Nils G. Kock

Urinary Diversion Via a Continent Ileal Reservoir: Clinical Results in 12 Patients

Urinary diversion via a continent ileal reservoir has been performed in 12 patients. An isolated ileal reservoir was constructed using the technique described for patients with a continent ileostomy. The ureters were implanted into an afferent segment provided with a reflux-preventing nipple valve. There were few operative complications and no operative mortality. Late complications involving malfunction of the nipple valves occurred in 8 patients and were corrected surgically. Postoperative followup presently is between 9 months and 6 1/2 years. Two patients have died: 1 in an accident and 1 of metastatic bladder carcinoma. The remaining 10 patients are continent and without reflux to the upper urinary tract. The reservoir generally is emptied by intermittent self-catheterization between 3 to 6 times daily. The volume capacity of the reservoir is more than 500 ml. Urinary cultures have been constantly negative in 7 patients and the contents of the reservoir more or less permanently contained bacteria in 5. Dilatation of the upper urinary tracts, progressive renal deterioration or metabolic disturbances have not been encountered. All patients are satisfied with this type of urinary diversion, especially those who have undergone other types of diversion previously.

Replacement of the Bladder by the Urethral Kock Pouch: Functional Results, Urodynamics and Radiological Features

After cystoprostatectomy for cancer of the bladder 43 men were provided with a detubularized, low pressure ileal reservoir (Kock pouch) connected to the urethra. Reflux was prevented by an intussusception valve. There was no operative mortality and few early complications. At followup the mean postoperative observation time was 13 months, with a range of 5 to 20 months. Late complications included manifestations of local tumor recurrence or distant metastases in 9 patients within 6 months postoperatively, which made adequate functional evaluation impossible. In 18 patients reflux to the upper urinary tract due to eversion or sliding of the antireflux valve occurred at various postoperative intervals. In 16 of these patients incontinence developed as a consequence of the reflux. Surgical correction of the failing antireflux valve restored reflux prevention and continence. Within 3 to 6 months the capacity of the reservoirs had reached an ultimate volume of approximately 600 ml. Pressure waves exceeding 40 cm. water seldom occurred in the mature reservoirs and then only at high filling volumes. The mean urethral resting resistance to flow was 64 cm. water. The configuration and function of the upper urinary tract improved or stabilized postoperatively. Of 34 evaluable patients 30 were continent during the day with a voiding frequency of 3 to 5 times and dry at night with a frequency of 0 to 2.

Further experience with the urethral Kock pouch

In 185 men a urethral Kock pouch was constructed as a bladder substitute after radical cystectomy for cancer. A total of 117 patients was followed for a minimum of 1 year and is fully evaluable. Of the patients 108 (92%) are completely continent during the day, while 85 (73%) are dry at night. Also, 8 patients had an excellent response to imipramine hydrochloride. Stability or improvement in the configuration of the upper tract was noted in 210 renal units (90%). A total of 24 renal units showed evidence of deterioration due to reflux (16) and an anastomotic stricture (8). Stability of the antireflux nipple valve was ensured by creation of a window in the mesentery of the corresponding bowel segment and by anchoring the valve to the wall of the pouch by an additional row of staples. On the basis of this favorable outcome the procedure is recommended for male patients for whom cystectomy is indicated and in whom the urethra can be preserved.

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

We followed 17 patients who underwent urinary diversion via a continent ileal reservoir (Kock pouch) with yearly examinations for 5 to 11 years postoperatively. The examinations involved control of renal function and configuration of the upper urinary tract. In 5 patients the upper urinary tract had become dilated during followup and in 2 of these renal scarring also had developed. All 5 patients had endured temporary outflow obstruction or reflux (stricture, overdistension of the reservoir or a defective antireflux valve). Of the patients 1 had a marked decrease in renal function before the outflow obstruction was corrected by an operation. Routine blood chemistry study was normal and hyperchloremic acidosis was not noted in any patient. After peroral loading of 6 patients with ammonium chloride significant excretion of titratable acid was found in the urine. Substitution with vitamin B12 was given to 6 patients due to subnormal values in 2 and borderline values in 4.

Urinary Diversion to the Augmented and Valved Rectum: Preliminary Results with a Novel Surgical Procedure

A new method for urinary diversion to the rectum was elaborated in animal experiments and currently has been used in 19 patients. Reflux of the rectal content to the colon and to the upper urinary tract is prevented by the fashioning of an intussusception valve at the rectosigmoid junction. The rectum is augmented by anastomosing an ileal patch to the anterior rectal wall. A transverse colostomy protects the construction for 6 to 8 weeks. Of the 19 patients 3 had local recurrence or metastasis within 6 months. Thus, 16 patients with a followup of 3 to 14 months are evaluable. All patients are continent during the daytime with an emptying frequency of 3 to 5 times and dry at night with a frequency of 0 to 2. In 3 patients partial sliding of the sigmoid intussusception valve occurred causing reflux of rectal contents to the sigmoid and to the right ureter in 1. Reflux to the upper urinary tract has not been revealed in any of the other patients. With 1 exception excretory urography has demonstrated either improvement or stabilization of the upper urinary tract post-operatively. The rectal capacity increased from 200 to 700 ml. after 6 months. With the reservoir full the mean basal pressure was 17 cm. water and the mean maximum pressure was 24 cm. water.

