Kock Pouch Research Articles

How to Avoid Clean Intermittent Catheterization in Men With Ileal Bladder Substitution

In male patients with ileal bladder substitute we ascertained the likelihood of spontaneous voiding failure, the corrective procedures required and the eventual outcomes. Following cystectomy and ileal bladder substitution for urothelial cancer between April 1985 and September 2002 male patients were identified and analyzed from the prospective departmental database. Four patients underwent ileum conduit conversion following urethral recurrence or pouch necrosis and were excluded from study. Funnel-shaped outlets were avoided during bladder substitute surgery after the first 4 patients with this configuration experienced voiding failure and required corrective procedures. Only patients with a minimum 5-year followup were assessed for voiding failure, corrective procedures and final outcomes. Of 354 patients with a median age of 65 years (range 36 to 84) treated with bladder substitute 180 (51%) were alive at 5 years. All 180 of these patients spontaneously voided within 3 months of surgery. During this 5-year observation period 22 (12%) patients experienced voiding problems requiring de-obstructive procedures. Following intervention 177 (98%) patients were spontaneously voiding by 5 years. Of 237 patients 77 (32%) were alive at 10 years. Of these 77 patients followed for another 5 years 10 (13%) had similar voiding problems requiring de-obstructive procedures. Subsequently 74 (96%) were voiding spontaneously by 10 years. Patients often fail to void spontaneously after ileal bladder substitution. However, if a funnel-shaped outlet is avoided and de-obstructive surgery is appropriately implemented, excellent long-term results are seen with spontaneous voiding and clean intermittent catheterization can be avoided.

Serosa Lined and Tapered Ileum as Primary and Secondary Continence Mechanism for Various Catheterizable Pouches

Incontinence of catheterizable ileocecal pouches with an umbilical stoma using the original Mainz pouch technique can be repaired by a secondary ileal intussusception nipple fixed in the ileocecal valve. In cases of a modified Mainz pouch with ureteral anastomosis to the prevalvular ileal segment another form of troubleshooting is necessary. In 4 of 112 patients (3.6%) with the modified Mainz pouch described by Roth incontinence or stenosis of the catheterizable stoma occurred. A 24 to 30 cm segment of ileum was isolated. The proximal 8 to 10 cm were tapered and seroserosally embedded in the U-shaped 2 x 8 to 10 cm long remainder of the segment. After excising the insufficient efferent limb this ileal segment was anastomosed to the pouch and the umbilicus with tapered ileum acting as the continence mechanism. In a fifth patient such a segment was used for ileocystoplasty with an umbilical stoma after bladder neck closure. At a median followup of 6 months (range 5 to 64) all 5 patients were fully continent with regular, easy self-catheterization via the umbilicus. The introduced method seems to be a promising continence mechanism for various forms of catheterizable pouches, not only for troubleshooting.

Delayed Kock Pouch Nipple Valve Failure: Is Revision Indicated?

This study was designed to review our experience with patients who, after more than 10 years of normal Kock pouch valve function, required repair of the valve. In addition, we describe the surgical techniques employed for valve repair. A retrospective chart review identified 31 patients who underwent Kock pouch revision after a minimum time interval between previous pouch surgery and the current revision of 10 (average, 19.7) years. The intraoperative findings included slipped valve, valve prolapse, and internal nipple valve fistulas. The procedures performed included standard valve reconstruction, turnaround procedures, pedicle repair, wall stapling, and oversewing of fistula. Twelve of the 31 patients failed the initial revision and required additional operations, with an overall pouch salvage success rate of 93 percent. Only two patients required excision of the pouch and conversion to a Brooke ileostomy. The procedures were performed with minimal morbidity and no mortality. Surgical revision can be offered to patients with a continent ileostomy complicated by delayed valve dysfunction with low morbidity and good functional outcome.

