- Email: [email protected]
Afferent Nipple Valve Malfunction Caused By anchoring Collar: An Unexpected Late Complication of the Kock Continent Ileal Reservoir
0022-5347/91/1451-0029$02.00/C
THEJOURNAL O F UROLOGY Copyright 0 1991 by AMERICANUROLOGICAL ASSOCIATION,INC
Vol. 146, 29-33, January 1991 Printed in Lr.S.A.
AFFERENT NIPPLE VALVE MALFUNCTION CAUSED BY ANCHORING COLLAR: AN UNEXPECTED LATE COMPLICATION OF T H E KOCK CONTINENT ILEAL RESERVOIR YOICHI ARAI, YUSAKU OKADA," TADASHI MATSUDA, SHUICHI HIDA, HIDEO TAKEUCHI, YUJI KIHARA AND OSAMU YOSHIDA? From the Departments of Urology, Faculty of Medicine, Kyoto University, Kyoto, and Public Toyooka Hospital, Toyooka, Japan
ABSTRACT
In the construction of a Kock continent ileal reservoir for urinary diversion, significantly high rates of late postoperative complications regarding nipple valves, the efferent limb in particular, have been reported. There are only a few reports on afferent nipple valve malfunction. A total of 42 patients who underwent a Kock pouch operation and were observed for more than 1 2 months (mean 38 months) was evaluated in terms of afferent nipple valve malfunction. Late afferent nipple valve complications were observed in 10 of the 42 patients (24%). These complications included erosion of the polyester fiber fabric used as a collar ( 5 patients), stenosis of the afferent limb (2) and obstruction of the afferent nipple by a mucous plug or fungus ball (3). The latter 2 complications were due to mechanical or dynamic obstruction of urine flow caused by a nonabsorbable collar. None of the 10 patients had problems with efferent nipple valve function. Our results suggest that the peristaltic direction of the intestine and the use of nonabsorbable material as a collar are primarily responsible for the late afferent nipple valve complications. Further modifications are needed to produce a stable nipple valve. Otherwise, simpler and more reliable alternative techniques of antireflux anastomosis should be considered. KEYWORDS:urinary diversion; anastomosis, surgical
Kock et a1 first reported on the revolutionary method of urinary diversion via the continent ileal reservoir.' The Kock pouch fulfills the essential criteria of a highly compliant internal reservoir in that it is truly continent, easy to catheterize and prevents reflux to the kidneys. This innovative procedure offers patients who require cutaneous urinary diversion for any reason an acceptable alternative to the standard ileal conduit. However, significantly high rates of late postoperative complications regarding nipple valves have been reported.'-4 The late complications mainly have involved problems with efferent nipple valve function and much attention has been focused on forming a stable nipple valve. Several important modifications have been made actually to reduce the frequency of efferent On - ~the other hand, there are only nipple valve m a l f ~ n c t i o n . ~ to the afferent limb a few reports on late c~mplications~related of the Kock p o u ~ h . ~Recently, -~ Akerlund et a1 reported on dilatation of the upper urinary tract caused by afferent limb malfunction in long-term followup cases.6 We also have reported on the major modifications of the .~ modioperative technique for stable nipple f ~ r m a t i o nThese fications have successfully eliminated the problems with the efferent nipple valve but have resulted in a surge of unexpected afferent nipple valve complications. We have experienced several types of afferent nipple malfunctions. Our report has concentrated mainly on problems with the afferent nipple valve in patients who have been followed for more than 1year. PATIENTS AND METHODS
From 1984 through 1989 urinary diversion via a Kock pouch was performed in 47 patients a t our hospitals. One patient underwent excision of the pouch and rediversion to a standard ileal conduit due to efferent nipple valve malfunction. Of 42 patients observed for more than 12 months 5 died of recurrent Accepted for publication June 12, 1990. * Current address: Department of Urology, Shiga University of Medical Science, Shiga, Japan. t Requests for reprints: Department of Urology, Faculty of Medicine, Kyoto University, Sakyo-ku, Kyoto 606, Japan.
