Technique of Creation of a Continent Internal Ileal Reservoir (Kock Pouch) for Urinary Diversion

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duced in 1973 by Opelz and Terasaki. Despite uncertainty as to its mechanism of action, and the optimal number and timing of transfusions, most transplantation centers now recommend deliberate transfusion of 5 to 10 units of blood containing viable leukocytes before cadaveric transplantation. The difference in 1-year cadaveric graft survival between patients receiving more than 10 transfusions and those receiving none was 60 per cent, with the former group having a 90 per cent graft survival. Despite its efficacy, this procedure does have some inherent risks, including the transmission of cytomegalovirus infection or nonA nonB viral hepatitis and humoral sensitization against potential donors. The latter risk may be high in multiparous women and patients who have had previous transplantation. Over-all, less than 5 per cent of the patients acquire widely reactive antibodies that would tend to preclude future transplantation. To obviate this difficulty, it has been suggested that azathioprine be administered along with the transfusions to reduce the risk of sensitization. Furthermore, the use of donor specific blood transfusions before transplantation appears to have a useful role in promoting the success of 1-haplotype, high mixed lymphocyte response living related donor recipient pairs. Another major advance in transplantation immunology has been the widespread use of more sensitive cross match techniques that allow the examination of previous and current serum specimens for humoral pre-sensitization. This type of investigation has revealed the diversity and functional heterogeneity of the various antilymphocyte antibodies. It generally is agreed that warm-reactive antibodies of the immunoglobulin G type, which are directed against T-lymphocytes, pose the major threat of transplant rejection. More than 30 per cent of all patients awaiting cadaveric transplantation are sensitized to more than 90 per cent of HLA antigens. Despite attempts to minimize sensitization during blood transfusions and an improving survival of first grafts, it is probable that transplantation in many of these patients shall remain impossible. Prednisone and azathioprine have been mainstays in clinical transplantation and immunosuppression since 1962. Another major development in the evolution of transplant immunology has been the more enlightened use of prednisone. Acute rejection episodes will occur in about 90 per cent of all cadaveric transplant recipients. High doses of steroids can reverse such episodes but in half of these patients the reversal is only transient. Further treatment with high dose steroid therapy may prolong graft survival but its toxicity renders continuation of such therapy futile and dangerous. Most transplant centers now limit pulse steroid therapy to 2 or 3 attempts. This approach has prolonged patient survival markedly and decreased morbidity by minimizing steroid-induced morbidity. Also important has been the realization that low dose or alternate day steroid therapy can be effective in the long-term maintenance of the graft. Naturally, the infectious and metabolic complications attendant to steroid therapy have been much reduced with this approach. Despite the more intelligent use of conventional immunosuppression, 1-year cadaveric graft survival remains suboptimal. Survival has been improved somewhat by the use of antilymphocyte antibodies. First introduced by Starzel in 1966, these antibodies are directed against lymphocyte surface antigens and are obtained from the sera of animals immunized with human lymphoid cells. Such preparations are termed antilymphocyte globulin and probably exert their effect through complement-mediated lymphocyte cytotoxicity. A 15 to 40 per cent improvement in 1-year graft survival for patients who received prophylactic antilymphocyte globulin in combination with im-

munosuppression has been demonstrated. Furthermore, antilymphocyte globulin may be used alone or in combination with pulse steroid therapy in the treatment of acute rejection episodes. In this regard antilymphocyte globulin appears to be equivalent to prednisone in its efficacy. The use of antilymphocyte globulin is not innocuous and has been associated with fever, mild thrombocytopenia, leukopenia and a serum sickness type reaction. This additional immunosuppression also increases the number of infections due to the family of herpesviruses. The major drawback to antilymphocyte globulin therapy is the variable efficacy and safety of the antibodies produced by various animals. The production of monoclonal antilymphocyte antibodies using hybridoma technology soon will allow uniformity of preparation and reliable product purity. Perhaps the most recent landmark development in transplantation immunosuppression was the introduction of cyclosporin to clinical use in 1978. The efficacy of this fungal peptide centers around its ability to block the production and the release of interleukin-2 from helper T-lymphocytes, thus, blunting the generation of cytotoxic T-cell subsets. Cyclosporin has been used in conjunction with low dose steroid therapy for recipients of cadaveric and 1-haplotype-matched living related transplants. Most studies have shown consistent enhancement in early graft survival of 10 to 20 per cent. With the addition of cyclosporin, lower cumulative steroid doses are required, thus, minimizing the toxic effects and infectious episodes. Areas of uncertainty include 1) the difficulty distinguishing cyclosporin-induced nephrotoxicity from rejection, 2) the possibility of drug-induced interstitial fibrosis and progressive renal insufficiency, 3) dose-dependent liver injury, 4) potential carcinogenesis and 5) high cost. Other areas of investigation on the horizon that may have additional efficacy include total lymphoid irradiation, prophylaxis of cytomegalovirus infection, immunological methods to overcome humoral pre-sensitization and development of organsharing programs among many transplant centers that would enlarge the supply of suitable cadaveric donor organs. There is little doubt that living related donor transplantation has distinct advantages over maintenance hemodialysis in the treatment of chronic renal failure. A distinction between cadaver transplantation and dialysis is more difficult primarily because differences in survival for comparably matched groups are relatively small. As a result, patient selection should be based primarily on the assessment of the quality of life offered by each modality. It would seem that most young and middleaged patients should consider cadaveric transplantation. Present and future developments in the area of transplant immunosuppression may allow for the greater applicability of this form of therapy. J. M. K. 3 figures, 49 references

