URODYNAMICS
URODYNAMIC EVALUATION OF PATIENTS W I T H CONTINENT URINARY DIVERSION USING CECAL RESERVOIR AND INTUSSUSCEPTED I L E O C E C A L VALVE BRUCE A. L O W E , M.D. JEFFREY R. W O O D S I D E , M.D. From the Division of Urology, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
ABSTRACT--Patients requiring bladder removal for malignant disease have undergone continent urinary diversion employing the ileocecal segment, using the cecum to construct a reservoir and an intussuscepted ileocecal valve as the continence mechanism. Five of these patients have been studied urodynamically and radiographically in the postoperative period. Incontinence was ]ound to be minimal and related only to a prolonged catheterization interval. Passive filling pressure and peristaltic pressure remained low in all patients and was lower than the nipple valve pressure in 4 of 5 patients. A transient increase in reservoir pressure at capacity with peristalsis exceeded the nipple peristaltic pressure in 1 patient and was associated with a small volume of h~continence. This resolved with a shortened catheterization interval. Reflux was not found in any subject studied. These studies indicate that the cecal segment can be used to construct a continent urinary reservoir that provides satisfactory function for the patient while maintaining an acceptable pressure volume relationship.
There has been renewed interest in continent urinary diversion in reeent years and a variety of techniques have been described that do not require external collection devices. Different bowel segments, primarily terminal ileum and cecum, have been found to be adaptable to the construction of these reservoirs. In m a n y systems an intussuscepted portion of small bowel is used as the continence mechanism. The Koek pouch, using terminal ileum as a reservoir and two intussuscepted sections of ileum to construct continent nipple valves, is a widely used method of continent diversion. Construetion was initially associated with a relatively high incidence of eomplieations, most of which have been prevented by modifications of the original proeedure.: However, this form of diversion continues to require a considerable investment of operative time and is dependent on the two continent valves to be effective. 2 Creation of these nipple valves is the most critical maneuver in the procedure and is the most common site of failure.1 Initial capacity is low and a significant
544
period of time is needed for the terminal ileum to acquire sufficient volume to produee an adequate reservoir.a The fleoeecal segment is readily available for the construetion of a large-capacity, low-pressure reservoir and can accommodate a large volume in the immediate postoperative period. The ileoceeal valve can be used for the eor:struetion of an intussuseepted nipple valve and its proximity in the cecal poueh makes this a simple maneuver to perform. Implantation of the ureters in a nonrefluxing fashion can be performed in the colon with little difficulty, thus, requiring only one nipple valve for effective eontinenee in the eeeal pouch. 4 Further, construction of an ileoeeeal poueh is technically simpler to perform than a continent ileal reservoir and is mueh less time-consuming.5 Prior experience with intact tubular/zed cecal segments in bladder augmentation procedures and continent reservoirs has shown that pressures within the segment can rise precipitously with peristaltic activity, 6 Disruption of these peristaltic
UIqOLOGY
JUNE 1990
VOLUME XXXV, NUMBER 6
TABLE I.
Clinical features in 5 patients
Patient
Sex
Age (Yrs.)
Tmnor Grade
Pathologic Stage
G.F. J.E L.H. D.M. L.T.
F M M M M
75 60 63 57 61
II II III III II
C1 B1 0 B1 B1
pressure waves can be accomplished by folding the cecal wall in a direction opposite to the norreal muscular orientation. 7 The fleocecal reservoir offers satisfactory continent diversion with a technically simpler design and potentially fewer sites of failure than the ileal reservoir. The functional activity of a urinary reservoir can be measured by urodynamics and predictioias regarding long-term effectiveness can be postulated. Five patients who have undergone urinary diversion using a continent fleoeecal segment had complete urodynamic testing of the cecal reservoir. The resuits of this study indicate that the ileoeecal reservoir provides an acceptable pressure-volume relationship and that patient's satisfaction is high. Material and Methods Four men and 1 w o m a n with transitional cell carcinoma of the bladder underwent radical cystectomy and continent urinary diversion using the iledcecal segment and an everted ureteral implant. The patients' ages at t h e time of surgery and the tumor grade and pathologic stage are shown in Table I. W h e n the patients returned for urodynamic evaluation, they were questioned about frequency and any difficulties encountered with catheterization, the occurrence of incontinence and the surrounding circumstances, and the ability to perceive fullness of the cecostomy. The patients were evaluated from four to eight months after surgery (mean 6.5 months).