malignant disease more than 18 months postoperatively and these patients were included in the followup material. Thus, the study group was comprised of 42 patients who were observed for a mean of 38 months (range 12 to 58 months). There were 34 men and 8 women between 24 and 82 years old (mean age 57 years). All patients were followed at regular intervals of 3 to 6 months. Postoperative excretory urography (IVP) was performed a t least once a year. Endoscopy of the Kock pouch was performed when indicated from the findings of the IVP or routine urinalysis. Afferent and efferent nipple valves were observed with a flexible cystoscope. The Kock pouch was constructed with virtually the same technique as was originally described by Kock et al,' except that a 0.7 mm. thick polyester fiber patch fabric instead of Marlex (polypropylene) mesh was used as the collar. Polyester fiber fabric is unabsorbable and is much softer than Marlex mesh. Three layers of staples were applied with a surgical stapler. During the last 4 years 2 major modifications have been made for the construction of a stable nipple valve as reported previously: 1 method involves removing serosa and mesenteric fat with a Cavitron Ultrasonic Surgical Aspirator in the area used for intussusception and involves anchoring the nipple valve to the pouch walL5 RESULTS
Late complications related to afferent limb malfunction were observed in 10 of the 42 patients (24%, see table). These complications included erosion of polyester fiber fabric into the pouch, stenosis of the afferent limb and obstruction of the afferent nipple valve (fig. 1).No patient had sliding or everted antireflux valves. The interval from the construction of the Kock pouch to the manifestation of these problems ranged from 24 to 58 months (mean 39.8 months). On the other hand, 4 of the 42 patients had efferent limb complications, including prolapse, eversion and slippage, that occurred within 1 year after construction of the Kock pouch. In all 10 patients with afferent limb complications there were no remarkable findings
30
ARAI AND ASSOCIATES
Summarv of 10 natients with afferent nioole value malfunction P t . No.
Postop. Observation (Mos.)
Type of Afferent Nipple Malfunction Collar erosion Collar erosion Collar erosion Collar erosion Collar erosion Nipple stenosis Nipple stenosis Obstruction by fungal bezoar Intermittent obstruction Intermittent obstruction
IVP Findings
Episodes of Pyelonephritis
Treatment
Afferent limb dilatation Bilat. hydronephrosis Lt. ureteral stone, It. hydronephrosis
Pos.
Collar removed
Neg. Neg.
Bilat. hydronephrosis Bilat. hydronephrosis Bilat. hydronephrosis Bilat. hydronephrosis Intermittent bilat. hydronephrosis
Pos. Pos. Pos. Neg. Pos.
Collar removed Collar and stone removed, bypass operation* Collar removed Observationt Collar removed Observationt Endoscopic removal of fungal hezoar
Intermittent bilat. hydronephrosis Intermittent bilat. hydronephrosis
Pos. Pos.
Diuresis, observation? Diuresis, observation?
* Lt. uretero-afferent limb bypass operation. t Removal of the collar is under consideration
FIG. 1. Various forms of afferent nipple valve trouble. A, normal afferent nipple. B, collar erosion. Note that erosion occurs on antimesenteric side of nipple. C, stenosis or obstruction of afferent limb by collar constriction.
in the efferent nipple valve and no mismanagement or overdistension of the reservoir. Erosion of polyester fiber fabric. A total of 5 patients had erosion of polyester fiber fabric used as a collar of the afferent limb. Endoscopy of the Kock pouch revealed polyester fiber fabric erosion on the antimesenteric side of the afferent nipple (fig. 1, B) with concomitant stone formation. There was no evidence of reflux on t h e cystograms of the Kock pouch. Patients l, 4 and 5 had several episodes of upper urinary tract infection and the postoperative IVPs showed varying degrees of dilatation of the bilateral upper urinary tracts. In patient 1 there was marked dilatation of the proximal part of the afferent limb (fig. 2). A percutaneous antegrade pyelogram demonstrated no stenosis of the ureterointestinal anastomoses in the 4 patients. In patient 3, who had a history of urolithiasis, a stone had formed a t t h e ureterointestinal junction, causing ipsilateral marked hydronephrosis. The polyester fiber fabric was dissected out from inside the pouch in 4 of the 5 patients and 1 was awaiting revision a t followup. No reolacement mesh was used on the afferent nipple. Patient 3 had undergone ureterolithotomy and a uretero-afferent limb bypass operation simultaneously. Followup IVPs showed improvement in the hydronephrosis in the 4 patients. The repair of the afferent valve stopped further episodes of pyelonephritis in patients 1 and 4. In patient 1 the dilatation of the afferent limb improved markedly. Stenosis of the afferent limb. Patients 6 and 7 showed marked bilateral hydronephrosis with no remarkable findings in the pouch. Antegrade pyelograms revealed stenosis of the afferent limb a t the entrance to t h e pouch where the collar was used. There was no evidence of ureteroanastomotic stricture. In
