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Long-term complications related to the modified Indiana pouch
ADULT UROLOGY
LONG-TERM COMPLICATIONS RELATED TO THE MODIFIED INDIANA POUCH DANIEL G. HOLMES, J. BRANTLEY THRASHER, GERALD Y. PARK, DEBORAH C. KUEKER, JOHN W. WEIGEL
AND
ABSTRACT Objectives. To describe a single-institution, single-surgeon experience with 125 modified Indiana pouches performed during a period of 14 years and their long-term complications. The modified Indiana pouch is a widely accepted and often used form of continent urinary diversion. Few studies have established the long-term complication rates associated with the procedure. Methods. A retrospective chart review of 129 modified Indiana pouches constructed from March 1985 to August 1998 was performed, and the long-term complications and reoperation rates were tabulated. Results. Complete information was obtained for 125 of the 129 charts, with a mean follow-up of 41.1 months (range 3 to 127). Complications occurred in 112 patients (89.6%; several patients had more than one complication), with a mean onset of 20.4 months (range 1 to 125) postoperatively. Seventy-three complications (58.4%) were due to the efferent limb, of which incontinence (defined as any leakage) was the most common (35 [28.0%]), followed by stomal stenosis in 19 (15.2%) and difficult catheterization in 12 (9.6%). Of the 26 pouch-related problems (21.8%) that occurred, the most common were stones in 13 (10.4%), perioperative leaks in 5 (4.0%), and perforations in 4 (3.2%). Ureteral anastomotic strictures were seen in 9 (7.2%). Other complications included gallstones in 32 (25.6%), kidney stones in 8 (6.4%), and small bowel obstruction in 6 (4.8%). Reoperation was performed in 65 patients (52.0%; several patients with more than one reoperation). Twenty-six (20.8%) of the patients required an open operation, and 39 (31.2%) received minimally invasive (percutaneous, endoscopic, extracorporeal shock wave lithotripsy) procedures. Sixty percent of the reoperations were minimally invasive. Reoperation was due to stomal stenosis in 18 (14.4%), pouch stones in 13 (10.4%), ureteral strictures in 9 (7.2%), and parastomal hernias in 6 (4.8%). Small bowel obstruction required reoperation in 5 patients (4.0%). Conclusions. In our experience, long-term complications of the modified Indiana pouch were mostly related to the efferent limb, and reoperations were usually due to stomal stenosis. Our data suggest that with longer follow-up, the complication and reoperation rates of the modified Indiana pouch appear to be higher than previously reported. UROLOGY 60: 603–606, 2002. © 2002, Elsevier Science Inc.
S
ince its introduction, the Indiana pouch has gained popularity as a form of continent urinary diversion. A few modifications have kept it relatively simple, and most series have reported few complications and low revision rates.1,2 We describe a retrospective review of a single institution, single surgeon (J.W.W.) experience with 125
From the Section of Urology, University of Kansas Medical Center, Kansas City, Kansas. Reprint requests: J. Brantley Thrasher, M.D., Section of Urology, University of Kansas Medical Center, 3900 Rainbow Boulevard, Subdler Building, Room 5022, Kansas City, KS 66160 Submitted: February 22, 2002, accepted (with revisions): May 28, 2002 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
modified Indiana pouches performed during a period of 14 years and their long-term complications. MATERIAL AND METHODS A retrospective chart review was made of 129 consecutive modified Indiana pouches, performed from March 1985 to August 1998 at the University of Kansas. In all patients, a cecoileal continent urinary reservoir was performed with the modified Indiana technique, as previously described by Rowland et al.3 Modifications to our technique occurred slowly during the course of 14 years as experience was gained. Between 26 to 30 cm of right colon and cecum were completely detubularized. The efferent limb was tapered over a 12F catheter and, for most cases, brought out through the umbilicus. The ileocecal valve was plicated and slightly intussuscepted over an 18F catheter. A 10F catheter was left in the efferent limb in the postoperative setting as a mold. Appendectomy 0090-4295/02/$22.00 PII S0090-4295(02)01945-3 603
TABLE I. Indications for surgery Diagnosis
n
Bladder cancer Interstitial cystitis Spina bifida Neurogenic bladder Other
38 32 23 18 14
was routinely performed, and 10 to 12 cm of terminal ileum was isolated to form the efferent limb. A cecostomy tube, as well as ureteral stents, was also standard. The indications for surgery are seen in Table I. The demographic data on such a large group of patients varied, yet in general reflected a busy tertiary care center. All patients underwent instruction for pouch training and care by an enterostomal nurse, including catheterization and irrigation protocols. They were then seen in clinic for routine follow-up examination, laboratory tests, and radiographic evaluation (ultrasonography). A data sheet kept by our enterostomal therapist prospectively recorded the complications according to pouch, efferent limb, ureter, kidney, and non-pouch related. A tally of reoperations for each complication was also kept. The hospital clinical charts and departmental records were also reviewed in a retrospective manner, and complete data were available for 125 of the 129 patients. The remaining 4 patients were lost to follow-up with only scant reviewable data.