Patient G.E J.E L.H. D.M. L.T.
Urodynamic technique A triple lumen urodynamic catheter with radiographic markers at the urethral and bladder perfusion apertures was used. s The pressure channels were perfused with sterile saline at 2 m L / m i n via a constant infusion pump, pressures measured with Statham transducers and recordings made on a Grass polygraph. The cecal reservoir was filled via the third channel at 60 mL/min with a radiographic contrast agent. The entire study was performed with fluoroscopic monitoring. After catheterizing the stoma, the catheter was slowly w i t h d r a w n and the urethral perfusion channel recorded a nipple-pressure profile, and the maximum nipple pressure was determined (Fig. 1). The cecal reservoir was then filled to 500 mL, and the filling pressure was recorded. The peristaltic pressures were determined. Finally, the maximum nipple pressure was measured with the reservoir full. Observation was made for any incontinence or vesicoureteral reflux. We did not fill the cecal reservoir to a volume greater than 500 mL because that volume is more than sufficient for catheterization on a four to six-hour interval, and we did not w a n t the patients to exceed that volume during daily activities. Results Patients catheterized and emptied the reservoir an average of six times a day. All patients except 1 could detect sensation when the reservoir became full and most catheterized at that
TABLE II. Urodynamicdata Resting Nipple Max. Filling Pressure Pressure (em H20) at 500 mL volume Empty Full (em H20) 35 63 11 50 120 18 42 35 24* 32 28 7 37 37 12
Reservoir Max. Peristaltic Pressure (era H20) 32 50 52 62 18
*Maximum reservoir capacity 400 mL.
UROLOGY
/
JUNE 1990
/
VOLUME XXXV, NUMBER 6
545
FlCtYRE 1. Left, nipple pressure profile showing maximum nipple pressure of 37 cm water. Bight, radiograph (exposed at X, left) shows location of radiographic marker at urethral perfusion aperture within proximal end of nipple (staple line).
time. All patients had at least occasional slight diffieulty inserting a eatheter through the stoma, usually when the reservoir was overly full. None of the patients required assistanee in catheterizing the stoma, and eatheterizations performed by the investigators for the urodynamics studies were not noted to be diffieult. Two patients never experienced incontinence, and in 3 patients minimal incontinence would oceur if the interval of catheterization was too great. No patient experienced a symptomatic or febrile urinary tract infection. The urodynamie d a t a obtained in the study are summarized in Table II. The maximum nipple pressure with the reservoir empty (range 32-50 cm water, mean 39 em water) tended to be lower than w h e n full (range 28-120 cm water, mean 56 em water) but variability among patients was great. The pressure rise in the reservoir was gradual and reached its peak at 500 mL. In no patient did detrimental filling pressure develop. In all patients the pressure in the nipple exceeded the reservoir pressure during filling. Peristaltic contractions with elevation of reservoir pressure occurred in all patients. These pressures ranged from 18-62 cm water (mean 50 em water) and were of short duration. Concomitant with these pressure rises, the pressure in the nipple also increased (Fig, 2). In 1 patient (L,H.) the peristaltic pressure at reservoir capacity exceeded the nipple pressure and incontinence occurred. No other patient demonstrated incontinence, and none had vesicoureteral reflux' Excretory pyelograms showed mild dilation of the upper tracts in 2 patients but prompt function was noted in both. There was no evidence of upper urinary tract obstruction in the remaining 3 patients.