patient 6 the afferent limb stenosis was severe (fig. 3, A ) and showed markedly elevated serum creatinine. Intraoperative findings revealed that polyester fiber fabric constricted the afferent limb (fig. 1, C) and the obstruction was relieved by the removal of the collar from the outside of the pouch (fig. 3, B). In patient 7, whose urographic findings were similar to those of patient 6, the collar was suspected to have caused afferent limb stenosis and revision was under consideration. Obstruction of the afferent nipple value. Patients 8 to 10 had frequent attacks of symptoms of upper urinary tract obstruction. Patient 8. who had reauired intravenous alimentation and broad-spectruk antibiotic' because of cancer recurrence and urinary tract infection, experienced several attacks of renal colic. The IVP performed during the colic attack showed bilateral hydronephrosis. Endoscopy of the Koch pouch revealed that the afferent nipple was obstructed by a grayish-white irregular mass compatible with fungal bezoar, which was successfully extracted with an endoscope. Urine culture yielded Candida species. The patient was continued on antifungal drugs and had no further episodes of obstruction but died of cancer 6 months later. Patients 9 and 10 also had intermittent renal colic. IVPs showed bilateral hydronephrosis each time with no evidence of antireflux valve malfunction. Urinalysis and urine culture did not yield candiduria. Urography revealed no stone shadow and endoscopy of the Kock pouch produced no remarkable findings. The obstruction was suspected to be caused by a small mucous plug in the afferent limb and was immediately relieved by rapid diuresis each time. Followup IVPs of patient 10 revealed that 3 lines of afferent nipple staples, which initially had been placed in parallel, were drawn towards each other a t the proximal ends (fig. 4). IVPs in patients 9 and 11 showed
AFFERENT N I P P L E VALVE MALFUNCTION CAUSED BY ANCHORING COLLAR
32
and they did n o t note hydronephrosis as a result of afferent .~ et a1 recently evaluated the influence nipple s t e n ~ s i sAkerlund of urinary diversion via a Kock pouch on the upper urinary tract in patients with a postoperative observation of 5 years or more.6 They showed that 5 of 17 patients (29%) had endured temporary outflow obstruction or reflux. Huffman also reported in cases followed for long terms a high incidence of afferent nipple valve calculi and stenosis of the afferent nipple valve." Afferent limb complications in our series were grossly unanticipated and were attributed mainly to the use of polyester fiber fabric as a collar (fig. 1). Polyester fiber fabric is much softer than Marlex mesh and was expected to eliminate the tendency of collar erosion. We had not experienced any complications associated with the use of the polyester fiber collar within the first 2 years. However, it has become apparent that if nonabsorbable material is used as a collar, even if the material is soft, there are risks of causing erosion or stone formation in the long term. The use of any other nonabsorbable materials should be avoided. I t should be noted that all of the patients who had afferent nipple valve troubles had no problems with respect to the efferent nipple valve function. As far as the efferent nipple is concerned, we have not experienced any problems associated with use of polyester fiber fabric as a collar. The efferent limb complications, such as eversion, prolapse or slippage, had the tendency to occur in the early postoperative period. On the contrary, the afferent limb complications caused by the anchoring collar occurred later. It is speculated that the isoperistaltic direction of the afferent limb, in conjunction with the use of nonabsorbable soft material as a collar, has a major role in this type of nipple valve malfunction (fig. 1).Stenosis of the afferent nipple by collar constriction could be caused by strong peristalsis of the intestine and might be regarded as the initial stage of collar erosion (fig. 1, C). Furthermore, in the patients who had intermittent obstruction of the afferent limb, nonabFIG. 2. Patient 1. I V P 38 months after construction of Kock pouch sorbable collar can cause dynamic obstruction of the afferent (P)shows marked dilatation of afferent limb (arrows) with mild stasis limb (fig. 4). of upper urinary tract. Obstruction of the urine outflow, either mechanical or dynamic, always should be considered whenever there are rethe same phenomenon. This finding is considered to be a result peated episodes symptomatic of urinary tract infection or a of collar constriction (fig. 1, C) and the removal of the collar is finding of upper tract dilatation on an IVP. Cystograms of the under consideration for the 2 patients. Kock pouch should be checked for evidence of reflux. Endoscopy of the Kock pouch can be easily performed to identify the afferent nipple abnormality. Antegrade pyelography also can DISCUSSION be useful to exclude ureteroanastomotic