From the Division of Urol%Lv, Department of Surgery, National ~hng-Ming Medical College, and Veterans Gene,ral Hospital, I " e" 2alp :,i, 'Ihiwan, Republic of China

ACT--Kock continent ileal reservoir for urinarg diversion was performed in 53 patients. ~asive bladder cancer (52) or neurogenic bladder (1). The postoperative,follow-up period m six to thirty-nine months, Th,e clinical results showed no metabolic daturbanc, e Of blood lyres or acidity. Prolapse o/f e~]erent rdpple valve developed in 4 patients (7.6%); and 2 ~ent revi,sional surgery with a good result. Another 4 patie*,tts (7.6 %) suffered from poor rice arm relatively frequent catheterization to empty the pouch was necessary to prevem •akae,, through the stoma. Urodynamic study of th,e Koek pouch in these 4 patients showed a tnetiona! nipple valve length and small pouch capacity. 7"he other 45 patients~(84.8 %) had intinunce. Urodynamie stud*] oj the pouch in 20 patients showed tow pressure (mean qf 13,,3 )) in the pouch and h,igh pressure (mean o)r 72.1 cm II20) at the efferent nipple valve. Three s,had unilateral hydronephrosh" in the follow-up intravenous urography. Corrective surgery ~osqsat the right ureteroih, al anastomosis "was done in 1 patient with normalization off the Innar~d tract afterward. The other 2 patients were managed by close observation ,for the mild ephro.sis. Symptomatic bacteriuria developed in only 3 patients (5.7 %) and responded well !iotic management. Beservoirography demonstrated no rGfIux into the upper urinary tract in ~ollow-~p patients. There was no significant change Of the renal ]unction at twenty@)ur after operation detected by radiomwlide, (laiI-Hippuran renal;functional ,s'tudy. AII patients :tisfied with Kock urinary diversion. ) •,



ent ileal reservoir has gained among urologists and patients t reported by Kock and coIt provides continence arid d~ereby providing a better the patients. For investigation surgical technique of urinary trted to perform Koek pouch urinary diversion in June, ~linical results (including urof the pouch and radionuclide tidy) showed the Koek pouch 1 was promising. Herein we at experience of urinary diver::ontinent ileal reservoir in 53

APEII~ 1990



Material and Medlods From June, 1984, to Februar> 1987, we performed 53 Kock continent ileal reservoirs for urinary diversion in 52 patients wRh invasive bladder cancer and 1 patient with neurogenie bladder. There were 47 males and (3 females beb,veen the ages of nine years and seventy-five years with a mean of 58.6 years, The surgical technique described by Koek et at. ~ was for lowed, w e used 7 F in diameter and 90 cm in length silicone single "J" for bilateral tlreteral stenting. Before at~ operation, laboratory examinatioils ineluding hemogram, serum blood urea nitroten (BUN), e~reatmme, ' " electrolytes, vitamin 317

B~,, folie acid, and blood gas analysis were checked. Radionuelide (*a~I-Hippuran) renal function study was also done. Surgieal principles for postoperative care were followed after the operation. The 2 single "J" ureteral stents were removed at postoperative day 10. The reservoir eatheter was clamped intermittently if reservoirography which was done two weeks after operation showed no leakage from the poueh. The patient was taught to do self-catheterization for emptDng the reservoir, usually three weeks after operation. At this time, the serum bioehemistr',; vitamin B12 and folie acid and blood gas were rechecked. In addition, urodynamie study to measure the intrapouch pressure and efferent nipple valve pressure profile including maximal nipple pressure, maximal nipple elosure pressure, and functional nipple length was done. The mmximal nipple pressure was defined as the maximal pressure along the nipple valve. The m ~ i m a l nipple closure pressure was defined as maximal difference b e t w ~ n nipple pressure and intrapoueh pressure. The patients were followed up on an outpatient basis every one to two months at the patient's convenience. We asked the frequency of catheter emptying of the pouch and the amount of urine at each catheterization. Also we checked the continence of the iteostomy stoma by direct observation to see whether or not urine leaked. The serum BUN, creatinine, dectrolytes, xdtamin B~a, folie aeid were examined every three months. Radiologic evaluation by intravenous urography and reservoirography was checked every six months. Endoscopy of the pouch with biopsy of the ileal mueosa was performed every six months for checkup of possible stone formation and mueosal change. A radionuelide renal funetion study was repeated at one month and every six months after operation. A urodynamie study of the pouch was done every six months after operation. The urine from the pouch was sent for bacterial stu@ every three months. Resutts The period of postoperative follow-up was from six to thirty-nine months, with a mean of 21.4 months. There was no operative mortality. Early complications occurred in 9 patients (%ble I). One patient had severe urine leakage at the left ureteroileal anastomosis, and an immediate surgical repair was mandatory. The


TAm~: I.

