of this study was to assess whether combined inferior pyramidal pedicle and superior glandular pedicle reduction mammaplasty can optimize nipple and breast projection. Attention will focus on the viability and sensation of the nipple areola complex. Nine patients with mammary hypertrophy were studied. The change in nipple position ranged from 7 to 13 cm. The amount of tissue removed from each breast ranged from 500 to 1150 g. Nipple/areola sensation was retained in all cases with the exception of one breast. Nipple/areola necrosis or hypopigmentation were not observed. Optimal central breast projection was maintained in all patients, and postoperative evaluation was carried out at 12 and 22 months. The patient satisfaction was very high.     

Safe delayed procedure of nipple reconstruction in poorly circulated nipple

Nipple‐areolar complex reconstruction represents the final step in breast reconstruction. However, there is no gold standard nipple reconstruction technique that addresses the issue of blood circulation in the flap, which is the most basic complication. Nipple reconstruction was performed in 21 patients. A delayed procedure was performed when a poor outcome was expected due to marginal pinpoint bleeding in the distal tip after flap elevation during nipple reconstruction. The delayed nipple reconstruction can be viewed as a safe and reliable method for improving nipple blood circulation, reducing complications, and enabling long‐term nipple projection maintenance in high‐risk patients.     

The Mainz pouch. Ileocecal reservoir, Mainz pouch

The surgical technique for creation of the Mainz-pouch uses 12cm of cecum and ascending colon and 2 ileal loops of the same length for construction of an urinary reservoir, which has proven to be applicable for bladder augmentation, bladder substitution as well as for continent urinary diversion. For the creation of a continent nipple in urinary diversion 6cm of ileum in addition are necessary. As a modification we use the non-infected submucosal imbedded appendix as continence mechanism. Since 1986 a total of 247 patients underwent a Mainz-pouch procedure: 54 for bladder augmentation, 27 for bladder substitution and 166 for continent diversion. The appendix as continence mechanism was used in 30. Postoperative mortality rested under 1%, early complications have been observed in 4.4% and late complications in 13.7% (mean follow-up of 35 months). In the bladder augmentation group 52 patients are completely dry, 2 patients have urge and frequency and 5 patients are on intermittent self catheterisation to avoid residual urine. In the bladder substitution group all patients are continent at daytime. At nighttime 3 patients have leakage if they don't empty their bladder all 4 hours. In the urinary diversion group all but 3 are completely dry and are on intermittent catheterization. The main problem of our initial series was prolapse of the continent nipple which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve or by using the submucosal imbedded appendix.     

The nipple valve as a sphincter substitute for the ileocecal valve: prevention of bacterial overgrowth in the small bowel

We evaluated the bacteriologic effect of a nipple valve substitute for the ileocecal valve in a canine model. Resection of the ileocecal valve and the distal 40% of the jejunoileum with end-to-end anastomosis was carried out in 10 dogs. In five of the dogs chosen randomly, a nipple valve was constructed at the anastomosis; in the remainder , a two-layer jejunocolostomy was formed. Microbiologic samples were taken at operation in the ascending colon and at three sites in the small intestine before resection and at reoperation 4 weeks later. These revealed a dramatic increase in anaerobic bacteria in the distal jejunum following jejunocolostomy without valve insertion but no increase following jejunocolostomy with nipple valve. There was a seven-log difference between the two groups in the mean anaerobic bacterial counts (P less than 0.05) measured 60 cm proximal to the anastomosis at the second operation. Results of aerobic cultures were similar but less dramatic. We conclude that construction of a nipple valve jejunocolostomy prevents anaerobic bacterial colonization of the proximal small bowel and may therefore be useful in the treatment or prevention of short bowel syndrome.     

Ileal substitute of ureter with reflux-plasty by terminal intussusception of bowel Animal experiments and clinical experience

The conflicting results reported after substitution of the ureter by isolated bowel segments suggest that the procedure is still hazardous. This induced us to check experimentally the performance of the ileal ureter with antireflux-plasty before using it clinically. The antireflux mechanism is constructed by intussuscepting the terminal 8 cm. of an isolated ileal segment into each other thus forming a nipple. After vesicoileostomy the nipple protrudes into the urinary bladder. In the pig vesicoileorenal reflux was prevented, and anterograde urinary flow from the kidney through the ileal ureter into the bladder was unobstructed. Finally, the case of a patient is recorded who was submitted to the same procedure successfully.     

