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Clinical Experience with the Kock Continent Ileal Reservoir for Urinary Diversion
0022-534 7/84/1326-1101$02.00/00 Vol. 132, December Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1984 by The Williams & Wilkins Co.
CLINICAL EXPERIENCE WITH THE KOCK CONTINENT ILEAL RESERVOIR FOR URINARY DIVERSION DONALD G. SKINNER, STUART D. BOYD
AND
GARY LIESKOVSKY
From the Division of Urology, Department of Surgery, University of Southern California School of Medicine, Los Angeles, California
ABSTRACT
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 selfcatheterization 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. Kock and associates have made a major contribution to the urological surgical armamentarium by developing a method to create a continent internal reservoir for urine using ileum. 1- 11 Following modification of the continent ileostomy developed for patients undergoing proctocolectomy for ulcerative colitis and after extensive experimentation with animals, Kock and associates reported their initial experience with 12 patients in 1982. 10 This innovative procedure now affords patients requiring cystectomy for bladder cancer or cutaneous urinary diversion for any reason a real alternative to the standard ileal conduit, which requires an external appliance. We report our experience with 51 patients undergoing creation of a Kock continent ileal reservoir for urinary diversion. Experience with the technique as described by Kock and associates, and a careful review of our early results have led to some modifications that we believe will improve the end result further. MATERIAL AND METHODS
From August 1982 through January 1984, 51 patients have undergone creation of the Kock continent ileal reservoir for cutaneous urinary diversion. There were 14 women between 19 and 56 years old, and 37 men between 24 and 75 years old. Previous urinary diversion was by ureterosigmoidostomy in 11 patients, standard ileal conduit in 7 and suprapubic cystotomy in 1. The 3 ureterosigmoidostomy patients underwent the new procedure because 2 had had obstruction at the ureterocolonic anastomosis, and 1 had recurrent pyelonephritis and poor continence. The patients with ileal conduits actively sought conversion to the new reservoir because of inability to Accepted for publication July 25, 1984. Read at annual meeting of American Urological Association, New Orleans, Louisiana, May 6-10, 1984.
maintain dryness or because of the psychosocial stigmas associated with having to wear an external appliance. The patient with a suprapubic cystotomy underwent creation of a Kock pouch because of the traumatic loss of the urethra and bladder neck owing to an automobile accident. Of the 11 patients who previously underwent urinary diversion 3 had received planned preoperative radiation therapy (1,600 to 4,500 rad) before cystectomy. A total of 39 patients underwent simultaneous radical cystectomy and creation of the continent Kock pouch, and 1 massively obese paraplegic patient underwent urinary diversion after development of numerous urethral fistulas associated with catheterization. Of the patients undergoing simultaneous cystectomy and urinary diversion 6 had received varying dosages of prior radiation therapy for pelvic malignancy. One patient received 1,600 rad and 2 received 4,500 rad as part of a planned combination of preoperative radiation therapy and radical cystectomy. Three patients who had failed prior definitive radiation therapy for bladder or urethral carcinoma had received doses of 6,000 to 7,000 rad. One additional patient, our only immediate failure, had received an unknown amount of abdominal and pelvic radiation preceded by a pelvic operation many years earlier for endometrial carcinoma. This patient suffered an enterocutaneous fistula through the pouch and was given successfully a standard ileal conduit 20 days after anterior exenteration. Over-all, 34 patients underwent simultaneous bilateral pelvic iliac lymph node dissection with en bloc radical cystectomy and creation of the continent ileal pouch for urinary diversion as primary treatment for high grade invasive bladder cancer. Surgical technique. Our technique, modified slightly from that described by Kock, has been reported in detail. 12 Technical points of importance include 1) A slightly longer
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segment of ileum is used than described originally by Kock and associates. The afferent and efferent limbs each are 17 cm. long and the pouch is created from 2, 22 cm. segments (fig. 1). 2) Approximately 7 to 8 cm. of mesentery are stripped off the ileum from the afferent and efferent limbs to allow creation of the continence and antireflux nipple valve mechanisms. This technique was described originally by Hendren in an effort to retain the intussuscepted ileum in the cecum for ileocecal
FIG. 1. A, various segments of terminal ileum chosen for creation of Kock pouch. Note that distal mesenteric division is into avascu!ar plane of mesentery extending toward base of mesentery and that proximal mesentery division is short to assure broad vascular supply to pouch. Usually, small window of mesentery and additional 3 to 5 cm. of small bowel are discarded proximal to over-all segment to assure good mobility to pouch and to small bowel anastomosis. Pouch itself is created from 2 central 22 cm. segments with each limb extending to or away from pouch being approximately 17 cm. long. If patient has existing ilea! conduit, afferent limb is created from only about 13 to 15 cm. of small bowel. B, 2, 22 cm. segments are joined by running 3-zero polyglycolic acid continuous suture. Lowest point of U should be directed caudally so that once pouch is formed afferent limb will drop readily to sacral promontory to facilitate ureteroileal anastomosis. Proximal end of afferent limb is closed with running Parker-Kerr suture. Then 2, 22 cm. segments of bowel are opened immediately adjacent to continuous serosal suture line to form pouch. C, mucosa is oversewn with 2 layers of 3, 3-zero polyglycolic acid continuous sutures to form watertight suture line. Note that serosal incision has been extended for several centimeters along afferent and efferent limbs so that when nipples are formed they are separated. Reprinted with permission. 12
bladder undiversion. 13 We believe that this step is important to avoid incorporation of the mesentery into the intussuscepted nipple, which could promote subsequent slippage or loss of the critical intussusception (fig. 2). 3) A 2.5 cm. Marlex strip then is passed through the window of Deaver adjacent and distal to the area of mesenteric stripping. Once the ileum is intussuscepted into the pouch the Marlex will serve as a collar to be attached to the pouch and fixed to the afferent or efferent limb to or from the pouch, respectively. 4) Four rows of 4.8 mm. staples then are applied to the intussuscepted segment, with the most distal staples placed at the base of the nipple and the 2 juxtamesenteric rows incorporated into the Marlex. We use the TA-55 automatic stapler with 4.8 mm. staples, which are not hemostatic and do not crush the bowel. Since staples at the end of the nipple do not contribute to maintenance of the intussusception, remain exposed and may form a nidus for subsequent stone formation, we remove routinely the 5 proximal staples from the apparatus before stapling (fig. 3). 5) Next, the index finger is passed through the nipple and the Marlex strip is sewn around the ileal segment with 2-zero nylon to fix the Marlex to the pouch and ileal segment. This technique prevents the Marlex from being so tight as to cause erosion and helps to prevent slippage of the nipple (fig. 4). 6) All mucosal suture lines are oversewn with 2 meticulous layers of running 3-zero polyglycolic acid sutures to prevent urinary leakage. 7) The Marlex collar and efferent segment of ileum are fixed to the anterior rectus fascia with 2 horizontal mattress sutures of No. 1 nylon. This step fixes the continent valve mechanism to the abdominal wall and prevents patient difficulty in catheterization owing to redundancy of the efferent limb of ileum (fig. 5). 8) No. 8 infant feeding tubes are passed across the ureteroileal anastomosis and through the afferent nipple into the pouch where they are left indwelling. 9) A No. 30 Medena tube is placed in the pouch with the drainage holes positioned well proximal to the efferent nipple. The Medena tube is left indwelling for 3 weeks. 10) A 1-inch Penrose drain is placed through a separate stab wound and sewn to the psoas with a single 3-zero chromic suture several inches away from the pouch. This drain should remain at least 48 hours after the Medena tube is removed. 11) In patients with existing ileal conduits we anastomose the pre-existing ileal conduit end-toend with the afferent limb of the Kock pouch, provided there is no ureteroileal obstruction. Redundant ileum from the conduit is discarded and the length of afferent ileum used for the pouch is reduced to 13 to 15 cm. Patients are rehospitalized 3 weeks postoperatively and endoscopy of the Kock ileal reservoir is performed for retrieval of the ureteral stents. Cystography of the reservoir is performed to detect leakage and an excretory urogram (IVP) is done. If no leakage is observed patients are instructed on self-catheterization and remain overnight to make sure they have no difficulty with catheterization. At rehospitalization when all tubes are removed patients are given aminoglycosides parenterally. Suppressant antibacterial medication also is given and is continued for 4 to 6 weeks after the patient is discharged from the hospital. In patients with good renal function Shoal's solution (sodium potassium citrate) or oral bicarbonate has not been necessary and patients use clean catheterization techniques. 14 Patients are followed initially at 4 months and then at 6month intervals. At each followup visit cystography of the reservoir, an IVP, serum determination of electrolytes and creatinine, and a pouch culture are obtained. RESULTS
The average operating time to create a Kock pouch is approximately 1.5 to 2.0 hours longer than that for creation of a standard ileal conduit. All other operating time remains approximately the same whether the pouch is done in conjunction with cystectomy or as a conversion of an existing ileal conduit.