stricture. Once signifThe most important factor in the success of the Kock pouch icant obstruction of the afferent limb occurs an appropriate is creation of the nipple valves to ensure continence and to correction should be considered promptly, since preservation prevent reflux. The major problem with the continent ileal of the upper urinary tract can be achieved and should be the reservoir has been the instability of the valves. The late com- goal in all cases. Our experience with afferent nipple problems plications mainly involve problems with continence or ease of indicates that when collar erosion occurs it is sufficient only to catheterization, that is with the function of the efferent nipple remove the nonabsorbable collar. Replacement of the anchoring ~ a l v e . In ~ - the ~ original report more than 50% of the patients collar is not required. It is not known whether a nipple valve constructed initially needed reoperation because of slippage.' Several modifications to prevent nipple valve malfunction have been reported. without the use of an anchoring collar will work well in all Skinner et a1 made substantial progress in strengthening the respects. Kock et a1 reported that there was a significantly high nipple valve by making the window of Deaver about 8 cm. long incidence of sliding or eversion of the antireflux valves when in the mesentery for the prevention of lipp page.^ Marlex collars an anchoring collar was not used.' Although research on prowere replaced by polyglycolic acid mesh to prevent erosion.34 ducing a stable nipple is ongoing, patients still must be aware Our 3 important modifications, the use of a polyester fiber that complications associated with the nipple valve function anchoring collar, treatment of the mesentery with a Cavitron may occur. T o eliminate the troublesome complications associated with Ultrasonic Surgical Aspirator and fixation of the nipple valves to the pouch wall, have also significantly decreased the inci- an antireflux nipple valve another easy and reliable antireflux ureteroileal reimplantation technique, such as the procedure of dence of the efferent nipple valve m a l f u n c t i ~ n . ~ .~ It had been expected that there would be fewer problems in Le Duc et al, might be applied to the ileal r e s e r ~ o i rHautmann the afferent nipple valve than in the efferent nipple. Sliding or et a1 used this ureteroileal implantation technique in the coneversion (prolapse) of the afferent nipple valve was mainly struction of the ileal neobladder and obtained excellent reresponsible for pyelonephritis or difficulty with the antireflux sults.1° We also are beginning to apply this simple method to valve Lieskovsky et a1 reported that the inci- the construction of the Kock pouch. Extended followups are dence of afferent nipple problems and pyelonephritis was required to determine which technique is more feasible in terms greatly decreased after technical modifications of the procedure of simplicity and reliability.
ARAI AND ASSOCIATES
FIG. 3. Patient 6. A, bilateral nephrostogram reveals severe stenosis of afferent limb. B, IVP after revision shows marked improvement in upper urinary tract.
FIG. 4. Patient 10. A, I V P 1 year after construction of Kock pouch. Note that 3 lines of afferent nipple staples are placed parallel (arrows). B, IVP 50 months after construction of Kock pouch reveals that staples are drawn towards each other at proximal tips (arrows). Note that 3 lines of efferent nipple staples are placed parallel in A and B. REFERENCES
1. Kock, N. G., Nilson, A. E., Nilsson, L. O., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J. Urol., 128:469, 1982. 2. Skinner, D. G., Boyd, S. D. and Lieskovsky 6.:Clinical experience with the Kock continent ileal reservoir for urinary diversion. J. Urol., 132: 1101, 1984. 3. Lieskovsky, G., Boyd, S. D. and Skinner, D. G.: Management of late complications of t h e Kock pouch form of urinary diversion. J. Urol., 189:1146, 1987. 4. Skinner, D. G., Lieskovsky, G. and Boyd, S.: Continent urinary diversion. J. Urol., 14 1:1323, 1989. 5. Okada, Y., Arai, Y., Oishi, K., Takeuchi, H. andYoshida, 0.: Stable formation of the nipple valve in Kock pouch for diversion of the urinary tract. Surg., Gynec. & Obst., 169:315, 1989. 6. Akerlund, S., Delin, K., Kock, N. G., Lycke, G., Philipson, B. M.
and Volkmann, R.: 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. J. Urol., 142:964, 1989. 7. Huffman, J. L.: Endoscopic management of complications of continent urinary diversion. In: Proceedings of the 7th World Congress on Endourology and ESWL, abstracts, p. 101, 1989. 8. Kock, N. G., Ghoneim, M. A,, Lycke, K. G. and Mahran, M. R.: Replacement of the bladder by the urethral Kock pouch: functional results, urodynamics and radiological features. J. Urol., 141:1111, 1989. 9. Le Duc, A., Camey, M. and Teillac, P.: An original antireflux ureteroileal implantation technique: long-term followup. J. Urol., 137:1156, 1987. 10. Hautmann, R. E., Egghart, G., Frohneberg, D. and Miller, K.: The ileal neobladder. J. Urol., 139:39, 1988.