两种乳晕切口在隆乳术中的应用探讨

目的：比较两种经乳晕不同切口行乳房假体隆乳术的效果。方法：2007年1月～2008年1月期间,28例女性就医者接受经乳晕路径假体隆乳术。随机分为两组,其中A组11例采用乳晕缘下半环切口入路,B组17例采用绕乳头基底部纵行乳晕切口入路。并对两种手术方法及术后6～12个月的随访进行了总结。结果：绕乳头基底部乳晕切口易于假体置入,手术操作灵活方便,保留乳房外形效果更好,术后乳晕部的剥离范围内感觉障碍较轻微,乳头感觉良好,切口瘢痕更加隐蔽。所有就医者于术后接受随访均感满意。结论：和常规经乳晕缘切口相比,绕乳头基底部纵行乳晕切口入路有较多的优点,在美学方面有明显优势,此方法值得在临床上推广应用。     

Nipple reconstruction in Asian females using banked cartilage graft and modified top hat flap.

Nipple reconstruction is usually the final stage of breast reconstruction and there are over 50 articles that describe different techniques. The majority of methods use local soft tissue as local flaps but they face the disadvantage of reduction in nipple projection after the initial two months. This is particularly troublesome in Asian females who may have wider nipples with prominent projection but small areola surface area. We developed a method to correct this problem using cartilage graft harvested during the initial breast reconstruction operation and banked beneath the skin flap. Using the modified 'top hat' flap, we found that no excess soft tissue is required to compensate for the reduction. We have used this method in 25 cases of nipple reconstruction and have obtained satisfactory result in projection.     

Total ligation of the left renal vein in the dog: an inappropriate model for varicocele

Induction of varicocele was attempted by ligation of the left renal vein (LRV) in male dogs (Group I). Before the operation and in the 4-month post-operative period, sperm count, sperm motility, and sperm morphology of Group I (n = 8) dogs were compared to sham operated animals (Group II, n = 5). Furthermore, haemodynamics as well as testicular and vascular morphology were studied. In Group I, changes in diameter and consistency of the spermatic cord were temporary. Semen quality was reduced significantly during the second month after ligation of the LRV, but improved thereafter. Haemodynamic studies revealed that LRV blood pressure was increased significantly in Group I dogs. An extensive venous collateral network replaced the occluded LRV. Retrograde blood flow in the left testicular vein (LTV) was observed only in the proximal part of the LTV of Group I dogs. In Group II dogs numerous pairs of sufficient valves prevented reflux into the LTV. Histological examination revealed that spermatogenesis was not impaired and that the left pampiniform plexus had not changed. The number of Leydig cells was decreased slightly in Group I dogs. Sufficient valves in the LTV prevented formation of a permanent varicocele.     

Nonrefluxing ileal ureteral replacement using the intussuscepted ileal nipple: laboratory studies

A new technique for nonrefluxing ureteral replacement using ileum has been developed. Five adult mongrel dogs were operated using this nonrefluxing ileal ureteral technique. Subsequent reoperation showed in every case the preservation of renal function, a nonrefluxing system and no evidence of pyelonephritis or hydronephrosis. Based on the intussuscepted ileal nipple used in the Kock continent ileostomy, this technique has application in candidates for urinary undiversion, situations of ureteral loss due to trauma and fibrosis, and in patients with tuberculous strictured ureters.     

Continent urostomy: a clinical experience in 20 patients

Urinary diversion via a continent ileal reservoir (modified Kock's procedure) was performed in 20 patients. Primary continent urostomy construction was carried out in 6 patients. Previous urinary diversion was present in 12 patients. Two patients were referred to us because a previous attempt to construct a continent reservoir urostomy had failed. There was no operative mortality. Three early complications occurred in 3 patients. Leakage from a uretero-enteric anastomosis in one patient and necrosis of a continence-providing valve in another patient necessitated reoperation. Late complications causing malfunction of the nipple valves required revisional surgery in 2 patients. Stoma stricture developed in 1 patient after 5 months and could be corrected surgically. The functional results were excellent. Continence was achieved without reflux to the upper urinary tract. Instead of a Kock pouch, an S-pouch was used. The continence and antireflux-providing valves were stapled to the reservoir wall. Slippage of the nipple valves did not occur. All our patients had consistently positive urine cultures and were without complaints. In a few cases, stone formation was observed usually on the staples at the tip of the valve. The stones were removed by forceps during endoscopy of the reservoir.