EXPERlEl\JCE Vii'J:'H }COCI( CONTINEI""~T ILEAL R.BSERVOIB, :f'OR URII~ARY DIVERS10J'
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.5 cm ma,lex collar
2.5 cm mariex collar
FIG. 2. Mesentery is divided next immediately adjacent to serosa of afferent-efferent limb for distance of nearly 8 cm. One usually leaves arcade and then places 2 cm. wide strip of Marlex, which will serve as collar to fix afferent-efferent limb to pouch once intussusception technique has been accomplished. Reprinted with permission. 12
A
B
FIG. 3. A, with Allis clamps passed approxi1nately halfway to Marlex strip mucosa is grasped and ileum is intussuscepted into pouch so that Marlex now lies adjacent to pouch and nipple valve mechanism is created. B, 4 longitudinal rows of automatic staples are placed with T-55 automatic stapling device and 4.8 mm. staples. Note that 5 staples have been removed from end of nipple, since are not required to maintain intussusception and remain exposed for possible stone formation. Staples at base of nipple in juxtamesenteric may involve Marlex collar to fix collar in place further. Reprinted with permission. 12
The operation is not difficult technically but it is tedious and attention to every detail is essential to ultimate success. The only operative mortality among the 51 patients resulted from a chain of events after postoperative bleeding but the Kock pouch was not believed to have contributed to this death. There were 10 early complications resulting in prolonged hospital stay. One patient had an enterocutaneous fistula through the pouch, which necessitated reoperation and conversion to a standard ileal conduit. This patient represents our only failure, probably owing to poor patient selection. The patient had received an unknown amount of old-time radiation for endometrial carcinoma after a pelvic operation. Two complications occurred as a direct result of inadequate pelvic drainage and both required reoperation to drain pelvic
abscesses. Three additional patients had prolonged drainage of urine through the Penrose drain site. Endoscopy of the reservoir in each case revealed migration of the Penrose drain into the pouch. All 3 leaks dried promptly with advancement of the drain. Subsequently, in other patients we have anchored the drain to the psoas muscle with a 3-zero chromic suture several centimeters away from the pouch. Several patients undergoing radical cystectomy with simultaneous pelvic lymph node dissection have had temporary lymph fistulas via the Penrose drain, resulting in a significant decrease in the serum albumin but no long-term sequelae have been observed. Otherwise, the long maintenance of the Penrose drain has not caused problems. Initially, we did not use a stent for the ureteroileal anasto-
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SKINNER, BOYD AND LIESKOVSKY
B
C
FIG. 4. A, finger is inserted through nipple and through area of Marlex so that Marlex can be pos1e,oned around afferent or efferent limb. Finger is used so that Marlex collar is not too tight to avoid possibility of erosion. Marlex is secured to pouch and respective limb of ileum with interrupted 2-zero nylon sutures. B, completed nipple valve mechanism with 1 to prevent reflux and 1 to provide continence with position of Marlex collar. C, Kock pouch then is closed in opposite direction to which it was opened. Pouch first is halved and then quartered, with each quarter closed with 2 layers of running 3-zero polygalactin continuous sutures to provide meticulous watertight closure. Reprinted with permission. 12
FIG. 5. Horizontal mattress sutures of No. 1 nylon are passed to anterior rectus fascia and collar of efferent limb of Kock pouch. One suture is placed laterally and 1 medial to pouch, and efferent limb is drawn through abdominal wall. These sutures then are secured so that Marlex is fixed to indirectus fascia, thus, affording short segment from Marlex collar to skin. Redundant efferent limb is excised. Reprinted with permission. 12
mosis or the afferent nipple, which resulted in prolonged urinary leakage in 5 patients, presumably from the proximal end of the afferent limb of the pouch. Patience and time solved the problem. All leakages healed spontaneously but all patients had prolonged hospital courses. Because of this problem we now place No. 8 infant feeding tubes through the afferent limb into the pouch to serve as a stent for the ureteroileal anastomosis and the antireflux nipple valve mechanism. These stents remain indwelling for 3 weeks and are removed simply endoscopically when the patient returns for instruction in self-catheterization. Since we began to use internal stents we have had no difficulties with urinary leakage. The table lists the results observed to date. Early in our experience we were not anchoring the Marlex collar adequately to the anterior rectus fascia and redundancy of the efferent limb made catheterization difficult. To date, reoperation was necessary in 5 patients to revise the continence valve mechanism. Reoperation was successful in all 5 patients, and all currently are completely continent and satisfied with the end result. When revision seems necessary we routinely take down the pouch from the abdominal wall, replace the Marlex strip and restaple the efferent nipple to make sure slippage has not caused the leakage. We have observed erosion of 1 Marlex strip from the afferent nipple valve. This problem was asymptomatic clinically and was encountered during a revision of the continence valve mechanism. The strip simply was removed. In the other patients who required reoperation the Marlex strip had become embedded with fibrous connective tissue without evident erosion and had to be dissected sharply from the pouch and ileal segment. Hyperchloremic acidosis was encountered in only 1 patient. This patient had compromised renal function before conversion to a Kock pouch as a direct result of a failed ureterosigmoidostomy and he had had metabolic hyperchloremic acidosis preoperatively. The patient currently is stable and compensated with oral bicarbonate supplement. He also finds life with the Kock pouch far more satisfactory than with the ureterosigmoidostomy. Patients with normal renal function do not require oral bicarbonate supplement. The mean capacity of the reservoir is between 800 and 1,000 cc, and ranges from 600 to 1,400 cc. Patients describe a feeling of fullness or slight cramping, indicating the need to empty the pouch. After 2 or 3 months most patients perform self-catheterization every 4 to 6 hours during the day and at 8-hour intervals during the night, depending on fluid intake. In most
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EXPERIENCE WITH KOCK CONTINENT ILEAL RESERVOIR FOR URINARY DIVERSION
Current status of patients with continent ilea/ reservoir Pt.