THEJOURNAL O F UROLOGY Copyright 0 1991 by AMERICANUROLOGICAL ASSOCIATION,INC
Vol. 146, 29-33, January 1991 Printed in Lr.S.A.
AFFERENT NIPPLE VALVE MALFUNCTION CAUSED BY ANCHORING COLLAR: AN UNEXPECTED LATE COMPLICATION OF T H E KOCK CONTINENT ILEAL RESERVOIR YOICHI ARAI, YUSAKU OKADA," TADASHI MATSUDA, SHUICHI HIDA, HIDEO TAKEUCHI, YUJI KIHARA AND OSAMU YOSHIDA? From the Departments of Urology, Faculty of Medicine, Kyoto University, Kyoto, and Public Toyooka Hospital, Toyooka, Japan
ABSTRACT
In the construction of a Kock continent ileal reservoir for urinary diversion, significantly high rates of late postoperative complications regarding nipple valves, the efferent limb in particular, have been reported. There are only a few reports on afferent nipple valve malfunction. A total of 42 patients who underwent a Kock pouch operation and were observed for more than 1 2 months (mean 38 months) was evaluated in terms of afferent nipple valve malfunction. Late afferent nipple valve complications were observed in 10 of the 42 patients (24%). These complications included erosion of the polyester fiber fabric used as a collar ( 5 patients), stenosis of the afferent limb (2) and obstruction of the afferent nipple by a mucous plug or fungus ball (3). The latter 2 complications were due to mechanical or dynamic obstruction of urine flow caused by a nonabsorbable collar. None of the 10 patients had problems with efferent nipple valve function. Our results suggest that the peristaltic direction of the intestine and the use of nonabsorbable material as a collar are primarily responsible for the late afferent nipple valve complications. Further modifications are needed to produce a stable nipple valve. Otherwise, simpler and more reliable alternative techniques of antireflux anastomosis should be considered. KEYWORDS:urinary diversion; anastomosis, surgical
Kock et a1 first reported on the revolutionary method of urinary diversion via the continent ileal reservoir.' The Kock pouch fulfills the essential criteria of a highly compliant internal reservoir in that it is truly continent, easy to catheterize and prevents reflux to the kidneys. This innovative procedure offers patients who require cutaneous urinary diversion for any reason an acceptable alternative to the standard ileal conduit. However, significantly high rates of late postoperative complications regarding nipple valves have been reported.'-4 The late complications mainly have involved problems with efferent nipple valve function and much attention has been focused on forming a stable nipple valve. Several important modifications have been made actually to reduce the frequency of efferent On - ~the other hand, there are only nipple valve m a l f ~ n c t i o n . ~ to the afferent limb a few reports on late c~mplications~related of the Kock p o u ~ h . ~Recently, -~ Akerlund et a1 reported on dilatation of the upper urinary tract caused by afferent limb malfunction in long-term followup cases.6 We also have reported on the major modifications of the .~ modioperative technique for stable nipple f ~ r m a t i o nThese fications have successfully eliminated the problems with the efferent nipple valve but have resulted in a surge of unexpected afferent nipple valve complications. We have experienced several types of afferent nipple malfunctions. Our report has concentrated mainly on problems with the afferent nipple valve in patients who have been followed for more than 1year. PATIENTS AND METHODS
From 1984 through 1989 urinary diversion via a Kock pouch was performed in 47 patients a t our hospitals. One patient underwent excision of the pouch and rediversion to a standard ileal conduit due to efferent nipple valve malfunction. Of 42 patients observed for more than 12 months 5 died of recurrent Accepted for publication June 12, 1990. * Current address: Department of Urology, Shiga University of Medical Science, Shiga, Japan. t Requests for reprints: Department of Urology, Faculty of Medicine, Kyoto University, Sakyo-ku, Kyoto 606, Japan.