546
Comment The long-term success of a continent urinary reservoir is dependent on achieving four goals during the course of the procedure: (1) creation of a large-capacity, low-pressure reservoir, (2) protection of the upper urinary tracts from reflux and obstruction, (3) a controlled and simple method of draining the reservoir eontents, and (4) avoidance of fluid and electrolyte disturbanees. 5,9 This study demonstrates that the ileoeecal segment successfully accomplishes these goals. In contrast to reservoirs fashioned from small bowel, the ileocecal segment has a large capacity of > 200 mL immediately in the postoperative period. 10 The capacity continues to increase over time as demonstrated by all patients having a capacity of 500 mL or greater at the time of study. In no patient was urinary frequency a problem. In fact, because of the large capacity aH patients tended to prolong catheterization interval until minimal overflow incontinence was noted in 3 of 5 patients. Maintaining the catheterization interval to between four to six hours was adequate to prevent incontinence in all patients. Passive filling pressures were low in alt patients. Pressures increased with peristalsis, but were of short duration and the magnitude was not considered to be potentially detrimental to the upper tracts. Excessive reservoir filling and peristaltic pressures have been implicated as a cause of upper tract deterioration in other systems using the ileoeeeal segment for augmentation. 11Prolonged exposure to high pressures in a urinary reservoir is a possible cause of failure of an intussuscepted nipple valve and a source of incontinence. 12 C o n t i n u e d low reservoir
UROLOGY
JUNE i990
VOLUME XXXV. NUMBER 6
t00 H20
..... ,
0 NIPPLE
70cm.
a
a
0 GECOSTOMY FmURE 9~. Left, simultaneous recording of nipple and cecal reservoir pressures during filling, Scales of pressure measurement are different because of magnitude of nipple pressures. With peristaltic contractions (a), reservoir pressure rises to 45 cm water and nipple pressure to 110 cm water. No ~ncontinence occurs.
pressures in these patients m a y protect against future d a m a g e to the upper tracts or a loss of continenee. The use of a cuffed ureteral nipple has been described as an effective means of preventing reflux, la The procedure is simple and has provided adequate proteetion against reflux thus far in this group of patients. Fixation of the flush stoma to the anterior abdominal fascia has provided excellent stability to the continence mechanism. No patient has thus far experienced any signifieant difficulty w i t h catheterization. For patients with diminished m a n u a l dexterity catheterization of an abdominal wall stoma is more easily accomplished than intermittent urethral catheterization. Thus we r e c o m m e n d the use of an abdominal stoma with the ileoeeeal segment rather t h a n a urethral anastomosis for continent diversion in these patients. Ineontinence has not been a significant problem in our patients. All patients had increased nipple pressures associated with increases in reservoir peristaltic pressures, which m a y be indicative of a coordination that naturally occurs with the use of bowel segments that are in continuity. In all eases this increase in nipple pressure eoineided w i t h the inereased reservoir pressure and prevented ineontinenee. In I patient a slight delay in the onset of increased nipple pressure during peristaltic activity of the reservoir was associated with mild incontinence. This was only noted to occur at reservoir capacity and vcas resolved by shortening the catheterization interval. We conclude that the ileoceeal segment for continent urinary diversion provides a satisfaetory physiologic and functional result and. is assoeiated with a m i n i m a l complieation rate. While t h e long-term results are not yet known, the prelJiminary results are eneouraging. Continent diversion provides the patient an excellent
UROLOGY
/
JUNE 1990
/
VOLUME XXXV, NUMBER 6
alternative to standard conduit diversion, and w h e n questioned all patients expressed a high degree of satisfaction with the results. It is our impression that there is a signifieant improvem e n t in the overall quality of life and patient satisfaction with continent diversion compared with standard conduit diversion relying on external collection devices. Division of Urology Oregon Health Sciences University, L588 3181 S.W. Sam Jackson Park Road Portland, Oregon 97201 (DR. LOWE) Refer~ilces 1. Skinner DS, Boyd SD, and Lieskovsky G: Clinical experience with the Kock continent ileal reservoir for urinary diversion, J Urol 132:1101 (1984). 2. Olsson CA: Continent urinary diversion (editorial), J Urol 132:1157 (1984). 3. Kock NG: The development of the continent ileal reservoir (Kock Pouch) and application in patients requiring urinary diversion, in King LR, Stone AR, and Webster GD (Eds) : Bladder Reconstruction and Continent Urinary Diversion, Chicago, Year Book Medical Publishers, Inc., 1987, pp 269-290. 