Date of Operation
JW CH HG RV AA MG KS MP AV AB
Aug. 1982 Nov. 1982 Dec. 1982 Dec. 1982 Jan. 1983 Feb. 1983 Feb. 1983 Feb. 1983 Mar. 1983 Mar. 1983
RT BG GM CR PA FV EW JP RB JS LA RS GF JV LS JS CH DB WP OM DB HR HL PK JT CT AC JH RS HS HH BW GH RF KS GC SK LT VA LC
Mar. 1983 Mar. 1983 Apr. 1983 Apr. 1983 Apr. 1983 Apr. 1983 Apr. 1983 May 1983 May 1983 May 1983 June 1983 June 1983 July 1983 July 1983 July 1983 July 1983 Aug. 1983 Aug. 1983 Aug. 1983 Aug. 1983 Aug. 1983 Sept. 1983 Oct. 1983 Oct. 1983 Oct. 1983 Nov. 1983 Nov. 1983 Nov. 1983 Nov. 1983 Dec. 1983 Dec. 1983 Dec. 1983 Dec. 1983 Jan. 1984 Jan. 1984 Jan. 1984 Jan. 1984 Jan. 1984 Jan. 1984 Jan. 1984
Characteristics
Reoperation for leakage Reoperation for leakage Reoperation for leakage Reoperation for leakage Pyelonephritis, reflux and leakage Reoperation for leakage Wisp reflux on It. side Slight hydronephrosis
Acidosis Ilea! loop Lt. hydronephrosis
Leakage
Leakage improving
Slight It. reflux Operative mortality
Pouch Culture
Continent
Capacity (ml.)
Acceptance
Neg. Pas. Pas. Pas. Pas. Pas. Pas. Pas. Pas. Pas.
Yes Yes Yes Yes Yes Yes Yes Yes Yes Improving
1,200 1,000 1,200 1,000 1,100 1,200 1,000 1,100 900 700
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent
Neg. Pas. Neg. Pas. Neg. Pas. Neg. Neg. Pas. Not applicable Pas. Pas. Pas. Pas. Pas. Neg. Pas. Neg. Pas. Pas. Neg. Neg.
Yes Yes Yes Yes Yes Yes Yes Yes Yes Not applicable Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes, daytime Yes Yes Yes Yes Yes Yes Yes Yes Improving Yes Yes Yes Yes Yes Not applicable Yes Yes Yes
1,100 900 1,000 1,400 1,100 1,000 1,400 1,000 1,400 Not applicable 700 1,000 900 1,000 800 1,200 1,100 900 1,000 900 800 600 1,000 900 1,000 900 900 900 800 700 400 800 900 900 600 1,200 Not applicable 600 600 600
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Poor Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Good Excellent Excellent Excellent Excellent Excellent Excellent Excellent
Neg. Neg. Pas. Neg. Neg. Neg. Not applicable Neg. Neg. Neg.
patients asymptomatic bacteriuria is noted, with cultures similar to those obtained from ileal conduits. A variety of pathogens have been encountered, usually sensitive to most antibiotics and not producing clinical symptoms. Only 3 patients have required rehospitalization for pyelonephritis: the only patient with significant reflux, a patient with moderate hydroureteronephrosis to the level of the ureteroileal anastomosis and a diabetic. So far the one clinical episode in each of these 3 patients has not prompted us to reoperate or to correct any structural defect. In general, continence has been excellent. In the 5 patients with poor continence reoperation and revision of the continence valve mechanism have resolved the problem. Patients with radiated bowel tend to have some leakage initially but continence improves significantly with time. DISCUSSION
Preliminary experience with the Kock pouch indicates that the procedure is one of the most innovative advances in the field of urinary diversion. The pouch fulfills the essential criteria of a low pressure internal reservoir by being truly continent, and easy to catheterize and empty, and by preventing reflux. The ileal mucosa used in the pouch appears to adapt
Good Excellent Excellent Excellent Excellent Excellent Not applicable Excellent Excellent Excellent
well to urine with decreased villus height and in time a nearly flat mucosa emerges, which may decrease absorption. 6• 10 To date, no evidence of late fibrosis, or adverse changes in the morphology or function of the intestinal wall has been observed. 6' 8 ' 10 For many years urologists and general surgeons have been interested in creating a continent internal reservoir but various problems have precluded its accomplishment. In 1950 Bricker and Eiseman tried to use the ileocecal segment, with anastomosis of the ureters into the cecum as in ureterosigmoidostomy, and used the ileocecal valve for continence. 15 However, all of their patients had leakage and when an associate discovered an appliance that could be placed around the ileal stoma to provide true dryness they quickly abandoned the ileocecal segment and used instead the ileal segment as a simpler conduit. The Bricker operation has remained the standard form of cutaneous urinary diversion since 1950.16' 17 Gilchrist18 and Sullivan19 and their associates reported better success with the ileocecal segment and in 1970 the Chicago group reported that continence was achieved in 94 per cent of 40 patients followed for 10 years. However, the operation never caught on and despite intussusception modifications reported by Zingg and Tscholl, 20 most investigators have had difficulty maintaining competence of the ileocecal valve. 21 - 23
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SKINNER, BOYD AND LIESKOVSKY
We have used the cecal segment since 1970 for bladder augmentation and lower urinary tract reconstruction. 24 Like Hendren, we have had difficulty preventing reflux unless the mesentery of the terminal ileum is divided, and the ileum is intussuscepted into the cecum and fixed by staples and a Marlex collar. 13 ·24 Hendren' s technique seems to have solved the problem of extussusception but nocturnal uninhibited contracture of the intact cecum has resulted in intermittent incontinence. In studies of the functional behavior of different types of bladder substitutes Kock and associates found that if the ileum is opened and the intestine is folded in a special way the motor activity in different parts counteract themselves, giving storage or reservoir properties to the intestinal pouch without the intermittent pressure spikes that occur when cecum is used as a reservoir. Therefore, the intermittent filling pressures within the Kock pouch are less than within a cecal segment reservoir. We believe that this is an important advantage that increases reservoir capacity as well as providing continence and preventing reflux. The most important factors in the success of the Kock pouch are creation and maintenance of the nipple valves to prevent reflux and to ensure continence. The principle of an intussuscepted nipple is an old surgical technique described originally by Watsuji in 1899 in the formation ofa gastrostomy. 25 Through the years a number of urologists and general surgeons have used this principle. Intussusception techniques have been reported in the literature as early as 1949. 26- 30 Other reports have followed and, although Leisinger and associates indicated in 1977 that creation of an intussuscepted nipple valve was simple,31 experience has shown, in fact, that construction of an effective valve that remains competent is far from easy. In the original 12 patients reported on by Kock and associates 6 needed reoperation because of slippage. 10 Turnbull reported that if the surgeon maintained intestinal continuity up to 8 cm. of mesentery could be stripped safely from the ileum without loss of viability. 32 Hendren supported this observation and intussuscepted successfully the terminal 8 cm. of ileum into the cecum in an effort to prevent reflux across the ileocecal valve in cases of undiversion bladder reconstruction. 13 Nonetheless, until the availability of nonhemostatic, nonreactive metal staples, the ability to maintain an intussuscepted segment was erratic. The combination of the Marlex strip, 4 rows of staples and a 5 cm. intussuscepted nipple ensures continence and prevents reflux. Careful creation of this valve mechanism is an important key to a successful, continent internal intestinal reservoir. Our preliminary experience indicates that the Kock pouch has far exceeded our initial expectations. Its capacity averages 1,000 cc without apparent absorptive problems in patients with good renal function. The pouch provides excellent continence and reflux has been observed in only 1 patient. The need for minor revision of the continent valve mechanism has been only 10 per cent in this series. In the original report by Kock and associates half of the patients had to undergo revision but improved surgical technique in experienced hands with modifications, such as stripping of the mesentery, use of staples and use of a Marlex strip, will reduce the need for revision. Perhaps the strongest advocates of the procedure are the patients, particularly those who previously had urinary diversion by an ileal conduit or ureterosigmoidostomy. Some long-term questions remain to be answered. 1) What will be the effect of metal staples in the intact urinary tract? To date, we have observed stone formation in only 2 patients and in both the stones formed on exposed staples at the end of the intussuscepted nipples. The staples near the base of the nipple become buried in the mucosa and we have not observed stones at that location. The distal staples are not needed to maintain intussusception and we currently remove 5 from the stapling device closest to the end of the nipple. Stones that do form within the pouch can be extracted easily endoscopically.
