No abstract

A new method for urinary diversion to the rectum was elaborated in animal experiments and currently has been used in 19 patients. Reflux of the rectal content to the colon and to the upper urinary tract is prevented by the fashioning of an intussusception valve at the rectosigmoid junction. The rectum is augmented by anastomosing an ileal patch to the anterior rectal wall. A transverse colostomy protects the construction for 6 to 8 weeks. Of the 19 patients 3 had local recurrence or metastasis within 6 months. Thus, 16 patients with a followup of 3 to 14 months are evaluable. All patients are continent during the daytime with an emptying frequency of 3 to 5 times and dry at night with a frequency of 0 to 2. In 3 patients partial sliding of the sigmoid intussusception valve occurred causing reflux of rectal contents to the sigmoid and to the right ureter in 1. Reflux to the upper urinary tract has not been revealed in any of the other patients. With 1 exception excretory urography has demonstrated either improvement or stabilization of the upper urinary tract post-operatively. The rectal capacity increased from 200 to 700 ml. after 6 months. With the reservoir full the mean basal pressure was 17 cm. water and the mean maximum pressure was 24 cm. water.

In 185 men a urethral Kock pouch was constructed as a bladder substitute after radical cystectomy for cancer. A total of 117 patients was followed for a minimum of 1 year and is fully evaluable. Of the patients 108 (92%) are completely continent during the day, while 85 (73%) are dry at night. Also, 8 patients had an excellent response to imipramine hydrochloride. Stability or improvement in the configuration of the upper tract was noted in 210 renal units (90%). A total of 24 renal units showed evidence of deterioration due to reflux (16) and an anastomotic stricture (8). Stability of the antireflux nipple valve was ensured by creation of a window in the mesentery of the corresponding bowel segment and by anchoring the valve to the wall of the pouch by an additional row of staples. On the basis of this favorable outcome the procedure is recommended for male patients for whom cystectomy is indicated and in whom the urethra can be preserved.

After cystoprostatectomy for cancer of the bladder 43 men were provided with a detubularized, low pressure ileal reservoir (Kock pouch) connected to the urethra. Reflux was prevented by an intussusception valve. There was no operative mortality and few early complications. At followup the mean postoperative observation time was 13 months, with a range of 5 to 20 months. Late complications included manifestations of local tumor recurrence or distant metastases in 9 patients within 6 months postoperatively, which made adequate functional evaluation impossible. In 18 patients reflux to the upper urinary tract due to eversion or sliding of the antireflux valve occurred at various postoperative intervals. In 16 of these patients incontinence developed as a consequence of the reflux. Surgical correction of the failing antireflux valve restored reflux prevention and continence. Within 3 to 6 months the capacity of the reservoirs had reached an ultimate volume of approximately 600 ml. Pressure waves exceeding 40 cm. water seldom occurred in the mature reservoirs and then only at high filling volumes. The mean urethral resting resistance to flow was 64 cm. water. The configuration and function of the upper urinary tract improved or stabilized postoperatively. Of 34 evaluable patients 30 were continent during the day with a voiding frequency of 3 to 5 times and dry at night with a frequency of 0 to 2.