RESULTS Complete information was obtained for 125 of the 129 charts, with a mean follow-up of 41.1 months (range 3 to 127). Patients were followed up until their most recent clinic appointment, correspondence with a following community urologist, or the patient’s death. Long-term complications occurred in 112 patients (89.6%; several patients had more than one complication) with a mean onset of 20.4 months (range 3 to 125) postoperatively. Seventy-three complications (58.4%) were due to the efferent limb, of which, incontinence (defined as any leakage) was the most common (35 [28.0%]), followed by stomal stenosis in 19 (15.2%), and difficult catheterization in 12 (9.6%). Of the 26 pouch-related problems (21.8%) that occurred, the most common were stones in 13 (10.4%), perioperative leaks in 5 (4.0%), and perforations in 4 (3.2%). Ureteral anastomotic strictures were seen in 9 (7.2%). Other complications included gallstones in 32 (25.6%), kidney stones in 8 (6.4%), and small bowel obstruction in 6 (4.8%). Reoperation was performed in 65 patients (52.0%; several patients with more than one reoperation). Twenty-six of the patients (20.8%) required an open operation, and 39 (31.2%) received minimally invasive (percutaneous, endoscopic, extracorporeal shock wave lithotripsy) procedures. Sixty percent of the reoperations were minimally invasive. Reoperation was due to stomal stenosis in 18 (14.4%), pouch stones in 13 (10.4%), ureteral 604
strictures in 9 (7.2%), and parastomal hernias in 6 (4.8%). Small bowel obstruction required reoperation in 5 patients (4.0%). All complications are listed in Table II. COMMENT The modified Indiana pouch has been extensively used since its development in the 1980s.1 Most studies have reported low complication and reoperation rates. A comprehensive list of these reports can be seen in Table III.2,4 –10 It should be noted that the mean follow-up in these series was approximately 24 months. In our series, with a mean follow-up of 41.1 months, we had a considerably higher long-term complication rate (89.6%) and reoperation rate (52.0%). In reviewing our database, we were very complete in reporting any complication, and thus we listed any sequelae as a complication. Most of the complications were related to the efferent limb, which is the most delicate part of the reconstruction. Incontinence (defined as any leakage), stomal stenosis, and difficulty catheterizing accounted for two thirds of our complications. Certainly, stomal stenosis and difficulty catheterizing, as well as pouch stones and gallstones, are complications that become more frequent with time. Our overall continence rate of 71.8% is similar to the 69.0% found in the original report by Rowland et al.,1 but it falls below the 94% to 100% rate found in other series.2,4,7,8 In this study, we did not attempt to quantify or characterize the incontinence, and we may have overestimated the true incidence of clinically significant incontinence, as our revision rate for incontinence was only 4.0%. Gallstones and pouch stones were the next most common complications (not often tracked in other series). The incidence of pouch stones was 10% in our series of 125 patients, occurring on average more than 4 years after the initial surgery. Presentation included pain, UTI, incontinence, trouble catheterizing, and asymptomatic follow-up. All stones were readily diagnosed by plain abdominal radiography, intravenous urography, ultrasonography, or pouchoscopy. The stones were often multiple, and some were quite large. Endoscopic removal was usually successful, but open removal was required for larger stones not amenable to closed techniques. Analysis revealed compositions ranging from calcium apatite to struvite, with a mucous or staple nidus. A more complete discussion of these unique complications has been previously published.11 Our ureteral anastomotic complication rate of 7.2% was similar to the 7% reported in the series by Wilson et al.6 Even though the mean time to complication development was 20.4 months, 34% of the complications occurred after 24 months (average follow-up UROLOGY 60 (4), 2002