2) What will be the long-term effect of bacteriuria in these patients? Cultures show that most of our patients have bacteriuria much like patients with an ileal conduit. Pyelonephritis has been observed in only 3 patients: 1 with reflux, 1 with moderate hydroureteronephrosis owing to slight stenosis at the ureteroileal anastomosis and 1 with diabetes. Generally, this bacteriuria is asymptomatic but its long-term meaning is unclear. Without reflux, presence of bacteria in an intestinal reservoir should be no different than the presence of bacteria in the terminal ileum of the intact intestinal tract. Kock and associates observed no long-term fibrosis or significant morphologic changes in the pouches of patients followed for 5 years. 10 3) Will the loss of 70 to 80 cm. of ileum cause absorptive deficits? Some of our patients have had early diarrhea but this has ceased by 3 months and we believe that there is sufficient terminal ileum remaining for vitamin B12 absorption. After our first 51 patients our enthusiasm for the procedure has increased and patient acceptance has been overwhelming. Not only do patients choose the Kock pouch when offered the alternatives of an ileal conduit or ureterosigmoidostomy, some come seeking it and after talking with a patient who has a Kock pouch they are uninterested in discussing alternatives. Obviously, not all patients are candidates. We have accepted purposely nearly every candidate regardless of the amount of previous radiation therapy. Prior radiation, even in doses between 6,000 and 7,000 rad, does not preclude the operation, although the complication rate probably will be higher. Our only failure, requiring conversion back to an ileal conduit, occurred in a patient who had had older radiation therapy for endometrial carcinoma. Patient selection obviously is important. A prior abdominal operation followed by radiation therapy increases the risk of failure. The operation probably should not be offered to patients with compromised renal function or those with advanced malignancy. Patient motivation, and a thorough understanding of the Kock pouch and its potential problems are essential prerequisites to the operation. The continent internal ileal reservoir as developed by Kock and associates is an important new addition to the urological armamentarium and offers a real alternative to the patient who requires cutaneous diversion. The majority of such patients are those with invasive bladder cancer. Recent reports indicate that radical cystectomy, with or without some form of preoperative radiation therapy, nearly doubles the survival rate obtained with any form of nonoperative therapy. 33 The major argument against aggressive surgical management in invasive bladder cancer has been that an operation required a permanent ileostomy and the need to wear an external appliance or bag. Therefore, many patients and physicians have chosen definitive radiation therapy as primary treatment, despite its lack of proved efficacy. Our experience has been that quality of life issues are extremely important in patient selection of therapeutic options, and a continent internal urinary reservoir offers a considerably better patient self-image than wearing an external appliance. Therefore, the development of a continent internal reservoir as an alternative to the standard ileal conduit might have a significant impact on the treatment of the estimated 10,000 patients within the United States who are diagnosed each year as having invasive bladder cancer.
Dr. Alex Gerber, Los Angeles, as a student of Kock brought this operation to the United States and stimulated us to begin clinical trials. REFERENCES
1. Kock, N. G.: Ileostomy without external appliances: a survey of 25 patients provided with intra-abdominal intestinal reservoir. Ann. Surg., 173: 545, 1971. 2. Kock, N. G., Nilson, A. E., Norlen, L., Sundin, T. and Trasti, H.: Changes in renal parenchyma and the upper urinary tracts following urinary diversion via a continent ileum reservoir. An experimental study in dogs. S<;and. J. Urol. Nephrol., suppl. 49,
EXPERIENCE VVITH KOCI( C00?TE,JEI"'.J'T ILEAL RESERVOIR FOR URINARY DIVERSION-
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7. 8. 9.
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11-22, 1978. N. G., Nilson, A. E., Norlen, L., Sundin, T. and Trasti, H.: Urinary diversion via a continent ileum reservoir: clinical experience. Scand. J. Urol. Nephroi., suppl. 49, pp. 23-31, 1978. Jagenburg, R., Kock, N. G., Norlen, L. and Trasti, H.: Clinical significance of changes in composition of urine during collection and storage in continent ileum reservoir urinary diversion. An experimental and clinical study. Scand. J. Urol. Nephrol., suppl. 49,pp. 43-48, 1978. Norlen, L. and Trasti, H.: Functional behaviour of the continent ileum reservoir for urinary diversion. An experimental and clinical study. Scand. J. Urol. Nephrol., suppl. 49, pp. 33-42, 1978. Hansson, H.-A., Kock, N. G., Norlen, L., Philipson, B., Trasti, H. and Ahren, C.: Morphological observations in pedicled ilea! grafts used for construction of continent reservoirs for urine. Scand. J. Urol. Nephrol., suppl. 49, pp. 49-61, 1978. Trasti, H.: Urinary diversion via a continent ileum reservoir. An experimental and clinical study. Scand. J. Urol. Nephrol., suppl. 49, pp. 5-10 and 63-68, 1978. Kock, N. G.: Evolution of ileostomy surgery. Canad. J. Surg., 24: 270, 1981. Philipson, B. M., Nilsson, L. 0., Norlen, L., Kock, N. G. and Ahren, C.: Mucosa! adaptation in ileum after long time exposure to urine. In: Mechanisms of Intestinal Adaptation. MTM Press Ltd., p. 613, 1982. Kock, N. G., Nilson, A. E., Nilsson, L. 0., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ilea! reservoir: clinical results in 12 patients. J. Urol., 128: 469, 1982. Gerber, A., Apt, M. K. and Craig, P. H.: The Kock continent ileostomy. Surg., Gynec. & Obst., 156: 345, 1983. Skinner, D. G., Lieskovsky, G. and Boyd, S. D.: Technique of creation of a continent internal ilea! reservoir (Kock pouch) for urinary diversion. Urol. Clin. N. Amer., in press. Hendren, W. H.: Reoperative ureteral reimplantation: management of the difficult case. el. Ped. Surg., 15: 770, 1980. Lapides, J., Diokno, A. C., Silber, S. J. and Lowe, B. S.: Clean, intermittent self-catheterization in the treatment of urinary tract disease. J. Urol., 107: 458, 1972. Bricker, E. M. and Eiseman, B.: Bladder reconstruction from cecum and ascending colon following resection of pelvic viscera. Ann. Surg., 132: 77, 1950.
