非失禁型尿路変向患者の術後問題点とそのケアー

Abstract

1)Kock pouch(K群) 124例, Indiana pouch(I群) 51例, 虫垂臍ストーマMainz pouch(M群) 4例について検討した. 2)手術関連死はK, I群各2例であった.早期合併症は創感染15例, イレウス5例にみた. 3)晩期合併症は, K群(108例)で輸出脚不全18例, 輸入脚不全23例, ストーマ狭窄7例等, I群(47例)では, ストーマ狭窄3例, パウチ変形, 導尿困難各2例であった. 4)晩期合併症に対する修復再手術は, それぞれ22例, 5例に施行された. 5)結石形成は, K, I群でそれぞれ30例, 3例であった. 6)M群では晩期合併症は認めていない. 7)尿禁制はK, I, M群でそれぞれ90.2, 93.0, 100%で得られ, 水腎症はそれぞれ41.0, 9.5, 0%にみられた

A self-catheterizable continent urinary reservoir has become one of the major options for urinary diversion in patients with invasive bladder cancer or other pelvic malignancies. We performed the Kock pouch, the Indiana pouch and the appendiceal Mainz pouch in 124, 51 and 4 patients with the mean followup periods of 50, 33, and 10 months, respectively. In the Kock pouch, the efferent and afferent nipple valve malfunction was seen in 16.7 and 21.3 percent each, requiring repair surgery, such as fixation of the efferent nipple to the pouch wall, reconstruction of an isoperistaltic nipple valve in the former, and removal of the Dacron fabric collar or re-anastomosis of the ureter to the pouch using LeDuc technique in the latter. In the Indiana pouch, stomal stenosis, an hourglass-like pouch deformity, difficult catheterization occurred in 3, 2 and 2 patients, respectively. Among the 4 patients with the appendiceal Mainz pouch, there were no major late postoperative complications except for mild stenosis of the conduit, handled with bougienage. As a whole, surgical revisions, related to urinary diversion, was done in 20.3, 10.6, 0 percent in the Kock, Indiana, Mainz pouch patients, respectively. Stone formation, mostly multiple and recurrent, occurred in 27.8, 6.4, 0 percent in the Kock, Indiana, Mainz pouch, respectively. Most of the stones were removed endoscopically via a stoma or by percutaneous approach. Acidosis was seen in 3 patients in both the Kock and Indiana pouch, and 3 patients with the Kock pouch suffered from symptomatic choleithiasis. At the time of the latest observation, continence was achieved in 90.2, 93.0, and 100 percent, whereas excretory urograms showed normal collecting systems in 64.5, 90.4, and 100 percent in the Kock, Indiana, and Mainz pouch, respectively. In conclusion, the Kock pouch, performed by an original method using unabsorbable polyester fabric collars and metallic staples, has an intolerably high rate of late complications, and either the modified Indiana pouch with ileal patch or the appendiceal Mainz pouch using the umbilicus as a stoma is recommended for a self-catheterization continent urinary diversion.