An Appliance-Free, Sphincter-Controlled Bladder Substitute: The Urethral Kock Pouch

A modified Kock pouch was constructed in 16 patients with cancer of the bladder in whom cystoprostatectomy was indicated. Surgery entailed creation of a Kock pouch with 1 valve for prevention of reflux. The pouch then was anastomosed to the urethral stump. There was no operative mortality. Followup ranged between 3 and 9 months. Excretory urograms revealed excellent upper tract function and good evacuation of the pouch with minimal residual urine. Urodynamic studies demonstrated a volume capacity of greater than 300 ml., with pressures of less than 40 cm. water. All patients were continent during the day. Nocturnal enuresis was observed in 4 patients, 3 of whom responded favorably to I-desamino-8-D-arginine vasopressin therapy. The procedure is suitable whenever the urethra can be preserved after cystectomy for cancer.

Volume Capacity and Pressure Characteristics of the Continent Ileal Reservoir Used for Urinary Diversion

The volume capacity and the pressure characteristics of the continent ileal reservoir for urinary diversion were studied at specific intervals postoperatively in 26 patients. The reservoir volume increased during the first year postoperatively from approximately 100 ml. at operation to a mean of 735 ml. and then remained stable during an observation period of up to 7 years. The basal pressure increased during filling from 0 to about 10 cm. water. During physiological conditions, that is when the reservoir was filled by diuresis, the basal pressure was equal to those pressures measured during saline infusion at corresponding reservoir volumes. Calculation of the magnitude of motor activity by 2 different methods showed a significant decrease in activity at 12 months compared to at 2 months after construction of the reservoir. Data from the continent urostomy reservoir were compared to corresponding data from the continent ileostomy and cecal reservoirs for fecal diversion, these being obtained in previous studies in our laboratory. The ileal reservoirs used for fecal or urinary diversion were practically identical with regard to volume capacity, basal pressure and motor activity. However, the cecal reservoir had a significantly lower volume capacity and higher basal pressure at corresponding reservoir volumes, while the motor activity was approximately 10 times greater than in the ileal reservoir. The results indicate that with regard to volume capacity and pressure characteristics the ileal reservoir is superior to the cecal reservoir as a receptacle for urine.

Intra-abdominal “Reservoir” in patients with permanent ileostomy

SummaryPreliminary experience with a new type of ileostomy provided with an intraperitoneal reservoir is presented.By splitting the distal part of the ileum at its antimesenteric border and folding the split intestine twice, a bladder-like container is formed by suturing the edges of the intestine. In this type of reservoir the motor activity in the different parts of the intestine counteract each other and no pressure waves appear on filling the reservoir. The outlet of the reservoir passes obliquely through the rectus muscle which closes the outlet so that no involuntary flow through the ileostomy is possible, either during rest or during coughing or straining. The capacity of the reservoir is between 300 and 600 ml, depending on the length of intestine used for the construction of the reservoir.To date, five patients have been provided with this type of ileostomy after panproctocolectomy for ulcerative colitis, and the results obtained from these patients are very encouraging. The patients empty their reservoir one to four times every 24 hours by inserting a plastic tube through the ileostomy. There is no involuntary flow of intestinal content through the ileostomy.

The quality of life after proctocolectomy and ileostomy: A study of patients with conventional ileostomies converted to continent ileostomies

SummaryA questionnaire was sent to ten patients who had had conventional ileostomies converted to continent ileostomies. The first part of the questionnaire was concerned with the function of the continent ileostomy. In the second part, the two types of ileostomies were compared with regard to functional aspects and their influences on the daily lives of the patients. When the patients compared the situation with the conventional ileostomy to the situation with the continent ileostomy, it was found that the conventional ileostomy influenced the daily lives of the patients much more than generally has been recognized, and also that successful conversion to the continent ileostomy eliminated most of the drawbacks of the conventional ileostomy.

Sexual adjustment in ileostomy patients before and after conversion to continent ileostomy

Questionnaires were sent to 48 ileostomy patients to evaluate the effects on sexual life of an ileostomate before and after conversion to a continent ileostomy. Forty-two patients (88 per cent) returned their questionnaires. Ninety-eight per cent of the patients had sometimes felt embarrassed, uncertain or inhibited by the conventional stoma, whereas only 24 per cent had these reactions after conversion to a continent ileostomy. About 80 per cent of the patients thought that the conventional ileostomy disturbed their sexual life because of the risk of leakage, odor, noise or because it was a physical hindrance, but no patient attributed such inhibitory influence to the continent ileostomy. Four men (31 per cent) and 15 women (52 per cent) reported that their sexual activity was reduced or absent when they had their conventional ileostomy. After conversion to a continent ileostomy all but one man and one woman considered their sexual activity to be normal. One-third of the patients claimed that the partner was embarrassed by the conventional ileostomy, but no partner admitted a negative reaction towards the continent ileostomy. Conversion to a continent ileostomy improved the quality of sexual life in about 85 per cent of both men and women.