LiO'l
16. Bricker, E. M.: Bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 17. Bricker, E.: Personal communication. 18. Gilchrist, R. K., Merricks, el. W., Hamlin, M. H. and Rieger, I. T.: Construction of a substitute bladder and urethra. Surg., Gynec. & Obst., 90: 752, 1950. 19. Sullivan, H., Gilchrist, R. K. and Merricks, J. W.: Ileocecal substitute bladder: long-term followup. J. Urol., 109: 43, 1973. 20. Zingg, E. and Tscholl, R.: Continent cecoileal conduit: preliminary report. J. Urol., 118: 724, 1977. 21. Turnbull, R. B. and Higgins, C. C.: Ilea! valve pouch for urinary diversion. Cleveland Clin. Quart., 24: 187, 1957. 22. Ashken, M. H.: An appliance-free ileocaecal urinary diversion; preliminary communication. Brit. J. Urol., 46: 631, 1974. 23. Ashken, M. H.: Continent ileocaecal urinary reservoir. J. Roy. Soc. Med., 71: 357, 1978. 24. Skinner, D. G.: Further experience with the ileocecal segment in urinary reconstruction. J. Urol., 128: 252, 1982. 25. Watsudji, H.: Eine Combinierte Anwendung des Hacker- und Fontan'schen Verfahrens bei der Gastrostomie. Mitt. d. med. Gesellszh. zu Tokyo, 13: 879, 1899. 26. Perl, J. I.: Intussuscepted conical valve formation injejunostomies. Surgery, 25: 297, 1949. 27. Basso, D. E.: The efficacy and applicability of an intussuscepted conical valve in preventing regurgitation and leakage of intestinal contents. Ann. Surg., 133: 477, 1951. 28. Smith, G. I. and Hinman, F., Jr.: The intussuscepted ilea! cystostomy. J. Urol., 73: 261, 1955. 29. Grey, D. N., Flynn, R. and Goodwin, W. E.: Experimental methods of ureteroneocystostomy: experiences with the ureteral intussusception to produce a nipple or valve. J. UroL, 77: 154, 1957. 30. Turner, R. D. and Goodwin, W. E.: Experiments with intussuscepted ilea! valve in ureteral substitution. J. Urol., 81: 526, 1959. 31. Leisinger, H. J., Schauwecker, H. and Siiuberli, H.: Dynamics of the continent ilea! bladder. An experimental study in dogs. Invest. Urol., 15: 49, 1977. 32. Turnbull, R. B., Jr.: Personal communication. 33. Skinner, D. G. and Lieskovsky, G.: Contemporary cystectomy with pelvic node dissection compared to preoperative radiation therapy plus cystectomy in management of invasive bladder cancer. J. Urot., 131: 1069, 1984.
THE JOURNAL OF UROLOGY
Copyright© 1984 by The Williams & Wilkins Co.
CLINICAL EXPERIENCE WITH THE KOCK CONTINENT ILEAL RESERVOIR FOR URINARY DIVERSION DONALD G. SKINNER, STUART D. BOYD
AND
GARY LIESKOVSKY
From the Division of Urology, Department of Surgery, University of Southern California School of Medicine, Los Angeles, California
ABSTRACT
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 selfcatheterization 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. Kock and associates have made a major contribution to the urological surgical armamentarium by developing a method to create a continent internal reservoir for urine using ileum. 1- 11 Following modification of the continent ileostomy developed for patients undergoing proctocolectomy for ulcerative colitis and after extensive experimentation with animals, Kock and associates reported their initial experience with 12 patients in 1982. 10 This innovative procedure now affords patients requiring cystectomy for bladder cancer or cutaneous urinary diversion for any reason a real alternative to the standard ileal conduit, which requires an external appliance. We report our experience with 51 patients undergoing creation of a Kock continent ileal reservoir for urinary diversion. Experience with the technique as described by Kock and associates, and a careful review of our early results have led to some modifications that we believe will improve the end result further. MATERIAL AND METHODS
From August 1982 through January 1984, 51 patients have undergone creation of the Kock continent ileal reservoir for cutaneous urinary diversion. There were 14 women between 19 and 56 years old, and 37 men between 24 and 75 years old. Previous urinary diversion was by ureterosigmoidostomy in 11 patients, standard ileal conduit in 7 and suprapubic cystotomy in 1. The 3 ureterosigmoidostomy patients underwent the new procedure because 2 had had obstruction at the ureterocolonic anastomosis, and 1 had recurrent pyelonephritis and poor continence. The patients with ileal conduits actively sought conversion to the new reservoir because of inability to Accepted for publication July 25, 1984. Read at annual meeting of American Urological Association, New Orleans, Louisiana, May 6-10, 1984.
maintain dryness or because of the psychosocial stigmas associated with having to wear an external appliance. The patient with a suprapubic cystotomy underwent creation of a Kock pouch because of the traumatic loss of the urethra and bladder neck owing to an automobile accident. Of the 11 patients who previously underwent urinary diversion 3 had received planned preoperative radiation therapy (1,600 to 4,500 rad) before cystectomy. A total of 39 patients underwent simultaneous radical cystectomy and creation of the continent Kock pouch, and 1 massively obese paraplegic patient underwent urinary diversion after development of numerous urethral fistulas associated with catheterization. Of the patients undergoing simultaneous cystectomy and urinary diversion 6 had received varying dosages of prior radiation therapy for pelvic malignancy. One patient received 1,600 rad and 2 received 4,500 rad as part of a planned combination of preoperative radiation therapy and radical cystectomy. Three patients who had failed prior definitive radiation therapy for bladder or urethral carcinoma had received doses of 6,000 to 7,000 rad. One additional patient, our only immediate failure, had received an unknown amount of abdominal and pelvic radiation preceded by a pelvic operation many years earlier for endometrial carcinoma. This patient suffered an enterocutaneous fistula through the pouch and was given successfully a standard ileal conduit 20 days after anterior exenteration. Over-all, 34 patients underwent simultaneous bilateral pelvic iliac lymph node dissection with en bloc radical cystectomy and creation of the continent ileal pouch for urinary diversion as primary treatment for high grade invasive bladder cancer. Surgical technique. Our technique, modified slightly from that described by Kock, has been reported in detail. 12 Technical points of importance include 1) A slightly longer
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SKINNER, BOYD AND LIESKOVSKY
segment of ileum is used than described originally by Kock and associates. The afferent and efferent limbs each are 17 cm. long and the pouch is created from 2, 22 cm. segments (fig. 1). 2) Approximately 7 to 8 cm. of mesentery are stripped off the ileum from the afferent and efferent limbs to allow creation of the continence and antireflux nipple valve mechanisms. This technique was described originally by Hendren in an effort to retain the intussuscepted ileum in the cecum for ileocecal
