Indiana Continent Urinary Reservoirによる尿路変更術 --特にpouch作成法に関する検討--

Abstract

1) 1987年10月よりの1年間にIndiana continent urinary reservoir (Indiana pouch)を15例に施行した.うちHeineke-Mikulicz法が8例に, ileal patch法が7例に行われた.男性13例, 女性2例で, 平均年齢は61歳であった.2)全体の成績は, 非常に良好な結果を得ているもの11例, 良好な結果1例, 不良2例, 死亡1例である.3)術後早期合併症の重篤なものは, GVHDによる死亡1例であった.4)晩期合併症では, 尿路感染による発熱が1例, pouch中央部の狭窄が1例にみられた.5) 12例は全く尿失禁がなく, 2例に種々の程度で溢流性尿失禁がみられた.全例とも腎への逆流はみらなかった.6)術後6ヵ月を経過した症例のpouch容量は約500 mlで一日の導尿回数は6～8回であった.ileal patch法ではより早期に低圧で大きなpouch容量を得ることができた

Over the last several years, internal reservoir type urinary diversions have become popular. We have already performed Kock continent ileal reservoir for urinary diversion in more than 80 patients. The experience with the Kock pouch prompted us to try a new form of continent urinary reservoir originally reported by Indiana University group. The Indiana pouch is a composite structure using ileum and cecum. The antireflux mechanism is provided with tunneled ureteral implantation along the tenia of the cecum. Plication of the terminal ileal segment along with the ileocecal valve maintains urinary continence. The tubular configuration of the cecum is completely disrupted with either an ileal patch or Heineke-Mikulicz re-configuration to construct a low pressure reservoir. Between October, 1987 and September, 1988, we performed Indiana continent urinary diversion in 15 cases: 13 males and 2 females, from 47 to 73 years old (mean age 61.3 years), 14 bladder cancer patients and 1 bladder sarcoma patient. The initial 8 patients underwent Heineke-Mikulicz type operation and the subsequent 7 patients ileal patch-type operation. Median followup has been 7 months. There were no major early complications but one postoperative death with blood transfusion related graft versus host disease (GVHD). The late complication occurred in 2 patients: 1 stenosis of the pouch due to insufficient detubularization of the cecum and 1 pyelonephritis required no admission. Serum electrolytes and vitamin B12 remained normal in all patients. Patients perform self-catheterization every 3-5 hours during the day and 0-2 times at night for volumes ranging up to 800 ml. With regard to volume capacity and pressure characteristics, the ileal patch type reservoir seemed to be superior to the Heineke-Mikulicz type pouch as a receptacle for urine. Over-all, 12 of 14 patients (86 per cent) have acceptable continence. The remaining 2 patients have significant daytime leakage requiring pads or a cutaneous bag. Followup examination with excretory urography showed no upper tract obstruction and X-rays of the pouch showed no reflux. Indiana pouch is a relatively simple continent urinary reservoir, since the steps of this technique already are familiar to urologists. It may be an alternative form of continent urinary diversion.