Half-Century Follow-up after coffey diversion in early Childhood; Risk for Colorectal Carcinoma

PURPOSE It is well known, there is an increased risk of developing colorectal carcinoma after a Coffey diversion. The aim of the present study was to analyse the time course of this development. MATERIAL AND METHODS Twenty-five children between the ages of 2 months and 8 years were operated on from 1944 to 1961. The reason for urinary diversion was bladder exstrophy in 21 cases, myelomeningocele 2 and other diagnoses in 2. The retrospective study was based on data from patient files. RESULTS After 50 years, almost all patients are rediverted to a Bricker conduit or Kock pouch due to hydronephrosis, upper urinary tract infections or risk for colorectal carcinoma. Only two patients still have a functioning Coffey. Five out of 25 patients are deceased, three from histologically verified colorectal cancer. One patient died from urinary sepsis four days after surgery and one for unknown reason 37 years after surgery. Three of the surviving patients have been treated for colorectal carcinoma. Thus, altogether 6 of the 25 patients (24%) have suffered from this kind of malignancy. The colorectal carcinoma developed in 2 patients when they still were diverted with the Coffey technique. However, the colorectal carcinoma occurred 2 years after rediversion to a Bricker conduit in one patient, 16 years there after in another one, and 20 years there after in a further 2 patients. CONCLUSIONS The risk of developing colorectal carcinoma persists for many years after rediversion which calls for life time follow-up with regular colonoscopies.

Continent Ileostomy: Current Status

Continent ileostomy (Kock pouch) is an alternative to end ileostomy for patients who have undergone total proctocolectomy. The procedure reached its height of popularity in the late 1960s and early 1970s, but has been supplanted by restorative proctocolectomy, an operation that preserves the natural route of defecation. Continent ileostomy is still appropriate for selected patients with ulcerative colitis and familial polyposis who are not candidates for restorative proctocolectomy, for whom restorative proctocolectomy or end ileostomy have failed, and in a few other selected cases. Complication rates have decreased during the past three decades following technical improvements, but remain significant. In this review, the author summarizes the current indications for continent ileostomy, examines recent technical modifications, and discusses the management of complications.

Long-Term Results of Reconstructive Surgery in Patients with Bladder Pain Syndrome/Interstitial Cystitis: Subtyping Is Imperative

To evaluate the long-term outcome after reconstructive surgery in patients with bladder pain syndrome/interstitial cystitis subdivided into subtypes. A total of 47 patients, fulfilling the National Institutes of Health/National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases criteria, were evaluated retrospectively. They all had undergone reconstructive surgery during the 25-year period of 1978 to 2003. The surgical procedures included noncontinent ureteroenterocutaneostomy (12 patients), supratrigonal cystectomy and ileocystoplasty (23 patients), continent urinary diversion (Kock pouch; 10 patients), continent orthotopic diversion (1 patient), and cecocystoplasty (1 patient). The series comprised 34 patients with classic Hunner type disease and 13 patients with nonulcer bladder pain syndrome/interstitial cystitis. The patients were preoperatively assessed by interview, visual analog pain scale, micturition diaries, urinalysis, intravenous urography, urethrocystoscopy, and bladder distension during anesthesia, including biopsy and, in selected cases, urodynamic evaluation. The data were obtained by surveying the clinical records. For 28 of the 34 patients with classic Hunner-type disease, the initial surgical procedure resulted in complete symptom resolution. Of the remaining 6 patients, 4 were successfully treated with a supplementary diversion procedure, cystectomy, or transurethral ulcer resection in the trigonal remnant. In contrast, only 3 of the 13 patients with nonulcer disease experienced symptom resolution after reconstructive surgery, and 2 of these required a supravesical diversion procedure. Reconstructive surgery for refractory bladder pain syndrome/interstitial cystitis is an appropriate last resort only for patients with end-stage Hunner's disease. The decision to embark on major reconstructive surgery in patients with bladder pain syndrome/interstitial cystitis should be preceded by a thorough preoperative evaluation, with emphasis on assessment to determine the relevant subtype (ie, classic or nonulcer disease).

An Unusual Reason for Kock Pouch Urinary Incontinence

We report the case of Kock pouch incontinence resulting from perforation of the efferent nipple valve by an unsuccessful catheterization attempt in a patient with a spinal cord injury. Continence was reestablished by surgical revision.