FIG. 1. A, various segments of terminal ileum chosen for creation of Kock pouch. Note that distal mesenteric division is into avascu!ar plane of mesentery extending toward base of mesentery and that proximal mesentery division is short to assure broad vascular supply to pouch. Usually, small window of mesentery and additional 3 to 5 cm. of small bowel are discarded proximal to over-all segment to assure good mobility to pouch and to small bowel anastomosis. Pouch itself is created from 2 central 22 cm. segments with each limb extending to or away from pouch being approximately 17 cm. long. If patient has existing ilea! conduit, afferent limb is created from only about 13 to 15 cm. of small bowel. B, 2, 22 cm. segments are joined by running 3-zero polyglycolic acid continuous suture. Lowest point of U should be directed caudally so that once pouch is formed afferent limb will drop readily to sacral promontory to facilitate ureteroileal anastomosis. Proximal end of afferent limb is closed with running Parker-Kerr suture. Then 2, 22 cm. segments of bowel are opened immediately adjacent to continuous serosal suture line to form pouch. C, mucosa is oversewn with 2 layers of 3, 3-zero polyglycolic acid continuous sutures to form watertight suture line. Note that serosal incision has been extended for several centimeters along afferent and efferent limbs so that when nipples are formed they are separated. Reprinted with permission. 12
bladder undiversion. 13 We believe that this step is important to avoid incorporation of the mesentery into the intussuscepted nipple, which could promote subsequent slippage or loss of the critical intussusception (fig. 2). 3) A 2.5 cm. Marlex strip then is passed through the window of Deaver adjacent and distal to the area of mesenteric stripping. Once the ileum is intussuscepted into the pouch the Marlex will serve as a collar to be attached to the pouch and fixed to the afferent or efferent limb to or from the pouch, respectively. 4) Four rows of 4.8 mm. staples then are applied to the intussuscepted segment, with the most distal staples placed at the base of the nipple and the 2 juxtamesenteric rows incorporated into the Marlex. We use the TA-55 automatic stapler with 4.8 mm. staples, which are not hemostatic and do not crush the bowel. Since staples at the end of the nipple do not contribute to maintenance of the intussusception, remain exposed and may form a nidus for subsequent stone formation, we remove routinely the 5 proximal staples from the apparatus before stapling (fig. 3). 5) Next, the index finger is passed through the nipple and the Marlex strip is sewn around the ileal segment with 2-zero nylon to fix the Marlex to the pouch and ileal segment. This technique prevents the Marlex from being so tight as to cause erosion and helps to prevent slippage of the nipple (fig. 4). 6) All mucosal suture lines are oversewn with 2 meticulous layers of running 3-zero polyglycolic acid sutures to prevent urinary leakage. 7) The Marlex collar and efferent segment of ileum are fixed to the anterior rectus fascia with 2 horizontal mattress sutures of No. 1 nylon. This step fixes the continent valve mechanism to the abdominal wall and prevents patient difficulty in catheterization owing to redundancy of the efferent limb of ileum (fig. 5). 8) No. 8 infant feeding tubes are passed across the ureteroileal anastomosis and through the afferent nipple into the pouch where they are left indwelling. 9) A No. 30 Medena tube is placed in the pouch with the drainage holes positioned well proximal to the efferent nipple. The Medena tube is left indwelling for 3 weeks. 10) A 1-inch Penrose drain is placed through a separate stab wound and sewn to the psoas with a single 3-zero chromic suture several inches away from the pouch. This drain should remain at least 48 hours after the Medena tube is removed. 11) In patients with existing ileal conduits we anastomose the pre-existing ileal conduit end-toend with the afferent limb of the Kock pouch, provided there is no ureteroileal obstruction. Redundant ileum from the conduit is discarded and the length of afferent ileum used for the pouch is reduced to 13 to 15 cm. Patients are rehospitalized 3 weeks postoperatively and endoscopy of the Kock ileal reservoir is performed for retrieval of the ureteral stents. Cystography of the reservoir is performed to detect leakage and an excretory urogram (IVP) is done. If no leakage is observed patients are instructed on self-catheterization and remain overnight to make sure they have no difficulty with catheterization. At rehospitalization when all tubes are removed patients are given aminoglycosides parenterally. Suppressant antibacterial medication also is given and is continued for 4 to 6 weeks after the patient is discharged from the hospital. In patients with good renal function Shoal's solution (sodium potassium citrate) or oral bicarbonate has not been necessary and patients use clean catheterization techniques. 14 Patients are followed initially at 4 months and then at 6month intervals. At each followup visit cystography of the reservoir, an IVP, serum determination of electrolytes and creatinine, and a pouch culture are obtained. RESULTS
The average operating time to create a Kock pouch is approximately 1.5 to 2.0 hours longer than that for creation of a standard ileal conduit. All other operating time remains approximately the same whether the pouch is done in conjunction with cystectomy or as a conversion of an existing ileal conduit.
EXPERlEl\JCE Vii'J:'H }COCI( CONTINEI""~T ILEAL R.BSERVOIB, :f'OR URII~ARY DIVERS10J'
1103
.5 cm ma,lex collar
2.5 cm mariex collar
FIG. 2. Mesentery is divided next immediately adjacent to serosa of afferent-efferent limb for distance of nearly 8 cm. One usually leaves arcade and then places 2 cm. wide strip of Marlex, which will serve as collar to fix afferent-efferent limb to pouch once intussusception technique has been accomplished. Reprinted with permission. 12
A
B
FIG. 3. A, with Allis clamps passed approxi1nately halfway to Marlex strip mucosa is grasped and ileum is intussuscepted into pouch so that Marlex now lies adjacent to pouch and nipple valve mechanism is created. B, 4 longitudinal rows of automatic staples are placed with T-55 automatic stapling device and 4.8 mm. staples. Note that 5 staples have been removed from end of nipple, since are not required to maintain intussusception and remain exposed for possible stone formation. Staples at base of nipple in juxtamesenteric may involve Marlex collar to fix collar in place further. Reprinted with permission. 12
The operation is not difficult technically but it is tedious and attention to every detail is essential to ultimate success. The only operative mortality among the 51 patients resulted from a chain of events after postoperative bleeding but the Kock pouch was not believed to have contributed to this death. There were 10 early complications resulting in prolonged hospital stay. One patient had an enterocutaneous fistula through the pouch, which necessitated reoperation and conversion to a standard ileal conduit. This patient represents our only failure, probably owing to poor patient selection. The patient had received an unknown amount of old-time radiation for endometrial carcinoma after a pelvic operation. Two complications occurred as a direct result of inadequate pelvic drainage and both required reoperation to drain pelvic