TABLE II. Long-term complications Patients (n)
Complication Pouch related Decreased pouch volume Perioperative pouch leak Pouch perforation Pouch stones Fistula Efferent limb Incontinence, total Incontinence, day Incontinence, night Parastomal hernia Difficult catheterization Stomal stenosis Ureter Reflux Ureteral stricture/obstruction Stones Kidney Pyelonephritis Kidney stones Renal insufficiency Hydronephrosis Non-pouch related Small bowel obstruction Adhesions Diarrhea Gallstones Vitamin B12 deficiency
Reoperations (n)
2 5 4 13 2
(1.6) (4.0) (3.2) (10.4) (1.6)
2 5 2 13 2
(1.6) (4.0) (1.6) (10.4) (1.6)
13 16 6 7 12 19
(10.4) (12.8) (4.8) (5.6) (9.6) (15.2)
3 1 1 6 2 18
(2.4) (0.8) (0.8) (4.8) (1.6) (14.4)
2 (1.6) 9 (7.2) 2 (1.6)
0 (0.0) 9 (7.2) 2 (1.6)
4 8 2 7
(3.2) (6.4) (1.6) (5.6)
0 2 0 0
(0.0) (1.6) (0.0) (0.0)
(4.8) (0.8) (2.4) (25.6) (7.2)
5 1 0 3 0
(4.0) (0.8) (0.0) (2.4) (0.0)
6 1 3 32 9
Numbers in parentheses are percentages.
TABLE III. Long-term complications in selected series Author Rowland and Kropp2 Bihrle4 Carr and Webster5 Wilson et al.6 Arai et al.7 Ahlering et al.8 Navon et al.9 Weijerman et al.10
Patients (n)
Follow-up
Complication (%)
Reoperation (%)
69 50 30 130 37 25 50 23
2 yr 2.5 yr 16 mo 1–16 mo 34 mo 3–12 mo 27.5 mo 41 mo
45 32 23 12 35 32 30 86
20.3 14 13 12 10.8 8 14 56
of other studies). Some categories of complications had an even longer latency period. For example, pouch stones had a mean presentation time of 49.5 months. In evaluating the individual complication categories, our experience was similar to that of many other reported series, but our overall complication rate was a bit higher. We believe that this was due to the cumulative effect of our comprehensive database and extended follow-up period. In terms of our higher reoperation rate, 60% were minimally invasive procedures (endoscopic, percutaneous, extracorporeal shock wave lithoUROLOGY 60 (4), 2002
tripsy), and the remainder required open abdominal surgery. One half of our operations were for stomal stenosis and pouch stones, which were easily managed on an outpatient basis. If we considered only our open reoperation rate of 20.8%, it was still higher than other series, but again our longer follow-up may account for this. The technique used in the construction of the continent diversion is a critical element in the development of complications. Modifications to our technique occurred slowly during the course of 14 years as experience was gained and represent 605
changes similar to those of other institutions. In the first 3 years, we formed the pouch with 30 to 32 cm of colon and subsequently reduced that to 26 to 30 cm secondary to difficulty with emptying and mucus accumulation. Initially, we used a tunneled nonrefluxing ureteral reimplantation, but later when the Le Duc technique came of age, we switched to it. We consistently used 8F pediatric feeding tubes as our ureteral stents. In terms of our continence mechanism, we used braided, nonabsorbable suture. Initially, we imbricated and intussuscepted our ileocecal valves aggressively. Later, we found that embrication with only a small degree of intussusception over an 18F catheter was successful. The efferent limb during our early experience was handsewn with 3-0 silk. With the advent