malignant disease more than 18 months postoperatively and these patients were included in the followup material. Thus, the study group was comprised of 42 patients who were observed for a mean of 38 months (range 12 to 58 months). There were 34 men and 8 women between 24 and 82 years old (mean age 57 years). All patients were followed at regular intervals of 3 to 6 months. Postoperative excretory urography (IVP) was performed a t least once a year. Endoscopy of the Kock pouch was performed when indicated from the findings of the IVP or routine urinalysis. Afferent and efferent nipple valves were observed with a flexible cystoscope. The Kock pouch was constructed with virtually the same technique as was originally described by Kock et al,' except that a 0.7 mm. thick polyester fiber patch fabric instead of Marlex (polypropylene) mesh was used as the collar. Polyester fiber fabric is unabsorbable and is much softer than Marlex mesh. Three layers of staples were applied with a surgical stapler. During the last 4 years 2 major modifications have been made for the construction of a stable nipple valve as reported previously: 1 method involves removing serosa and mesenteric fat with a Cavitron Ultrasonic Surgical Aspirator in the area used for intussusception and involves anchoring the nipple valve to the pouch walL5 RESULTS
Late complications related to afferent limb malfunction were observed in 10 of the 42 patients (24%, see table). These complications included erosion of polyester fiber fabric into the pouch, stenosis of the afferent limb and obstruction of the afferent nipple valve (fig. 1).No patient had sliding or everted antireflux valves. The interval from the construction of the Kock pouch to the manifestation of these problems ranged from 24 to 58 months (mean 39.8 months). On the other hand, 4 of the 42 patients had efferent limb complications, including prolapse, eversion and slippage, that occurred within 1 year after construction of the Kock pouch. In all 10 patients with afferent limb complications there were no remarkable findings
30
ARAI AND ASSOCIATES
Summarv of 10 natients with afferent nioole value malfunction P t . No.
Postop. Observation (Mos.)
Type of Afferent Nipple Malfunction Collar erosion Collar erosion Collar erosion Collar erosion Collar erosion Nipple stenosis Nipple stenosis Obstruction by fungal bezoar Intermittent obstruction Intermittent obstruction
IVP Findings
Episodes of Pyelonephritis
Treatment
Afferent limb dilatation Bilat. hydronephrosis Lt. ureteral stone, It. hydronephrosis
Pos.
Collar removed
Neg. Neg.
Bilat. hydronephrosis Bilat. hydronephrosis Bilat. hydronephrosis Bilat. hydronephrosis Intermittent bilat. hydronephrosis
Pos. Pos. Pos. Neg. Pos.
Collar removed Collar and stone removed, bypass operation* Collar removed Observationt Collar removed Observationt Endoscopic removal of fungal hezoar
Intermittent bilat. hydronephrosis Intermittent bilat. hydronephrosis
Pos. Pos.
Diuresis, observation? Diuresis, observation?
* Lt. uretero-afferent limb bypass operation. t Removal of the collar is under consideration
FIG. 1. Various forms of afferent nipple valve trouble. A, normal afferent nipple. B, collar erosion. Note that erosion occurs on antimesenteric side of nipple. C, stenosis or obstruction of afferent limb by collar constriction.
in the efferent nipple valve and no mismanagement or overdistension of the reservoir. Erosion of polyester fiber fabric. A total of 5 patients had erosion of polyester fiber fabric used as a collar of the afferent limb. Endoscopy of the Kock pouch revealed polyester fiber fabric erosion on the antimesenteric side of the afferent nipple (fig. 1, B) with concomitant stone formation. There was no evidence of reflux on t h e cystograms of the Kock pouch. Patients l, 4 and 5 had several episodes of upper urinary tract infection and the postoperative IVPs showed varying degrees of dilatation of the bilateral upper urinary tracts. In patient 1 there was marked dilatation of the proximal part of the afferent limb (fig. 2). A percutaneous antegrade pyelogram demonstrated no stenosis of the ureterointestinal anastomoses in the 4 patients. In patient 3, who had a history of urolithiasis, a stone had formed a t t h e ureterointestinal junction, causing ipsilateral marked hydronephrosis. The polyester fiber fabric was dissected out from inside the pouch in 4 of the 5 patients and 1 was awaiting revision a t followup. No reolacement mesh was used on the afferent nipple. Patient 3 had undergone ureterolithotomy and a uretero-afferent limb bypass operation simultaneously. Followup IVPs showed improvement in the hydronephrosis in the 4 patients. The repair of the afferent valve stopped further episodes of pyelonephritis in patients 1 and 4. In patient 1 the dilatation of the afferent limb improved markedly. Stenosis of the afferent limb. Patients 6 and 7 showed marked bilateral hydronephrosis with no remarkable findings in the pouch. Antegrade pyelograms revealed stenosis of the afferent limb a t the entrance to t h e pouch where the collar was used. There was no evidence of ureteroanastomotic stricture. In