Clinical usefulness of urodynamic assessment for maintenance of bladder function in patients with spinal cord injury

The vast majority of spinal cord lesions cause neurogenic bladder disorders. Detrusor hyperreflexia presents a major risk factor for renal damage in these patients. We evaluated the long-term results of patients with spinal cord injury treated at our institution. Eighty spinal cord injury patients (60 male, 20 female; mean age 29.6 years) with at least one follow-up visit a year for a minimum of five consecutive years, were included in this retrospective analysis. Follow-up included urodynamic evaluation, sonography of the upper and lower urinary tract, urine examination, and evaluation of renal function. Treatment modifications were based on the urodynamic findings. Mean follow-up was 67.3 months (range 60-103 months). At initial presentation, 51 patients performed intermittent catheterization, 7 had indwelling catheters, 10 utilized reflex voiding, 2 patients presented with a Brindley stimulator, 10 patients used abdominal straining. At the end of our study, no patient had signs of renal damage. To achieve that goal, 8 patients underwent sphincterotomy, 3 received a Brindley stimulator, 3 underwent bladder augmentation, one Kock pouch was performed, and 12 patients were treated with botulinum-A-toxin injections in the detrusor. Twenty-two patients received intravesical anticholinergic therapy. In merely three patients, treatment was not modified during the entire follow-up. In the long term, treatment strategy of neurogenic bladder dysfunction in patients with spinal cord injury had to be modified in almost all patients. 18.8% underwent surgery. For protection of the upper urinary tract and maintenance of continence, regular urodynamic follow-up is warranted.

Holmium: Yttrium Aluminium Garnet Laser Lithotripsy for Symptomatic Kock Pouch Calculi

Kock first described continent ileostomy for fecal diversion in 1969 as an alternative procedure to conventional ileostomy. Later, this procedure was replaced by restorative proctocolectomy with ileal pouch anal anastomosis as the procedure of choice. The main reasons for its virtual abandonment include technical difficulty, high morbidity, and the need for a stoma. To our knowledge, this report is the first published case of successful enterolith destruction and retrieval from a Kock pouch, using a Holmium: yttrium aluminium garnet laser. This outpatient procedure can avoid the morbidity and cost of a laparotomy.

Long-Term Outcome and Quality of Life After Continent Ileostomy

This study was designed to evaluate long-term outcomes for patients undergoing Kock continent ileostomy, identify factors associated with adverse outcomes, and compare changes in quality of life after removal of the reservoir. The records of all patients (n = 330) undergoing continent ileostomy at the Cleveland Clinic Foundation between 1974 and 2001 were reviewed. Patient-related, intraoperative, and postoperative factors were evaluated as predictor variables of long-term pouch survival. Quality of life was evaluated using the continent ileostomy surgery follow-up questionnaire and the Cleveland Global Quality of Life scale (n = 216). These were compared between patients with continent ileostomy (n = 181) and patients who underwent removal of the continent ileostomy and conversion to an end stoma (n = 35). The median patient follow-up was 11 (range, 1-27) years. The median revision-free pouch interval was 14 (95 percent confidence interval, 11-17) months. The 10-year and 20-year pouch survival was 87 and 77 percent, respectively. Patients had an average of 3.7(range, 1-28) complications and 2.9 (range, 1-27) pouch revisions during follow-up. On multivariate analysis, Crohn's disease (hazard ratio = 4.5), female gender (hazard ratio = 2.4), fistula development (hazard ratio = 3), and body mass index (hazard ratio = 2.4 per 5 unit increase) were independent predictors of pouch failure. Quality of life measurements for patients with a continent ileostomy were higher on all scales in comparison with patients who had the Kock reservoir and then reverted to a Brooke ileostomy. Despite the associated morbidity with continent ileostomy surgery, long-term results and quality of life were encouraging. Continent ileostomy may be offered as an attractive long-term option to select patients whose only alternative is an end ileostomy.