of stapling devices, we began using GIA staplers over a 12F catheter. During the first 4 years, we brought the stomas out through the abdominal wall, but in the past 10 years we have used the umbilicus. We now leave a 10F catheter in the efferent limb as a mold in the postoperative setting. When comparing the complications of our first 7 years experience with those of the last 7 years, no appreciable difference could be seen in the specific complications. We believe our results with the evolving technique are an accurate representation of the complications that would be seen at any institution performing a similar number of the procedures, because our complication rates in each category closely paralleled those of other large series when broken down by specific complication (Table II). Twenty-five percent of our patient population carried the diagnosis of interstitial cystitis. Certainly this patient population has many physical and potentially psychological issues that could confuse the interpretation of complications. Yet, in a separate analysis of the quality-of-life data (soon to be published), this population benefited immensely from continent diversion. More importantly, they did not appear to have a higher complication rate. To remove this patient population from consideration in this study would only weaken any conclusions that might be drawn.
606
CONCLUSIONS In our experience, the long-term complications associated with the modified Indiana continent urinary reservoir were primarily related to the efferent limb, and reoperations were most often due to stomal stenosis. When stratifying by complication, our rates paralleled those of other series. However, our data suggest that with longer and more complete follow-up, the complication and reoperation rates appear to be higher than previously reported. This information is important to relay in counseling our patients (especially our younger patients). Verification of our findings from other series with long-term follow-up will be necessary to assess the durability and overall morbidity of this procedure. REFERENCES 1. Rowland RG, Mitchell ME, Bihrle R, et al: Indiana continent urinary reservoir. J Urol 137: 1136 –1139, 1987. 2. Rowland RG, and Kropp BP: Evolution of the Indiana continent urinary reservoir. J Urol 152: 2247–2251, 1994. 3. Rowland RG, Webster GD, and Goldwater B: Right colon reservoir using a plicated tapered ileal outlet, in Urinary Diversions: Scientific Foundations and Clinical Practice. Oxford, Isis Medical Media, 1995, pp 229 –235. 4. Bihrle R: The Indiana pouch continent urinary reservoir. Urol Clin North Am 24: 773–779, 1997. 5. Carr LK, and Webster GD: Kock versus right colon continent urinary diversion: comparison of outcome and reoperation rate. Urology 48: 711–714, 1996. 6. Wilson TG, Moreno JG, Weinberg A, et al: Late complications of the modified Indiana pouch. J Urol 151: 331– 334, 1994. 7. Arai Y, Mutsushi K, Terachi T, et al: Long-term followup of the Kock and Indiana pouch procedures. J Urol 150: 51–55, 1993. 8. Ahlering TE, Weinberg AC, and Razor B: A comparative study of the ileal conduit, Kock pouch, and modified Indiana pouch. J Urol 142: 1193–1196, 1989. 9. Navon ND, Wong AK, Weinberg AC, et al: A comparative study of postoperative complications associated with the modified Indiana pouch in elderly versus younger patients. J Urol 154: 1325–1328, 1995. 10. Weijerman PC, Schurmans JR, Hop WC, et al: Morbidity and quality of life in patients with orthotopic and heterotopic continent urinary diversion. Urology 51: 51–56, 1998. 11. Holmes DG, Park GY, Thrasher BJ, et al: Incidence of cholelithiasis in 125 continent urinary diversions. J Urol 165: 1897–1899, 2001.