Complications after Ko& urinary] dit;ersion


Left ureteroileal anw~tomotie leakage Wound infection Wound disruption Severe reservoir and urinary tract fungus infection Persistent lymph and peritoneal fluid leakage for 1 month LATE COMPLIC~CrIONS

Prolapse of efferent nipple valve Stenosis at right ureteroileal anastomosis resulted in marked hydronephrosis Parastomal hernia Poor continence Intestinal obstruction No easy catheterization into poueh

leakage stopped and the upper u turned to normal after repair. ' fection, which occurred in 4 pat: well to dressing change and anti| merit. ~P,vo patients had wound a heavy abdominal strain and t( days to have wound healing aft management. One patient with tus suffered from fungus infeetic and urinary tract. After intrap, and intravenous injection wi drugs, patient's infection subsk lymph and peritoneal fluid leaf in 1 patient, and it was spontane one month after operation. Late complications occurred (Table I). Prolapse of the efferm was found in 4 patients (7.6%) patients underwent revision ot with a good result. Another pati disease about sixteen months at The remaining patient was on t for revisionai surger> There-w~ the anastomosis between the ri$ the inlet segment resulting in phrosis in i patient about five operation. Corrective surgery fi was performed with norrnalizatk urinary tract. Parastomat hernia {ltOLOCY


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_..:.....i ....pair was performed with ]tinenee was experienced sly of the pouch in these functional nipple length a small pouch eapacit> :he efferent nipple valve the continence. One paestinal obstruction at six m. A lysis of adhesion leased the obstruction efs complained of a 1Rtle ing into the pouch. Some :t from the stoma to the J. After gentle digital exn of the exact tract from r could be inserted easily nine, electrolytes which ;6 patients in the follownormal limits. Blood gas tents also was within norerative follow-up serum I showed within normal ts examined. ~nch was performed in 16 :mation at the staple site J in half of all the followpieally the ileal mucosa de change and no mawas demonstrated iIl the patients, only 3 suffered ms. All responded well to atinent in 49 patients. }aeity at six months after mately 500 mL, and the .}ouch by eatheterizing it Poor continence was ex;. They had to catheterize frequently to prevent :h the ileostomy stoma. )It length (less than 2.5 ~apacity was fo,tnd in the he 4 poorly continent pat patients with prolapsed nts with poor continence, netion of lhe efferent nip-cent (8/53). Urodynamic ~mh at three to thirty-six n in 20 patients demon(mean of 13.3 cm tL:O) in [e maximal nipple closure 8 em H~eO) arid maximal APf¢H~ 1 9 9 0

\ O I . U M E XXXX&N[ MBER 4

nipple pressure (mean of 72.! cm H~O) at efferent nipple valve, l~ A radionuelide renal function study done in 25 patients showed no significant change of total renal function at twenty-four monl:hs after operafion, > Intravenous urography demonstrated unilateral hydronephrosis down to the ureteroileal anastomosis in 3 of 45 patients. As mentioned, I patient received revisional surgery with a good result and the other 2 patients were managed by close observation for mild hydronephrosis; follow-up radiologic examinations demonstra[ed ~he upper urinary tract was not getting worse, fieservoirography was done at a variable follow-up period, which showed no reflux from the pouch to the tipper urinary tract in atl 3I patients examined. Corn m ent Conventional urinary diversion using iteal conduit had two major disadvantages: ileoureferal reflux and urine incontinence. The fl° eoureteral reflux would result in ascending urinary tract infection and deterioration of renal function, ~:~ and urine incontinence made the patient carry ar~ external appliance ineonvenientl?: Since the innovative breakthrough of the surgical technique for urinary diversion was first developed by Koek, ~ Lhe disadvantages of ileal conduit have been eliminated. The Koek continent ileal reservoir usually provides continence and prevents reflux. ~'4~' In this study, urine contineaee was achieved in the majority of the patients. Though 4 of alt the patients suffered from prolapse of the efferent nipple valve, the surgical result of revision of the nipple wflve was good in 2 of 4 patients. Another patient died of disease and the remaining patient was waiting for repair. With growing experience and adapting the modified technique for fixing the nipple vaive,>; ~he incidence of desuseeption of the nipple v~ve should be deereased. The ineidenee of poor continence due to the efferent nipple valve disorder (e.g., shortened nipple valve Iengeh) would also decrease as well. The volume capaeRy of the pouch could reach 500--{300 mL within six months after operation. This finding is almost ~he same as that in Koek's series. 4 Though higher incidence of bacteriuria (80 %) was noted in our patients as compared with that in Koek's series, 4 onty 3 had symptoms develop and they were managed 31(j