Afferent intussuscepted antireflux nipple valve complications in the Kock pouch for continent urinary diversion Early results with a modified technique

To analyse the risk of afferent nipple valve stenosis and its consequences and management in patients with a Kock pouch for continent urinary diversion and to study the early results after using an alternative antireflux technique. Sixty patients consecutively operated on with a conventional Kock reservoir for continent cutaneous urinary diversion between 1988 and 2001 were analysed with regard to the occurrence of afferent nipple valve stenosis and its clinical characteristics. Sixteen patients operated on for continent urinary diversion during the period 2002-04 had the antireflux valve constructed according to the serous-lined extramural ileal valve technique. Eight patients with a conventional Kock pouch developed true afferent nipple valve stenosis and the risk approached 30% after 15 years. Dilatation and stenting were usually successful. The high risk of afferent nipple valve stenosis when using the intussuscepted nipple valve in the construction of a Kock reservoir for continent cutaneous urinary diversion calls for an alternative method for anastomosing the ureters to the reservoir. Our early results with the combined Kock/T-pouch are promising.

The Kock reservoir ileostomy: a review of its development, problems and role in modern surgical practice.

The Kock continent ileostomy reservoir was designed in an attempt to overcome many of the problems associated with the conventional ileostomy. An account is given of the technical developments of this procedure since its inception. An intussusception valve within the reservoir is necessary for continence. However, valve failure is a common problem and the developments in construction which have helped to overcome this are described. The major complications associated with the continent ileostomy are discussed in detail, and an attempt is made to define its present role in the treatment of inflammatory disease of the colon.

Thirty Years of Experience Living With a Continent Ileostomy

This study describes long-term adjustment of people with a continent ileostomy. Subjects were 68 people (25 males and 43 females) who underwent an operation for ulcerative colitis with a continent ileostomy (Kock pouch). The median number of years subjects had lived with a continent reservoir was 31 (range 29-36) at follow-up and the median subject age was 60 (40-89). Subjects completed a 36-item questionnaire designed to assess adjustment to ostomy surgery. Subjects ranked the questionnaire using a 6-point Likert scale; a response alternative "not relevant" was available. Content analysis was conducted on subjects' responses to an open-ended question covering aspects of their quality of life. High median adjustment ratings were found for all 36 statements; the maximum median rating of 6 appeared on 28 items. Eight items with the lowest median ratings were in the following domains: embarrassing situations, activity, body image, sexuality, and good care. Five items on medical care and 3 items on sexuality were most frequently considered "not relevant" by respondents. The most frequently mentioned quality-of-life domains were family, health, friends, and employment. Content analysis indicated that respondents were self-reliant, although they indicated that they experienced considerable impediments to bowel evacuation outside of the home. In the long-term, people with a continent ileostomy have good self-care. The quality and availability of public restrooms, however, reduces their daily activities away from home.

Continent cutaneous urinary diversion in patients with spinal cord injury

Retrospective study. To examine the functional results and effect on quality of life of continent cutaneous urinary diversion in spinal cord injured patients. Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden. A total of 10 patients with spinal cord injury (SCI). The patients were operated on with an ileal reservoir (Kock reservoir or T-pouch), Cr-EDTA clearance was determined preoperatively and at follow-up. The patients answered a questionnaire concerning reservoir function, various activities and quality of life. The patient charts were reviewed. One patient died of pulmonary embolism 3 years after surgery. Two patients were reoperated on for reservoir perforation. All patients were satisfied/very satisfied with their reservoirs. Half of them reported improved ability to perform various activities. Eight out of nine patients reported improved quality of life. For a selected group of patients with SCI, continent cutaneous urinary diversion provides successful outcome with improved quality of life.