4. Webster GD, and Bertram RA: Continent catheterizable urinary diversion using the iIeoeeeal segment with stapled intussusception of the fleocecal valve, J Urol 135:465 (1986). 5. Goldwasser B, and Webster GD: Continent urinary diversion. J Urol 134:227 (i985). 6. Hedlund H, Lin&strom K, and Mansson W: Dynamics of a continent caeeal reservoir for urinary diversion, Br J Urot 56" 366 (1984). 7. Goldwasser B, Barret DM, and Benson RC: Complete bladder replacement using the detubularized right colon, in King LR, Stone AR, and Webster GD (Eds): o p c i t . , 3 pp 360-366. 8. Woo&side JR, and McGuire EJ: Clinical evaluation of new urodynamic catheter, Urology 26:95 (1985). 9. Thuroff JW, e t aI: The Mainz pouch (mixed augmentation ileum and cecum) for btadder augmentation and continent diversion, J UroI 136:17 (1986). 1O. Webster GD, and King LR: Further commentary: cecal bladder, in King LR, Stone AR, and Webster GD (E&S): o p cir., 3 pp 206-207. 11. Goldwasser B, and Webster GD: Augmentation and substitution enteroeystoplasty, J Urol 135:215 (1986). 12. Mansson W, Colleen S, and Sundin T: Continent caecal reservoir in urinary diversion, Br J Uro156:359 (1984), 13. Turner-Warwick R: Cystoplasty, in Blandy jP (Ed): UroIogy, Oxford, England, Blackwell Scientific Publications, t976.
547
URODYNAMIC EVALUATION OF PATIENTS W I T H CONTINENT URINARY DIVERSION USING CECAL RESERVOIR AND INTUSSUSCEPTED I L E O C E C A L VALVE BRUCE A. L O W E , M.D. JEFFREY R. W O O D S I D E , M.D. From the Division of Urology, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
ABSTRACT--Patients requiring bladder removal for malignant disease have undergone continent urinary diversion employing the ileocecal segment, using the cecum to construct a reservoir and an intussuscepted ileocecal valve as the continence mechanism. Five of these patients have been studied urodynamically and radiographically in the postoperative period. Incontinence was ]ound to be minimal and related only to a prolonged catheterization interval. Passive filling pressure and peristaltic pressure remained low in all patients and was lower than the nipple valve pressure in 4 of 5 patients. A transient increase in reservoir pressure at capacity with peristalsis exceeded the nipple peristaltic pressure in 1 patient and was associated with a small volume of h~continence. This resolved with a shortened catheterization interval. Reflux was not found in any subject studied. These studies indicate that the cecal segment can be used to construct a continent urinary reservoir that provides satisfactory function for the patient while maintaining an acceptable pressure volume relationship.
There has been renewed interest in continent urinary diversion in reeent years and a variety of techniques have been described that do not require external collection devices. Different bowel segments, primarily terminal ileum and cecum, have been found to be adaptable to the construction of these reservoirs. In m a n y systems an intussuscepted portion of small bowel is used as the continence mechanism. The Koek pouch, using terminal ileum as a reservoir and two intussuscepted sections of ileum to construct continent nipple valves, is a widely used method of continent diversion. Construetion was initially associated with a relatively high incidence of eomplieations, most of which have been prevented by modifications of the original proeedure.: However, this form of diversion continues to require a considerable investment of operative time and is dependent on the two continent valves to be effective. 2 Creation of these nipple valves is the most critical maneuver in the procedure and is the most common site of failure.1 Initial capacity is low and a significant
544
period of time is needed for the terminal ileum to acquire sufficient volume to produee an adequate reservoir.a The fleoeecal segment is readily available for the construetion of a large-capacity, low-pressure reservoir and can accommodate a large volume in the immediate postoperative period. The ileoceeal valve can be used for the eor:struetion of an intussuseepted nipple valve and its proximity in the cecal poueh makes this a simple maneuver to perform. Implantation of the ureters in a nonrefluxing fashion can be performed in the colon with little difficulty, thus, requiring only one nipple valve for effective eontinenee in the eeeal pouch. 4 Further, construction of an ileoeeeal poueh is technically simpler to perform than a continent ileal reservoir and is mueh less time-consuming.5 Prior experience with intact tubular/zed cecal segments in bladder augmentation procedures and continent reservoirs has shown that pressures within the segment can rise precipitously with peristaltic activity, 6 Disruption of these peristaltic
UIqOLOGY
JUNE 1990
VOLUME XXXV, NUMBER 6
TABLE I.