UROLOGY 60 (4), 2002
LONG-TERM COMPLICATIONS RELATED TO THE MODIFIED INDIANA POUCH DANIEL G. HOLMES, J. BRANTLEY THRASHER, GERALD Y. PARK, DEBORAH C. KUEKER, JOHN W. WEIGEL
AND
ABSTRACT Objectives. To describe a single-institution, single-surgeon experience with 125 modified Indiana pouches performed during a period of 14 years and their long-term complications. The modified Indiana pouch is a widely accepted and often used form of continent urinary diversion. Few studies have established the long-term complication rates associated with the procedure. Methods. A retrospective chart review of 129 modified Indiana pouches constructed from March 1985 to August 1998 was performed, and the long-term complications and reoperation rates were tabulated. Results. Complete information was obtained for 125 of the 129 charts, with a mean follow-up of 41.1 months (range 3 to 127). Complications occurred in 112 patients (89.6%; several patients had more than one complication), with a mean onset of 20.4 months (range 1 to 125) postoperatively. Seventy-three complications (58.4%) were due to the efferent limb, of which incontinence (defined as any leakage) was the most common (35 [28.0%]), followed by stomal stenosis in 19 (15.2%) and difficult catheterization in 12 (9.6%). Of the 26 pouch-related problems (21.8%) that occurred, the most common were stones in 13 (10.4%), perioperative leaks in 5 (4.0%), and perforations in 4 (3.2%). Ureteral anastomotic strictures were seen in 9 (7.2%). Other complications included gallstones in 32 (25.6%), kidney stones in 8 (6.4%), and small bowel obstruction in 6 (4.8%). Reoperation was performed in 65 patients (52.0%; several patients with more than one reoperation). Twenty-six (20.8%) of the patients required an open operation, and 39 (31.2%) received minimally invasive (percutaneous, endoscopic, extracorporeal shock wave lithotripsy) procedures. Sixty percent of the reoperations were minimally invasive. Reoperation was due to stomal stenosis in 18 (14.4%), pouch stones in 13 (10.4%), ureteral strictures in 9 (7.2%), and parastomal hernias in 6 (4.8%). Small bowel obstruction required reoperation in 5 patients (4.0%). Conclusions. In our experience, long-term complications of the modified Indiana pouch were mostly related to the efferent limb, and reoperations were usually due to stomal stenosis. Our data suggest that with longer follow-up, the complication and reoperation rates of the modified Indiana pouch appear to be higher than previously reported. UROLOGY 60: 603–606, 2002. © 2002, Elsevier Science Inc.
S
ince its introduction, the Indiana pouch has gained popularity as a form of continent urinary diversion. A few modifications have kept it relatively simple, and most series have reported few complications and low revision rates.1,2 We describe a retrospective review of a single institution, single surgeon (J.W.W.) experience with 125
From the Section of Urology, University of Kansas Medical Center, Kansas City, Kansas. Reprint requests: J. Brantley Thrasher, M.D., Section of Urology, University of Kansas Medical Center, 3900 Rainbow Boulevard, Subdler Building, Room 5022, Kansas City, KS 66160 Submitted: February 22, 2002, accepted (with revisions): May 28, 2002 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
modified Indiana pouches performed during a period of 14 years and their long-term complications. MATERIAL AND METHODS A retrospective chart review was made of 129 consecutive modified Indiana pouches, performed from March 1985 to August 1998 at the University of Kansas. In all patients, a cecoileal continent urinary reservoir was performed with the modified Indiana technique, as previously described by Rowland et al.3 Modifications to our technique occurred slowly during the course of 14 years as experience was gained. Between 26 to 30 cm of right colon and cecum were completely detubularized. The efferent limb was tapered over a 12F catheter and, for most cases, brought out through the umbilicus. The ileocecal valve was plicated and slightly intussuscepted over an 18F catheter. A 10F catheter was left in the efferent limb in the postoperative setting as a mold. Appendectomy 0090-4295/02/$22.00 PII S0090-4295(02)01945-3 603
TABLE I. Indications for surgery Diagnosis
n
Bladder cancer Interstitial cystitis Spina bifida Neurogenic bladder Other
38 32 23 18 14
was routinely performed, and 10 to 12 cm of terminal ileum was isolated to form the efferent limb. A cecostomy tube, as well as ureteral stents, was also standard. The indications for surgery are seen in Table I. The demographic data on such a large group of patients varied, yet in general reflected a busy tertiary care center. All patients underwent instruction for pouch training and care by an enterostomal nurse, including catheterization and irrigation protocols. They were then seen in clinic for routine follow-up examination, laboratory tests, and radiographic evaluation (ultrasonography). A data sheet kept by our enterostomal therapist prospectively recorded the complications according to pouch, efferent limb, ureter, kidney, and non-pouch related. A tally of reoperations for each complication was also kept. The hospital clinical charts and departmental records were also reviewed in a retrospective manner, and complete data were available for 125 of the 129 patients. The remaining 4 patients were lost to follow-up with only scant reviewable data.