abscesses. Three additional patients had prolonged drainage of urine through the Penrose drain site. Endoscopy of the reservoir in each case revealed migration of the Penrose drain into the pouch. All 3 leaks dried promptly with advancement of the drain. Subsequently, in other patients we have anchored the drain to the psoas muscle with a 3-zero chromic suture several centimeters away from the pouch. Several patients undergoing radical cystectomy with simultaneous pelvic lymph node dissection have had temporary lymph fistulas via the Penrose drain, resulting in a significant decrease in the serum albumin but no long-term sequelae have been observed. Otherwise, the long maintenance of the Penrose drain has not caused problems. Initially, we did not use a stent for the ureteroileal anasto-
1104
A
SKINNER, BOYD AND LIESKOVSKY
B
C
FIG. 4. A, finger is inserted through nipple and through area of Marlex so that Marlex can be pos1e,oned around afferent or efferent limb. Finger is used so that Marlex collar is not too tight to avoid possibility of erosion. Marlex is secured to pouch and respective limb of ileum with interrupted 2-zero nylon sutures. B, completed nipple valve mechanism with 1 to prevent reflux and 1 to provide continence with position of Marlex collar. C, Kock pouch then is closed in opposite direction to which it was opened. Pouch first is halved and then quartered, with each quarter closed with 2 layers of running 3-zero polygalactin continuous sutures to provide meticulous watertight closure. Reprinted with permission. 12
FIG. 5. Horizontal mattress sutures of No. 1 nylon are passed to anterior rectus fascia and collar of efferent limb of Kock pouch. One suture is placed laterally and 1 medial to pouch, and efferent limb is drawn through abdominal wall. These sutures then are secured so that Marlex is fixed to indirectus fascia, thus, affording short segment from Marlex collar to skin. Redundant efferent limb is excised. Reprinted with permission. 12
mosis or the afferent nipple, which resulted in prolonged urinary leakage in 5 patients, presumably from the proximal end of the afferent limb of the pouch. Patience and time solved the problem. All leakages healed spontaneously but all patients had prolonged hospital courses. Because of this problem we now place No. 8 infant feeding tubes through the afferent limb into the pouch to serve as a stent for the ureteroileal anastomosis and the antireflux nipple valve mechanism. These stents remain indwelling for 3 weeks and are removed simply endoscopically when the patient returns for instruction in self-catheterization. Since we began to use internal stents we have had no difficulties with urinary leakage. The table lists the results observed to date. Early in our experience we were not anchoring the Marlex collar adequately to the anterior rectus fascia and redundancy of the efferent limb made catheterization difficult. To date, reoperation was necessary in 5 patients to revise the continence valve mechanism. Reoperation was successful in all 5 patients, and all currently are completely continent and satisfied with the end result. When revision seems necessary we routinely take down the pouch from the abdominal wall, replace the Marlex strip and restaple the efferent nipple to make sure slippage has not caused the leakage. We have observed erosion of 1 Marlex strip from the afferent nipple valve. This problem was asymptomatic clinically and was encountered during a revision of the continence valve mechanism. The strip simply was removed. In the other patients who required reoperation the Marlex strip had become embedded with fibrous connective tissue without evident erosion and had to be dissected sharply from the pouch and ileal segment. Hyperchloremic acidosis was encountered in only 1 patient. This patient had compromised renal function before conversion to a Kock pouch as a direct result of a failed ureterosigmoidostomy and he had had metabolic hyperchloremic acidosis preoperatively. The patient currently is stable and compensated with oral bicarbonate supplement. He also finds life with the Kock pouch far more satisfactory than with the ureterosigmoidostomy. Patients with normal renal function do not require oral bicarbonate supplement. The mean capacity of the reservoir is between 800 and 1,000 cc, and ranges from 600 to 1,400 cc. Patients describe a feeling of fullness or slight cramping, indicating the need to empty the pouch. After 2 or 3 months most patients perform self-catheterization every 4 to 6 hours during the day and at 8-hour intervals during the night, depending on fluid intake. In most
1105
EXPERIENCE WITH KOCK CONTINENT ILEAL RESERVOIR FOR URINARY DIVERSION
Current status of patients with continent ilea/ reservoir Pt.
Date of Operation
JW CH HG RV AA MG KS MP AV AB
Aug. 1982 Nov. 1982 Dec. 1982 Dec. 1982 Jan. 1983 Feb. 1983 Feb. 1983 Feb. 1983 Mar. 1983 Mar. 1983
RT BG GM CR PA FV EW JP RB JS LA RS GF JV LS JS CH DB WP OM DB HR HL PK JT CT AC JH RS HS HH BW GH RF KS GC SK LT VA LC
Mar. 1983 Mar. 1983 Apr. 1983 Apr. 1983 Apr. 1983 Apr. 1983 Apr. 1983 May 1983 May 1983 May 1983 June 1983 June 1983 July 1983 July 1983 July 1983 July 1983 Aug. 1983 Aug. 1983 Aug. 1983 Aug. 1983 Aug. 1983 Sept. 1983 Oct. 1983 Oct. 1983 Oct. 1983 Nov. 1983 Nov. 1983 Nov. 1983 Nov. 1983 Dec. 1983 Dec. 1983 Dec. 1983 Dec. 1983 Jan. 1984 Jan. 1984 Jan. 1984 Jan. 1984 Jan. 1984 Jan. 1984 Jan. 1984
Characteristics
Reoperation for leakage Reoperation for leakage Reoperation for leakage Reoperation for leakage Pyelonephritis, reflux and leakage Reoperation for leakage Wisp reflux on It. side Slight hydronephrosis
Acidosis Ilea! loop Lt. hydronephrosis
Leakage
Leakage improving
Slight It. reflux Operative mortality
Pouch Culture
Continent
Capacity (ml.)
Acceptance
Neg. Pas. Pas. Pas. Pas. Pas. Pas. Pas. Pas. Pas.
Yes Yes Yes Yes Yes Yes Yes Yes Yes Improving
1,200 1,000 1,200 1,000 1,100 1,200 1,000 1,100 900 700
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent
Neg. Pas. Neg. Pas. Neg. Pas. Neg. Neg. Pas. Not applicable Pas. Pas. Pas. Pas. Pas. Neg. Pas. Neg. Pas. Pas. Neg. Neg.
Yes Yes Yes Yes Yes Yes Yes Yes Yes Not applicable Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes, daytime Yes Yes Yes Yes Yes Yes Yes Yes Improving Yes Yes Yes Yes Yes Not applicable Yes Yes Yes
1,100 900 1,000 1,400 1,100 1,000 1,400 1,000 1,400 Not applicable 700 1,000 900 1,000 800 1,200 1,100 900 1,000 900 800 600 1,000 900 1,000 900 900 900 800 700 400 800 900 900 600 1,200 Not applicable 600 600 600
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Poor Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Good Excellent Excellent Excellent Excellent Excellent Excellent Excellent
Neg. Neg. Pas. Neg. Neg. Neg. Not applicable Neg. Neg. Neg.