DIVERSION Technique of Creation of a Continent Internal Heal Reservoir (Kock Pouch) for Urinary Diversion D. G. SKINNER, G. LIESKOVSKY ANDS. D. BOYD, Division of Urology, Department of Surgery, University of Southern California Medical Center, Los Angeles, California Urol. Clin. N. Amer., 11: 741-749 (Nov.) 1984 Kock and associates have made a major contribution to the urological surgical armamentarium by developing a method to

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create a continent internal urinary reservoir out of ileum (Scand. J. Urol. Nephrol., suppl., 49: 11 and 23, 1978). 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 (J. Urol., 128: 469, 1982). This innovative procedure now offers patients requiring cystectomy for bladder cancer or cutaneous urinary diversion for any reason an alternative to the standard ilea! conduit, which requires an external appliance. The authors have used the technique described originally by Kock and associates and have made what they believe to be some important modifications. From August 1982 through January 1984 the procedure was performed in 51 patients. The preliminary results with the Kock pouch indicate that the procedure is one of the most innovative advances in the field of urinary diversion. It 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 ilea! mucosa used in the pouch appears to adapt well to urine with decreased villus height, and in time a nearly flat mucosa emerges that may decrease absorption. To date, no evidence has been seen of late fibrosis, or adverse changes in the morphology or function of the intestinal wall. The continent internal ilea! reservoir as developed by Kock and associates is an important new addition to the urological surgical armamentarium and offers an alternative to the patient who requires cutaneous diversion. A complete bibliography is included with this article, listing all reports on the Kock pouch to date. Surgeons contemplating performing this procedure should familiarize themselves thoroughly with the clinical and experimental experience to date. The majority of potential candidates for the Kock pouch 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. The major argument against aggressive surgical management in patients with invasive bladder cancer has been that an operation required a permanent ileostomy and the need for an external appliance. Therefore, many patients and physicians have chosen definitive radiation therapy as primary treatment despite its lack of proved efficacy. The experience reported has been that quality of life issues are extremely important in the selection of therapeutic options, and a continent internal urinary reservoir offers a considerably better self-image than an external appliance. Therefore, the development of a continent internal reservoir as an alternative to the standard ilea! conduit might have a significant impact on the treatment of the estimated 10,000 patients who are diagnosed in the United States each year as having invasive bladder cancer. G. P. M. 9 figures, 16 references

ANDROLOGY Fertility Prospects for Children With Cryptorchidism P. E. GILHOOLY, F. MEYERS AND J. K. LATTIMER, Pediatric

Urology Service, Squier Urological Clinic, Babies Hospital, Columbia-Presbyterian Medical Center, New York, New York Amer. J. Dis. Child., 138: 940-943 (Oct.) 1984 The authors surveyed 231 of 800 patients with cryptorchidism treated between 1936 and 1968. Of 145 married patients 45

had been treated for bilateral and 100 for unilateral cryptorchidism. There was no difference between the fertility rate of patients with unilateral cryptorchidism and the general population, regardless of age at operation. Among the patients with bilateral cryptorchidism the paternity rate tended to decrease as the age at operation increased. The paternity rate of patients with unilaterally undescended testes was 80 per cent, compared to 35 per cent for those with bilaterally undescended testes. Although at variance with other series, these data suggest that most patients with unilateral cryptorchidism have a normal contralateral testis. G. W. K. 1 figure, 2 tables, 39 references

Editorial comment. The authors have assessed the contention that a defect may exist in the contralateral scrotal testis of children with unilateral undescended testis by means of chart reviews and recording paternity rates. Of the survey responders the paternity rates of individuals with corrected unilateral and bilateral descended testes were 80 and 35 per cent, respectively. The timing of operation did not seem to affect the fertility rate in the unilateral group but an operation was performed later, on the average, in the bilateral cryptorchidism group in which the paternity rate decreased as the age at operation increased. The incidence of fertility in individuals with uncorrected unilateral cryptorchidism was approximately 40 per cent. The authors conclude that children with unilateral undescended testis have no intrinsic or inherent decrease in future fertility unless correction of the undescended testis is delayed markedly when fertility becomes reduced and approaches that of children with corrected bilateral undescended testes. They believe that children with bilateral undescended testes constitute a different group, often with an inherent spermatogenic deficiency that is superimposed upon the anatomical abnormality of maldescent, or perhaps a cause of the failure of the testes to descend. The authors have shown that fertility in children with corrected unilateral undescended testis is similar to that found in the normal population. However, the contention that a contralateral testis may be defective in parameters other than clinical fertility was not assessed. M. M.

PEDIATRIC UROLOGY Newborn Circumcision: An Economic Perspective D. CADMAN, A. GAFNI AND J. MCNAMEE, Departments of Pediatrics, and Clinical Epidemiology and Biostatistics, McMasters University, Hamilton, Ontario, Canada and Leon Recanati Graduate School of Business Administration, TelAviv University, Tel-Aviv, Israel Canad. Med. Ass. J., 131: 1353-1354 (Dec. 1) 1984 The authors performed a cost-benefit analysis of newborn circumcision in the hope of establishing a threshold amount of benefit, measured in dollars, that would justify the procedure on economic grounds. The dollar cost of the procedure averaged $38.32 per circumcision. The cost of circumcising 100,000 infants was slightly more than 3.8 million dollars. The incidence of carcinoma of the penis is 2 per 100,000 patients. The cost of treatment and lost earnings for a case of carcinoma of the penis in a 50-year-old man is $103,000. The authors conclude that the monetary benefit of circumcision in newborns greatly exceeds this figure and, therefore, no economic benefit accrues to