Okada Y, Hamaguchi A, Kageyama S, Tomoyoshi T, Kawakita M, Terai A, Yoshida O
Department of Urology, Shiga University of Medical Science.
Hinyokika Kiyo. 1995 Nov;41(11):947-52.
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.
可自行导尿的可控性尿流改道术已成为浸润性膀胱癌或其他盆腔恶性肿瘤患者尿流改道的主要选择之一。我们分别为124例、51例和4例患者实施了Kock袋、印第安纳袋和阑尾 Mainz 袋手术，平均随访时间分别为50个月、33个月和10个月。在Kock袋中，传出乳头瓣和传入乳头瓣功能障碍的发生率分别为16.7%和21.3%，需要进行修复手术，如将传出乳头固定在袋壁上，前者重建等蠕动乳头瓣，后者去除涤纶织物套环或采用LeDuc技术将输尿管重新吻合至袋体。在印第安纳袋中，分别有3例、2例和2例患者出现造口狭窄、沙漏样袋畸形和导尿困难。在4例阑尾 Mainz 袋患者中，除了导管轻度狭窄经扩张术处理外，没有出现严重的术后晚期并发症。总体而言，Kock袋、印第安纳袋、Mainz袋患者中与尿流改道相关的手术修正率分别为20.3%、10.6%、0%。结石形成大多为多发且复发，在Kock袋、印第安纳袋、Mainz袋中的发生率分别为27.8%、6.4%、0%。大多数结石通过造口内镜或经皮途径取出。Kock袋和印第安纳袋各有3例患者出现酸中毒，Kock袋有3例患者出现有症状的胆石症。在最近一次观察时，Kock袋、印第安纳袋和Mainz袋的控尿率分别为90.2%、93.0%和100%，而排泄性尿路造影显示Kock袋、印第安纳袋和Mainz袋中收集系统正常的比例分别为64.5%、90.4%和100%。总之，采用不可吸收聚酯织物套环和金属吻合钉的原始方法实施的Kock袋晚期并发症发生率高得令人难以忍受，对于可自行导尿的可控性尿流改道，建议采用带回肠补片的改良印第安纳袋或使用脐部作为造口的阑尾Mainz袋。