Ileoanal Pouch Neoplasia in Familial Adenomatous Polyposis: An Underestimated Threat

Ileal pouch-anal anastomosis is one of the two main options available for the surgical treatment of patients with familial adenomatous polyposis. Its main advantage is the minimal risk of rectal cancer but a possible Achilles heel is the recurrence of epithelial neoplasia at the ileal pouch-anal anastomosis and within the ileal pouch. The significance of ileoanal anastomotic and ileal pouch adenomas is not yet fully appreciated, and there is a false sense of security about this operation. The consequences of worsening pouch polyposis are serious in that endoscopic treatment is unlikely to be an effective way of controlling it. This study has been done to alert those caring for patients with familial adenomatous polyposis to the looming danger of pouch polyposis and to suggest ways to deal with it. Studies reporting ileoanal pouch adenomas, ileal pouch-anal anastomotic cancers, and ileal pouch cancers in patients with familial adenomatous polyposis were reviewed. Reports of adenomas in Kock pouches and in Brooke ileostomies in the setting of familial adenomatous polyposis were included. The primary end points of the study were the time between pouch construction and the diagnosis of neoplasia, the age of the patients at the diagnosis of neoplasia, and the severity of the neoplasia. There were 18 studies reporting pouch neoplasia, 15 with adenomas, and 3 with cancer. Ten were case reports, five were retrospective studies, and three were prospective studies. All three prospective studies showed that the incidence of pouch adenomas increases with time of follow-up and that the severity of the polyposis varies. The median time from pouch construction to diagnosis of pouch adenomas was 4.7 years and the range was 0.5 to 12 years. There were six studies reporting eight patients with cancer at the ileal pouch-anal anastomosis, diagnosed a median of 8 years after pouch construction (range, 3-20 years). One-half of the cancers were locally advanced (T4) and one-half were not (T1 or T2). One-half followed stapled anastomosis and one-half were after mucosectomy. There were eight case reports of cancer described in an ileostomy in patients with familial adenomatous polyposis. The median time from ileostomy construction to the ileostomy cancers was 25 (range, 9-40) years. The combination of fecal stasis, adenomatous epithelium, and a germline APC mutation is a potent recipe for epithelial neoplasia. There is increasing evidence that this happens in an ileostomy but that the process is much faster in an ileal pouch. Endoscopic treatment of ileal adenomas is likely to be difficult, reducing the options for their control to excising the entire pouch or chemoprevention.

Prophylaxis against bone loss in Kock reservoir patients with reduced glomerular filtration rate

We investigated whether treatment with calcium carbonate and vitamin D3 can improve the bone mineral content of patients with ileal reservoirs for continent urinary diversion and a reduced glomerular filtration rate (GFR). Twenty-six patients with Kock reservoirs were included in the study. Bone mineralization was determined using dual-energy X-ray absorptiometry. Kidney function was estimated from Cr-EDTA clearance and serum cystatin C concentration. Osteocalcin and parathyroid hormone in serum were also measured. Patients with reduced GFR were treated with calcium carbonate and vitamin D3 perorally. Bone mineral density in the femur neck and hip increased in the treatment group, as reflected by an improved T score. Patients with ileal reservoirs for continent urinary diversion and reduced kidney function should be supplemented with calcium carbonate and vitamin D3 in order to reduce the long-term risk of osteoporosis.

Continent Ileostomy: Current Experience

This study was designed to review our recent experience with continent ileostomies and evaluate patient outcomes. Retrospective chart reviews and phone interviews of patients who underwent a continent ileostomy operation from 1993 to 2003 at the Ochsner Clinic Foundation were performed. Twenty-four patients (19 females; age range, 22-73 years) had construction of continent ileostomies (modified Kock pouch). There were no intraoperative mortalities or stoma-related deaths. The mean operating room time for primary construction was 3.9 +/- 0.57 hours with a mean length of stay of 7 +/- 2 days. The average follow-up period was 66 (range, 6-134) months. The most common underlying indication for the construction of a continent ileostomy was ulcerative colitis (71 percent). Thirteen patients had a continent ileostomy created for conversion of a Brooke ileostomy and seven for a failed ileoanal pouch. Other indications included colonic inertia and incontinence in three patients and one patient who had failed multiple operations for Hirschsprung's disease. A total of 28 revisions were performed in 14 patients (58 percent). Six patients required multiple procedures. Operative revisions included 12 skin level revision for stenosis, 11 operations for valve repairs, and 1 each for peristomal hernia repair, stomal relocation, and pouch repair for fistulas. Two patients had their pouches removed (Crohn's disease and inability to manage pouch). The need for revision by 12 months was 29 percent, and the average time period before the first revision was 24 months (range, 4 days to 109 months). The overall failure rate (converted to conventional ileostomy) was only 8.3 percent. Ninety percent of the patients have continent pouches and are satisfied with their pouch function. Continent ileostomies continue to have a high rate of reoperations, reasonable functional results, and are a viable option for failed ileal pouch-anal pouch patients. Surgeons electing to perform continent ileostomies must carefully select their patients and advise them of the high potential for reoperations. Despite a high reoperation rate, patients are pleased with their continent ileostomies.