patient 6 the afferent limb stenosis was severe (fig. 3, A ) and showed markedly elevated serum creatinine. Intraoperative findings revealed that polyester fiber fabric constricted the afferent limb (fig. 1, C) and the obstruction was relieved by the removal of the collar from the outside of the pouch (fig. 3, B). In patient 7, whose urographic findings were similar to those of patient 6, the collar was suspected to have caused afferent limb stenosis and revision was under consideration. Obstruction of the afferent nipple value. Patients 8 to 10 had frequent attacks of symptoms of upper urinary tract obstruction. Patient 8. who had reauired intravenous alimentation and broad-spectruk antibiotic' because of cancer recurrence and urinary tract infection, experienced several attacks of renal colic. The IVP performed during the colic attack showed bilateral hydronephrosis. Endoscopy of the Koch pouch revealed that the afferent nipple was obstructed by a grayish-white irregular mass compatible with fungal bezoar, which was successfully extracted with an endoscope. Urine culture yielded Candida species. The patient was continued on antifungal drugs and had no further episodes of obstruction but died of cancer 6 months later. Patients 9 and 10 also had intermittent renal colic. IVPs showed bilateral hydronephrosis each time with no evidence of antireflux valve malfunction. Urinalysis and urine culture did not yield candiduria. Urography revealed no stone shadow and endoscopy of the Kock pouch produced no remarkable findings. The obstruction was suspected to be caused by a small mucous plug in the afferent limb and was immediately relieved by rapid diuresis each time. Followup IVPs of patient 10 revealed that 3 lines of afferent nipple staples, which initially had been placed in parallel, were drawn towards each other a t the proximal ends (fig. 4). IVPs in patients 9 and 11 showed
AFFERENT N I P P L E VALVE MALFUNCTION CAUSED BY ANCHORING COLLAR
32
and they did n o t note hydronephrosis as a result of afferent .~ et a1 recently evaluated the influence nipple s t e n ~ s i sAkerlund of urinary diversion via a Kock pouch on the upper urinary tract in patients with a postoperative observation of 5 years or more.6 They showed that 5 of 17 patients (29%) had endured temporary outflow obstruction or reflux. Huffman also reported in cases followed for long terms a high incidence of afferent nipple valve calculi and stenosis of the afferent nipple valve." Afferent limb complications in our series were grossly unanticipated and were attributed mainly to the use of polyester fiber fabric as a collar (fig. 1). Polyester fiber fabric is much softer than Marlex mesh and was expected to eliminate the tendency of collar erosion. We had not experienced any complications associated with the use of the polyester fiber collar within the first 2 years. However, it has become apparent that if nonabsorbable material is used as a collar, even if the material is soft, there are risks of causing erosion or stone formation in the long term. The use of any other nonabsorbable materials should be avoided. I t should be noted that all of the patients who had afferent nipple valve troubles had no problems with respect to the efferent nipple valve function. As far as the efferent nipple is concerned, we have not experienced any problems associated with use of polyester fiber fabric as a collar. The efferent limb complications, such as eversion, prolapse or slippage, had the tendency to occur in the early postoperative period. On the contrary, the afferent limb complications caused by the anchoring collar occurred later. It is speculated that the isoperistaltic direction of the afferent limb, in conjunction with the use of nonabsorbable soft material as a collar, has a major role in this type of nipple valve malfunction (fig. 1).Stenosis of the afferent nipple by collar constriction could be caused by strong peristalsis of the intestine and might be regarded as the initial stage of collar erosion (fig. 1, C). Furthermore, in the patients who had intermittent obstruction of the afferent limb, nonabFIG. 2. Patient 1. I V P 38 months after construction of Kock pouch sorbable collar can cause dynamic obstruction of the afferent (P)shows marked dilatation of afferent limb (arrows) with mild stasis limb (fig. 4). of upper urinary tract. Obstruction of the urine outflow, either mechanical or dynamic, always should be considered whenever there are rethe same phenomenon. This finding is considered to be a result peated episodes symptomatic of urinary tract infection or a of collar constriction (fig. 1, C) and the removal of the collar is finding of upper tract dilatation on an IVP. Cystograms of the under consideration for the 2 patients. Kock pouch should be checked for evidence of reflux. Endoscopy of the Kock pouch can be easily performed to identify the afferent nipple abnormality. Antegrade pyelography also can DISCUSSION be useful to exclude ureteroanastomotic