RESULTS Complete information was obtained for 125 of the 129 charts, with a mean follow-up of 41.1 months (range 3 to 127). Patients were followed up until their most recent clinic appointment, correspondence with a following community urologist, or the patient’s death. Long-term complications occurred in 112 patients (89.6%; several patients had more than one complication) with a mean onset of 20.4 months (range 3 to 125) postoperatively. Seventy-three complications (58.4%) were due to the efferent limb, of which, incontinence (defined as any leakage) was the most common (35 [28.0%]), followed by stomal stenosis in 19 (15.2%), and difficult catheterization in 12 (9.6%). Of the 26 pouch-related problems (21.8%) that occurred, the most common were stones in 13 (10.4%), perioperative leaks in 5 (4.0%), and perforations in 4 (3.2%). Ureteral anastomotic strictures were seen in 9 (7.2%). Other complications included gallstones in 32 (25.6%), kidney stones in 8 (6.4%), and small bowel obstruction in 6 (4.8%). Reoperation was performed in 65 patients (52.0%; several patients with more than one reoperation). Twenty-six of the patients (20.8%) required an open operation, and 39 (31.2%) received minimally invasive (percutaneous, endoscopic, extracorporeal shock wave lithotripsy) procedures. Sixty percent of the reoperations were minimally invasive. Reoperation was due to stomal stenosis in 18 (14.4%), pouch stones in 13 (10.4%), ureteral 604
strictures in 9 (7.2%), and parastomal hernias in 6 (4.8%). Small bowel obstruction required reoperation in 5 patients (4.0%). All complications are listed in Table II. COMMENT The modified Indiana pouch has been extensively used since its development in the 1980s.1 Most studies have reported low complication and reoperation rates. A comprehensive list of these reports can be seen in Table III.2,4 –10 It should be noted that the mean follow-up in these series was approximately 24 months. In our series, with a mean follow-up of 41.1 months, we had a considerably higher long-term complication rate (89.6%) and reoperation rate (52.0%). In reviewing our database, we were very complete in reporting any complication, and thus we listed any sequelae as a complication. Most of the complications were related to the efferent limb, which is the most delicate part of the reconstruction. Incontinence (defined as any leakage), stomal stenosis, and difficulty catheterizing accounted for two thirds of our complications. Certainly, stomal stenosis and difficulty catheterizing, as well as pouch stones and gallstones, are complications that become more frequent with time. Our overall continence rate of 71.8% is similar to the 69.0% found in the original report by Rowland et al.,1 but it falls below the 94% to 100% rate found in other series.2,4,7,8 In this study, we did not attempt to quantify or characterize the incontinence, and we may have overestimated the true incidence of clinically significant incontinence, as our revision rate for incontinence was only 4.0%. Gallstones and pouch stones were the next most common complications (not often tracked in other series). The incidence of pouch stones was 10% in our series of 125 patients, occurring on average more than 4 years after the initial surgery. Presentation included pain, UTI, incontinence, trouble catheterizing, and asymptomatic follow-up. All stones were readily diagnosed by plain abdominal radiography, intravenous urography, ultrasonography, or pouchoscopy. The stones were often multiple, and some were quite large. Endoscopic removal was usually successful, but open removal was required for larger stones not amenable to closed techniques. Analysis revealed compositions ranging from calcium apatite to struvite, with a mucous or staple nidus. A more complete discussion of these unique complications has been previously published.11 Our ureteral anastomotic complication rate of 7.2% was similar to the 7% reported in the series by Wilson et al.6 Even though the mean time to complication development was 20.4 months, 34% of the complications occurred after 24 months (average follow-up UROLOGY 60 (4), 2002