Extracolonic Manifestations of Familial Adenomatous Polyposis After Proctocolectomy

Extracolonic manifestations have a major effect on the morbidity and mortality of patients with familial adenomatous polyposis following proctocolectomy. Case review study. Colorectal unit, university-affiliated hospital. Fifty patients (25 males and 25 females) with familial adenomatous polyposis WHO underwent proctocolectomy between January 1988 and October 2003. Ileal pouch-anal anastomosis (n = 41), Kock pouch (n = 1), end ileostomy (n = 6). Two patients underwent total colectomy with an ileorectal anastomosis. Clinical follow-up and telephone interview; contact with clinicians following up patients elsewhere. The patients' median age at surgery was 33 years. The mean length of follow-up was 74 months. Four patients were lost to follow-up. Extracolonic manifestations were diagnosed in 38 patients (76%). Twelve patients had 14 desmoid tumors: 7 were treated surgically and 7 medically (these patients received celecoxib and tamoxifen citrate therapy). Of the 41 patients who underwent upper gastrointestinal tract endoscopy, 11 developed duodenal and/or ampullary adenomas. Three patients had endoscopic polypectomy and 1 underwent a Whipple operation. Among the 29 patients who underwent pouchoscopy, 5 had pouch adenomas and 3 had adenomas that were found in the rectal stump. Two patients died--one of a huge mesenteric desmoid tumor and the other of an aggressive mesenteric malignant fibrous histiocytoma. Long-term morbidity and mortality were strongly related to the development of mesenteric tumors and ampullary-duodenal polyps. Early detection of desmoid tumors, duodenal, pouch, and rectal cuff adenomas by periodic computed tomography, gastroduodenoscopy, and pouchoscopy, respectively, may allow control by medical therapy, endoscopy, or limited surgical procedures. In most patients control of desmoid tumors was achieved using a combination of celecoxib and tamoxifen citrate therapy.

Fistule artério-urétérale, à propos de trois cas

On connection with four cases of arterio-uro-enteric fistula in three patients and after a review of the literature, the authors propose to make light on this extremely rare complication describing aetiologies factors and the diagnostic means and therapeutics. Two patients had had a pelvic exenteration with respectively Bricker and Kock pouch. The third patient had had an anterior resection in blok with the right deferent duct and right seminal gland. All three received high doses of radiotherapy. These fistulas had appeared by abundant haemorrhages. The surgical operation in urgency had made it possible to treat these fistulas with success in two patients. The other patient had deceased of cataclysmic haemorrhage.

Continent cutaneous urinary diversion is still a valid alternative after cystectomy for bladder carcinoma

We compared patient opinions concerning reservoir/bladder function as well as quality of life (QOL) after cystectomy for bladder carcinoma and continent cutaneous urinary diversion or orthotopic bladder reconstruction. Fifteen patients with Kock reservoirs (11 females, 4 males) and 11 men with orthotopic bladders answered the European Organization for Research and Treatment of Cancer quality-of-life questionnaire-C30 as well as specially constructed questions concerning reservoir/bladder function. The glomerular filtration rate (GFR) was determined using Cr-EDTA or iohexol clearance. Functioning and global health/QOL scales did not differ between the two groups of operated patients or between diverted patients and gender- and age-matched groups from the general population. The majority of the patients were satisfied/very satisfied with their diversion but more patients were troubled by leakage in the orthotopic bladder group than in the Kock reservoir group. The GFR was similar in the two groups. Continent cutaneous urinary diversion is associated with fewer leakage problems than orthotopic bladder reconstruction after cystectomy for bladder carcinoma.