Kock Continent Ileal Urinary Reservoirの臨床経験

Abstract

From July 1985 through January 1986, 43 patients underwent urinary diversion that included creation of a continent reservoir from an ileal segment, according to the method described originally by Kock. An important modification included removal of a narrow strip of mesentery for 8 cm along the afferent and efferent limbs of the pouch to allow adequate ileal intussusception and fixation of the nipple valves to prevent reflux and to ensure continence. A strip of PGA mesh serves as a collar to fix the afferent-efferent limb to the pouch once the intussusception technique has been accomplished. The use of a narrow Marlex strip allows fixation to the abdominal wall both lateral and medial to the stoma site (insert). This strip is important in preventing a parastomal hernia and helps fix the continence valve mechanism to the posterior abdominal wall. Previous urinary diversion was by ureterosigmoidostomy in 2 patients, standard ileal conduit in 8 and chronic dialysis after nephrectomy of solitary kidney and cystectomy in 1. A total of 32 patients underwent simultaneous anterior exenteration or radical cystectomy for pelvic malignancy. There were 4 postoperative deaths and early complications occurred in one patient. Late complications occurred in only 3 patients: they required reoperation and revision of the continence valve mechanism. The end result in 39 of 43 patients has been an overwhelming success. Patients perform self-catheterization every 4 to 6 hours during the day and once at night for volumes ranging up to 1, 400 cc. Serum electolytes have remained normal in all patients. X-ray of the Kock pouch have shown no evidence of reflux, and all excretory urograms have demonstrated either normal upper tracts without obstruction or improvement in patients with preoperative hydronephrosis. Although preliminary, this clinical trial suggests that the quality of life for patients considered previously to be candidates for cutaneous diversion can be improved markedly by a modified Kock continent ileal reservoir. During the same time, 21 patients out of 278 patients who underwent creation of a Kock continent ileal urinary reservoir since August 1982, underwent revision of Kock pouch. Two of those required subsequent reoperation and revision of the continence valve mechanism. The end result in all patients has been an overwhelming success.