Clinical experience with the Kock continent ileal reservoir for urinary diversion

From August 1982 through January 1984, 51 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 to prevent reflux and to ensure continence. Previous urinary diversion was by ureterosigmoidostomy in 3 patients, standard ileal conduit in 7 and suprapubic cystotomy in 1. A total of 39 patients underwent simultaneous anterior exenteration for pelvic malignancy. There was 1 postoperative death and early complications occurred in 10 patients. Of these 10 patients 4 required reoperation: 2 for drainage of a pelvic abscess, 1 for conversion to a standard ileal conduit and 1 for bleeding. Late complications occurred in only 8 patients: 5 required reoperation and revision of the continence valve mechanism, and 3 required hospitalization for brief episodes of pyelonephritis. The end result in 49 of 50 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 electrolytes have remained normal and hyperchloremic acidosis has been encountered in only 1 patient who had had compromised renal function preoperatively with hyperchloremic acidosis as a result of previous ureterosigmoidostomy. X-rays of the Kock pouch have shown evidence of reflux in only 1 patient, 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.