Clinical features in 5 patients
Patient
Sex
Age (Yrs.)
Tmnor Grade
Pathologic Stage
G.F. J.E L.H. D.M. L.T.
F M M M M
75 60 63 57 61
II II III III II
C1 B1 0 B1 B1
pressure waves can be accomplished by folding the cecal wall in a direction opposite to the norreal muscular orientation. 7 The fleocecal reservoir offers satisfactory continent diversion with a technically simpler design and potentially fewer sites of failure than the ileal reservoir. The functional activity of a urinary reservoir can be measured by urodynamics and predictioias regarding long-term effectiveness can be postulated. Five patients who have undergone urinary diversion using a continent fleoeecal segment had complete urodynamic testing of the cecal reservoir. The resuits of this study indicate that the ileoeecal reservoir provides an acceptable pressure-volume relationship and that patient's satisfaction is high. Material and Methods Four men and 1 w o m a n with transitional cell carcinoma of the bladder underwent radical cystectomy and continent urinary diversion using the iledcecal segment and an everted ureteral implant. The patients' ages at t h e time of surgery and the tumor grade and pathologic stage are shown in Table I. W h e n the patients returned for urodynamic evaluation, they were questioned about frequency and any difficulties encountered with catheterization, the occurrence of incontinence and the surrounding circumstances, and the ability to perceive fullness of the cecostomy. The patients were evaluated from four to eight months after surgery (mean 6.5 months).
Patient G.E J.E L.H. D.M. L.T.
Urodynamic technique A triple lumen urodynamic catheter with radiographic markers at the urethral and bladder perfusion apertures was used. s The pressure channels were perfused with sterile saline at 2 m L / m i n via a constant infusion pump, pressures measured with Statham transducers and recordings made on a Grass polygraph. The cecal reservoir was filled via the third channel at 60 mL/min with a radiographic contrast agent. The entire study was performed with fluoroscopic monitoring. After catheterizing the stoma, the catheter was slowly w i t h d r a w n and the urethral perfusion channel recorded a nipple-pressure profile, and the maximum nipple pressure was determined (Fig. 1). The cecal reservoir was then filled to 500 mL, and the filling pressure was recorded. The peristaltic pressures were determined. Finally, the maximum nipple pressure was measured with the reservoir full. Observation was made for any incontinence or vesicoureteral reflux. We did not fill the cecal reservoir to a volume greater than 500 mL because that volume is more than sufficient for catheterization on a four to six-hour interval, and we did not w a n t the patients to exceed that volume during daily activities. Results Patients catheterized and emptied the reservoir an average of six times a day. All patients except 1 could detect sensation when the reservoir became full and most catheterized at that
TABLE II. Urodynamicdata Resting Nipple Max. Filling Pressure Pressure (em H20) at 500 mL volume Empty Full (em H20) 35 63 11 50 120 18 42 35 24* 32 28 7 37 37 12
Reservoir Max. Peristaltic Pressure (era H20) 32 50 52 62 18
*Maximum reservoir capacity 400 mL.