effectively with antibiotics. By properly emptying the pouch to decrease the residual urine, the relapse of symptomatic bacteriuria could be avoided. I)uring follow-up period, if the intravenous urography demonstrated marked hydronephrosis down to the ureteroileal anastomosis, revisional surgery was required to normalize the upper urinary tract. The reservoirography showed no reflux fiom the pouch to the upper urinary tract in all patients examined. Also most of o;lr patient,,; had no dilatation of upper urinary tract on the intravenous urography fihns. These probably w e r e relevant to no change of renal fimction at twenty-four months after operation determined by radionuelide stud?< When fl~e urine was stored in the intestine instead o; urinary bladder, harmful reabsorption of the electrolytes and water sometimes resuited in eleetrolyle imbalance or change of blood aei~ty and caused much concern. Metabolic disorder was not found in any of our patients. This may be owing to the structural change of the ileal mueosa to decreased absorption and mucus excretion 4 though it was not demonstrated in endoscopic biopsy of the ileal mueosa of the pouch in our patients. Because the pouch was constructed by using a rather long segment of the ileum near the ileoeeeal junction, we were also concerned about the possible inadequate reabsorption of vitamin B,s and folio acid. The blood level of vitamin BI2 and folie acid was still within normal range in aI1 of our patients, even at thirty months after operation in some of the patients. ~Ib avoid the impedance of the drainage of the upper urinary tract, it is important to have the pressure in the pouch low. Also low pressure in the pouch could prevent continuous force against the nipple valves. Thereby the incidence of desuseeption of the nipple valve is minimized. The manometry of the pouch in our patients demonstrated a low pressure (mean of 13.3 em H.20) in the reservoir which was ahnost the same as that reported by Berghmd s or Nor& gren ;~ and their co-workers. In measuring the nipple pressure profile, a high pressure zone was recorded at the efferent nipple vMve area with a mean maximal nipple pressure of 72.1 cm H,20. ~ This value along with the low intrapouch pressure was found to have a great con[ribution to the continence that was provided by the pouch.


Low pressure in the pouch als< storage of the urine. The pouch enlarged as increasing amounts c into the pouch. In most of om pouch eapaeiey at six months was approximately 500 mL wh larger than that at three weeks (about 100 mL). Though the construetion of tt for urinary diversion is a time-co cal technique, the operating tirm ened as experienee accumulates the most postoperative trouble~ tion in regard to the malfunctio~ valves can be prevented by the fled teehnique for better and too! of the nipple vah es. The patient' improved. All of our patients with Kock pouch urinary diw they did not need to carry an exte and were able to enjoy their daft We are encouraged to continue t continent ileal reservoir as a bett urinary diversion procedure.

(DR, Reference,s 1. Koek NG, et ah Urinary diversion vi~ voir: clinical results in 12 patients, J tyrol la. Ct~en KK, Chang LS, and Chen clinieal out~:ome of Koek pouch continm Urol 141:94 (1989}. lb. Chen KK, et al: Prospective radio evaluation and its correlation with radiolo~ with Koek pouch urinary diversion (abst 244A (1988). 2. Philip NH, Williams JL, aml By~ urinary diversion: long-term follow-up it:

515 (1%0).

3. Orr JD, Shand JEG, Watters DAK, conduR uriuary diversion in ehiIdren. An term resut¢, Br J Urol 53:424 (1981). 4. Koek NG, Norlen L, Philipson BM, continent ileal r~ervoir (Koek pouch) World J Uro! 3:146 (1985). 5. Skinner DG, Boyd SD, and Lie.sko~ rienee with the Kock continent ileal reset zion, J Urol Iag.: 1101 (1984). 6. Gerber A: The Koek continent ileal : eat urhmry diversion, Am J Surg 148:15 t 7. Gerber A, Apt MK, and Craig PH: ' eostom3~ Stag Gyneeol Obstet 156:345 (1 8. Berghmd B, Koek NG, Norlen L, a ume capacity and pressure charaeteristi::s reservoir used t:or urinary diversion, j Uro 9. Nordgren S, Cohen Z, Creig PD, aI sure studies on the ermtinent reservoir ile Obstet 155:646 (1982).



AP1{IL 1990 /


Clinical experience of Kock pouch continent urinary diversion.

Kock continent ileal reservoir for urinary diversion was performed in 53 patients with invasive bladder cancer (52) or neurogenic bladder (1). The pos...
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