patients asymptomatic bacteriuria is noted, with cultures similar to those obtained from ileal conduits. A variety of pathogens have been encountered, usually sensitive to most antibiotics and not producing clinical symptoms. Only 3 patients have required rehospitalization for pyelonephritis: the only patient with significant reflux, a patient with moderate hydroureteronephrosis to the level of the ureteroileal anastomosis and a diabetic. So far the one clinical episode in each of these 3 patients has not prompted us to reoperate or to correct any structural defect. In general, continence has been excellent. In the 5 patients with poor continence reoperation and revision of the continence valve mechanism have resolved the problem. Patients with radiated bowel tend to have some leakage initially but continence improves significantly with time. DISCUSSION
Preliminary experience with the Kock pouch indicates that the procedure is one of the most innovative advances in the field of urinary diversion. The pouch fulfills the essential criteria of a low pressure internal reservoir by being truly continent, and easy to catheterize and empty, and by preventing reflux. The ileal mucosa used in the pouch appears to adapt
Good Excellent Excellent Excellent Excellent Excellent Not applicable Excellent Excellent Excellent
well to urine with decreased villus height and in time a nearly flat mucosa emerges, which may decrease absorption. 6• 10 To date, no evidence of late fibrosis, or adverse changes in the morphology or function of the intestinal wall has been observed. 6' 8 ' 10 For many years urologists and general surgeons have been interested in creating a continent internal reservoir but various problems have precluded its accomplishment. In 1950 Bricker and Eiseman tried to use the ileocecal segment, with anastomosis of the ureters into the cecum as in ureterosigmoidostomy, and used the ileocecal valve for continence. 15 However, all of their patients had leakage and when an associate discovered an appliance that could be placed around the ileal stoma to provide true dryness they quickly abandoned the ileocecal segment and used instead the ileal segment as a simpler conduit. The Bricker operation has remained the standard form of cutaneous urinary diversion since 1950.16' 17 Gilchrist18 and Sullivan19 and their associates reported better success with the ileocecal segment and in 1970 the Chicago group reported that continence was achieved in 94 per cent of 40 patients followed for 10 years. However, the operation never caught on and despite intussusception modifications reported by Zingg and Tscholl, 20 most investigators have had difficulty maintaining competence of the ileocecal valve. 21 - 23
1106
SKINNER, BOYD AND LIESKOVSKY
We have used the cecal segment since 1970 for bladder augmentation and lower urinary tract reconstruction. 24 Like Hendren, we have had difficulty preventing reflux unless the mesentery of the terminal ileum is divided, and the ileum is intussuscepted into the cecum and fixed by staples and a Marlex collar. 13 ·24 Hendren' s technique seems to have solved the problem of extussusception but nocturnal uninhibited contracture of the intact cecum has resulted in intermittent incontinence. In studies of the functional behavior of different types of bladder substitutes Kock and associates found that if the ileum is opened and the intestine is folded in a special way the motor activity in different parts counteract themselves, giving storage or reservoir properties to the intestinal pouch without the intermittent pressure spikes that occur when cecum is used as a reservoir. Therefore, the intermittent filling pressures within the Kock pouch are less than within a cecal segment reservoir. We believe that this is an important advantage that increases reservoir capacity as well as providing continence and preventing reflux. The most important factors in the success of the Kock pouch are creation and maintenance of the nipple valves to prevent reflux and to ensure continence. The principle of an intussuscepted nipple is an old surgical technique described originally by Watsuji in 1899 in the formation ofa gastrostomy. 25 Through the years a number of urologists and general surgeons have used this principle. Intussusception techniques have been reported in the literature as early as 1949. 26- 30 Other reports have followed and, although Leisinger and associates indicated in 1977 that creation of an intussuscepted nipple valve was simple,31 experience has shown, in fact, that construction of an effective valve that remains competent is far from easy. In the original 12 patients reported on by Kock and associates 6 needed reoperation because of slippage. 10 Turnbull reported that if the surgeon maintained intestinal continuity up to 8 cm. of mesentery could be stripped safely from the ileum without loss of viability. 32 Hendren supported this observation and intussuscepted successfully the terminal 8 cm. of ileum into the cecum in an effort to prevent reflux across the ileocecal valve in cases of undiversion bladder reconstruction. 13 Nonetheless, until the availability of nonhemostatic, nonreactive metal staples, the ability to maintain an intussuscepted segment was erratic. The combination of the Marlex strip, 4 rows of staples and a 5 cm. intussuscepted nipple ensures continence and prevents reflux. Careful creation of this valve mechanism is an important key to a successful, continent internal intestinal reservoir. Our preliminary experience indicates that the Kock pouch has far exceeded our initial expectations. Its capacity averages 1,000 cc without apparent absorptive problems in patients with good renal function. The pouch provides excellent continence and reflux has been observed in only 1 patient. The need for minor revision of the continent valve mechanism has been only 10 per cent in this series. In the original report by Kock and associates half of the patients had to undergo revision but improved surgical technique in experienced hands with modifications, such as stripping of the mesentery, use of staples and use of a Marlex strip, will reduce the need for revision. Perhaps the strongest advocates of the procedure are the patients, particularly those who previously had urinary diversion by an ileal conduit or ureterosigmoidostomy. Some long-term questions remain to be answered. 1) What will be the effect of metal staples in the intact urinary tract? To date, we have observed stone formation in only 2 patients and in both the stones formed on exposed staples at the end of the intussuscepted nipples. The staples near the base of the nipple become buried in the mucosa and we have not observed stones at that location. The distal staples are not needed to maintain intussusception and we currently remove 5 from the stapling device closest to the end of the nipple. Stones that do form within the pouch can be extracted easily endoscopically.
2) What will be the long-term effect of bacteriuria in these patients? Cultures show that most of our patients have bacteriuria much like patients with an ileal conduit. Pyelonephritis has been observed in only 3 patients: 1 with reflux, 1 with moderate hydroureteronephrosis owing to slight stenosis at the ureteroileal anastomosis and 1 with diabetes. Generally, this bacteriuria is asymptomatic but its long-term meaning is unclear. Without reflux, presence of bacteria in an intestinal reservoir should be no different than the presence of bacteria in the terminal ileum of the intact intestinal tract. Kock and associates observed no long-term fibrosis or significant morphologic changes in the pouches of patients followed for 5 years. 10 3) Will the loss of 70 to 80 cm. of ileum cause absorptive deficits? Some of our patients have had early diarrhea but this has ceased by 3 months and we believe that there is sufficient terminal ileum remaining for vitamin B12 absorption. After our first 51 patients our enthusiasm for the procedure has increased and patient acceptance has been overwhelming. Not only do patients choose the Kock pouch when offered the alternatives of an ileal conduit or ureterosigmoidostomy, some come seeking it and after talking with a patient who has a Kock pouch they are uninterested in discussing alternatives. Obviously, not all patients are candidates. We have accepted purposely nearly every candidate regardless of the amount of previous radiation therapy. Prior radiation, even in doses between 6,000 and 7,000 rad, does not preclude the operation, although the complication rate probably will be higher. Our only failure, requiring conversion back to an ileal conduit, occurred in a patient who had had older radiation therapy for endometrial carcinoma. Patient selection obviously is important. A prior abdominal operation followed by radiation therapy increases the risk of failure. The operation probably should not be offered to patients with compromised renal function or those with advanced malignancy. Patient motivation, and a thorough understanding of the Kock pouch and its potential problems are essential prerequisites to the operation. The continent internal ileal reservoir as developed by Kock and associates is an important new addition to the urological armamentarium and offers a real alternative to the patient who requires cutaneous diversion. The majority of such patients are those with invasive bladder cancer. Recent reports indicate that radical cystectomy, with or without some form of preoperative radiation therapy, nearly doubles the survival rate obtained with any form of nonoperative therapy. 33 The major argument against aggressive surgical management in invasive bladder cancer has been that an operation required a permanent ileostomy and the need to wear an external appliance or bag. Therefore, many patients and physicians have chosen definitive radiation therapy as primary treatment, despite its lack of proved efficacy. Our experience has been that quality of life issues are extremely important in patient selection of therapeutic options, and a continent internal urinary reservoir offers a considerably better patient self-image than wearing an external appliance. Therefore, the development of a continent internal reservoir as an alternative to the standard ileal conduit might have a significant impact on the treatment of the estimated 10,000 patients within the United States who are diagnosed each year as having invasive bladder cancer.
Dr. Alex Gerber, Los Angeles, as a student of Kock brought this operation to the United States and stimulated us to begin clinical trials. REFERENCES
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