TABLE II. Long-term complications Patients (n)
Complication Pouch related Decreased pouch volume Perioperative pouch leak Pouch perforation Pouch stones Fistula Efferent limb Incontinence, total Incontinence, day Incontinence, night Parastomal hernia Difficult catheterization Stomal stenosis Ureter Reflux Ureteral stricture/obstruction Stones Kidney Pyelonephritis Kidney stones Renal insufficiency Hydronephrosis Non-pouch related Small bowel obstruction Adhesions Diarrhea Gallstones Vitamin B12 deficiency
Reoperations (n)
2 5 4 13 2
(1.6) (4.0) (3.2) (10.4) (1.6)
2 5 2 13 2
(1.6) (4.0) (1.6) (10.4) (1.6)
13 16 6 7 12 19
(10.4) (12.8) (4.8) (5.6) (9.6) (15.2)
3 1 1 6 2 18
(2.4) (0.8) (0.8) (4.8) (1.6) (14.4)
2 (1.6) 9 (7.2) 2 (1.6)
0 (0.0) 9 (7.2) 2 (1.6)
4 8 2 7
(3.2) (6.4) (1.6) (5.6)
0 2 0 0
(0.0) (1.6) (0.0) (0.0)
(4.8) (0.8) (2.4) (25.6) (7.2)
5 1 0 3 0
(4.0) (0.8) (0.0) (2.4) (0.0)
6 1 3 32 9
Numbers in parentheses are percentages.
TABLE III. Long-term complications in selected series Author Rowland and Kropp2 Bihrle4 Carr and Webster5 Wilson et al.6 Arai et al.7 Ahlering et al.8 Navon et al.9 Weijerman et al.10
Patients (n)
Follow-up
Complication (%)
Reoperation (%)
69 50 30 130 37 25 50 23
2 yr 2.5 yr 16 mo 1–16 mo 34 mo 3–12 mo 27.5 mo 41 mo
45 32 23 12 35 32 30 86
20.3 14 13 12 10.8 8 14 56
of other studies). Some categories of complications had an even longer latency period. For example, pouch stones had a mean presentation time of 49.5 months. In evaluating the individual complication categories, our experience was similar to that of many other reported series, but our overall complication rate was a bit higher. We believe that this was due to the cumulative effect of our comprehensive database and extended follow-up period. In terms of our higher reoperation rate, 60% were minimally invasive procedures (endoscopic, percutaneous, extracorporeal shock wave lithoUROLOGY 60 (4), 2002
tripsy), and the remainder required open abdominal surgery. One half of our operations were for stomal stenosis and pouch stones, which were easily managed on an outpatient basis. If we considered only our open reoperation rate of 20.8%, it was still higher than other series, but again our longer follow-up may account for this. The technique used in the construction of the continent diversion is a critical element in the development of complications. Modifications to our technique occurred slowly during the course of 14 years as experience was gained and represent 605
changes similar to those of other institutions. In the first 3 years, we formed the pouch with 30 to 32 cm of colon and subsequently reduced that to 26 to 30 cm secondary to difficulty with emptying and mucus accumulation. Initially, we used a tunneled nonrefluxing ureteral reimplantation, but later when the Le Duc technique came of age, we switched to it. We consistently used 8F pediatric feeding tubes as our ureteral stents. In terms of our continence mechanism, we used braided, nonabsorbable suture. Initially, we imbricated and intussuscepted our ileocecal valves aggressively. Later, we found that embrication with only a small degree of intussusception over an 18F catheter was successful. The efferent limb during our early experience was handsewn with 3-0 silk. With the advent of stapling