stricture. Once signifThe most important factor in the success of the Kock pouch icant obstruction of the afferent limb occurs an appropriate is creation of the nipple valves to ensure continence and to correction should be considered promptly, since preservation prevent reflux. The major problem with the continent ileal of the upper urinary tract can be achieved and should be the reservoir has been the instability of the valves. The late com- goal in all cases. Our experience with afferent nipple problems plications mainly involve problems with continence or ease of indicates that when collar erosion occurs it is sufficient only to catheterization, that is with the function of the efferent nipple remove the nonabsorbable collar. Replacement of the anchoring ~ a l v e . In ~ - the ~ original report more than 50% of the patients collar is not required. It is not known whether a nipple valve constructed initially needed reoperation because of slippage.' Several modifications to prevent nipple valve malfunction have been reported. without the use of an anchoring collar will work well in all Skinner et a1 made substantial progress in strengthening the respects. Kock et a1 reported that there was a significantly high nipple valve by making the window of Deaver about 8 cm. long incidence of sliding or eversion of the antireflux valves when in the mesentery for the prevention of lipp page.^ Marlex collars an anchoring collar was not used.' Although research on prowere replaced by polyglycolic acid mesh to prevent erosion.34 ducing a stable nipple is ongoing, patients still must be aware Our 3 important modifications, the use of a polyester fiber that complications associated with the nipple valve function anchoring collar, treatment of the mesentery with a Cavitron may occur. T o eliminate the troublesome complications associated with Ultrasonic Surgical Aspirator and fixation of the nipple valves to the pouch wall, have also significantly decreased the inci- an antireflux nipple valve another easy and reliable antireflux ureteroileal reimplantation technique, such as the procedure of dence of the efferent nipple valve m a l f u n c t i ~ n . ~ .~ It had been expected that there would be fewer problems in Le Duc et al, might be applied to the ileal r e s e r ~ o i rHautmann the afferent nipple valve than in the efferent nipple. Sliding or et a1 used this ureteroileal implantation technique in the coneversion (prolapse) of the afferent nipple valve was mainly struction of the ileal neobladder and obtained excellent reresponsible for pyelonephritis or difficulty with the antireflux sults.1° We also are beginning to apply this simple method to valve Lieskovsky et a1 reported that the inci- the construction of the Kock pouch. Extended followups are dence of afferent nipple problems and pyelonephritis was required to determine which technique is more feasible in terms greatly decreased after technical modifications of the procedure of simplicity and reliability.
ARAI AND ASSOCIATES
FIG. 3. Patient 6. A, bilateral nephrostogram reveals severe stenosis of afferent limb. B, IVP after revision shows marked improvement in upper urinary tract.
FIG. 4. Patient 10. A, I V P 1 year after construction of Kock pouch. Note that 3 lines of afferent nipple staples are placed parallel (arrows). B, IVP 50 months after construction of Kock pouch reveals that staples are drawn towards each other at proximal tips (arrows). Note that 3 lines of efferent nipple staples are placed parallel in A and B. REFERENCES
1. Kock, N. G., Nilson, A. E., Nilsson, L. O., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J. Urol., 128:469, 1982. 2. Skinner, D. G., Boyd, S. D. and Lieskovsky 6.:Clinical experience with the Kock continent ileal reservoir for urinary diversion. J. Urol., 132: 1101, 1984. 3. Lieskovsky, G., Boyd, S. D. and Skinner, D. G.: Management of late complications of t h e Kock pouch form of urinary diversion. J. Urol., 189:1146, 1987. 4. Skinner, D. G., Lieskovsky, G. and Boyd, S.: Continent urinary diversion. J. Urol., 14 1:1323, 1989. 5. Okada, Y., Arai, Y., Oishi, K., Takeuchi, H. andYoshida, 0.: Stable formation of the nipple valve in Kock pouch for diversion of the urinary tract. Surg., Gynec. & Obst., 169:315, 1989. 6. Akerlund, S., Delin, K., Kock, N. G., Lycke, G., Philipson, B. M.
and Volkmann, R.: 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. J. Urol., 142:964, 1989. 7. Huffman, J. L.: Endoscopic management of complications of continent urinary diversion. In: Proceedings of the 7th World Congress on Endourology and ESWL, abstracts, p. 101, 1989. 8. Kock, N. G., Ghoneim, M. A,, Lycke, K. G. and Mahran, M. R.: Replacement of the bladder by the urethral Kock pouch: functional results, urodynamics and radiological features. J. Urol., 141:1111, 1989. 9. Le Duc, A., Camey, M. and Teillac, P.: An original antireflux ureteroileal implantation technique: long-term followup. J. Urol., 137:1156, 1987. 10. Hautmann, R. E., Egghart, G., Frohneberg, D. and Miller, K.: The ileal neobladder. J. Urol., 139:39, 1988.