devices, we began using GIA staplers over a 12F catheter. During the first 4 years, we brought the stomas out through the abdominal wall, but in the past 10 years we have used the umbilicus. We now leave a 10F catheter in the efferent limb as a mold in the postoperative setting. When comparing the complications of our first 7 years experience with those of the last 7 years, no appreciable difference could be seen in the specific complications. We believe our results with the evolving technique are an accurate representation of the complications that would be seen at any institution performing a similar number of the procedures, because our complication rates in each category closely paralleled those of other large series when broken down by specific complication (Table II). Twenty-five percent of our patient population carried the diagnosis of interstitial cystitis. Certainly this patient population has many physical and potentially psychological issues that could confuse the interpretation of complications. Yet, in a separate analysis of the quality-of-life data (soon to be published), this population benefited immensely from continent diversion. More importantly, they did not appear to have a higher complication rate. To remove this patient population from consideration in this study would only weaken any conclusions that might be drawn.
606
CONCLUSIONS In our experience, the long-term complications associated with the modified Indiana continent urinary reservoir were primarily related to the efferent limb, and reoperations were most often due to stomal stenosis. When stratifying by complication, our rates paralleled those of other series. However, our data suggest that with longer and more complete follow-up, the complication and reoperation rates appear to be higher than previously reported. This information is important to relay in counseling our patients (especially our younger patients). Verification of our findings from other series with long-term follow-up will be necessary to assess the durability and overall morbidity of this procedure. REFERENCES 1. Rowland RG, Mitchell ME, Bihrle R, et al: Indiana continent urinary reservoir. J Urol 137: 1136 –1139, 1987. 2. Rowland RG, and Kropp BP: Evolution of the Indiana continent urinary reservoir. J Urol 152: 2247–2251, 1994. 3. Rowland RG, Webster GD, and Goldwater B: Right colon reservoir using a plicated tapered ileal outlet, in Urinary Diversions: Scientific Foundations and Clinical Practice. Oxford, Isis Medical Media, 1995, pp 229 –235. 4. Bihrle R: The Indiana pouch continent urinary reservoir. Urol Clin North Am 24: 773–779, 1997. 5. Carr LK, and Webster GD: Kock versus right colon continent urinary diversion: comparison of outcome and reoperation rate. Urology 48: 711–714, 1996. 6. Wilson TG, Moreno JG, Weinberg A, et al: Late complications of the modified Indiana pouch. J Urol 151: 331– 334, 1994. 7. Arai Y, Mutsushi K, Terachi T, et al: Long-term followup of the Kock and Indiana pouch procedures. J Urol 150: 51–55, 1993. 8. Ahlering TE, Weinberg AC, and Razor B: A comparative study of the ileal conduit, Kock pouch, and modified Indiana pouch. J Urol 142: 1193–1196, 1989. 9. Navon ND, Wong AK, Weinberg AC, et al: A comparative study of postoperative complications associated with the modified Indiana pouch in elderly versus younger patients. J Urol 154: 1325–1328, 1995. 10. Weijerman PC, Schurmans JR, Hop WC, et al: Morbidity and quality of life in patients with orthotopic and heterotopic continent urinary diversion. Urology 51: 51–56, 1998. 11. Holmes DG, Park GY, Thrasher BJ, et al: Incidence of cholelithiasis in 125 continent urinary diversions. J Urol 165: 1897–1899, 2001.
UROLOGY 60 (4), 2002