UROLOGY
/
JUNE 1990
/
VOLUME XXXV, NUMBER 6
545
FlCtYRE 1. Left, nipple pressure profile showing maximum nipple pressure of 37 cm water. Bight, radiograph (exposed at X, left) shows location of radiographic marker at urethral perfusion aperture within proximal end of nipple (staple line).
time. All patients had at least occasional slight diffieulty inserting a eatheter through the stoma, usually when the reservoir was overly full. None of the patients required assistanee in catheterizing the stoma, and eatheterizations performed by the investigators for the urodynamics studies were not noted to be diffieult. Two patients never experienced incontinence, and in 3 patients minimal incontinence would oceur if the interval of catheterization was too great. No patient experienced a symptomatic or febrile urinary tract infection. The urodynamie d a t a obtained in the study are summarized in Table II. The maximum nipple pressure with the reservoir empty (range 32-50 cm water, mean 39 em water) tended to be lower than w h e n full (range 28-120 cm water, mean 56 em water) but variability among patients was great. The pressure rise in the reservoir was gradual and reached its peak at 500 mL. In no patient did detrimental filling pressure develop. In all patients the pressure in the nipple exceeded the reservoir pressure during filling. Peristaltic contractions with elevation of reservoir pressure occurred in all patients. These pressures ranged from 18-62 cm water (mean 50 em water) and were of short duration. Concomitant with these pressure rises, the pressure in the nipple also increased (Fig, 2). In 1 patient (L,H.) the peristaltic pressure at reservoir capacity exceeded the nipple pressure and incontinence occurred. No other patient demonstrated incontinence, and none had vesicoureteral reflux' Excretory pyelograms showed mild dilation of the upper tracts in 2 patients but prompt function was noted in both. There was no evidence of upper urinary tract obstruction in the remaining 3 patients.
546
Comment The long-term success of a continent urinary reservoir is dependent on achieving four goals during the course of the procedure: (1) creation of a large-capacity, low-pressure reservoir, (2) protection of the upper urinary tracts from reflux and obstruction, (3) a controlled and simple method of draining the reservoir eontents, and (4) avoidance of fluid and electrolyte disturbanees. 5,9 This study demonstrates that the ileoeecal segment successfully accomplishes these goals. In contrast to reservoirs fashioned from small bowel, the ileocecal segment has a large capacity of > 200 mL immediately in the postoperative period. 10 The capacity continues to increase over time as demonstrated by all patients having a capacity of 500 mL or greater at the time of study. In no patient was urinary frequency a problem. In fact, because of the large capacity aH patients tended to prolong catheterization interval until minimal overflow incontinence was noted in 3 of 5 patients. Maintaining the catheterization interval to between four to six hours was adequate to prevent incontinence in all patients. Passive filling pressures were low in alt patients. Pressures increased with peristalsis, but were of short duration and the magnitude was not considered to be potentially detrimental to the upper tracts. Excessive reservoir filling and peristaltic pressures have been implicated as a cause of upper tract deterioration in other systems using the ileoeeeal segment for augmentation. 11Prolonged exposure to high pressures in a urinary reservoir is a possible cause of failure of an intussuscepted nipple valve and a source of incontinence. 12 C o n t i n u e d low reservoir
UROLOGY
JUNE i990
VOLUME XXXV. NUMBER 6
t00 H20
..... ,
0 NIPPLE
70cm.
a
a
0 GECOSTOMY FmURE 9~. Left, simultaneous recording of nipple and cecal reservoir pressures during filling, Scales of pressure measurement are different because of magnitude of nipple pressures. With peristaltic contractions (a), reservoir pressure rises to 45 cm water and nipple pressure to 110 cm water. No ~ncontinence occurs.
pressures in these patients m a y protect against future d a m a g e to the upper tracts or a loss of continenee. The use of a cuffed ureteral nipple has been described as an effective means of preventing reflux, la The procedure is simple and has provided adequate proteetion against reflux thus far in this group of patients. Fixation of the flush stoma to the anterior abdominal fascia has provided excellent stability to the continence mechanism. No patient has thus far experienced any signifieant difficulty w i t h catheterization. For patients with diminished m a n u a l dexterity catheterization of an abdominal wall stoma is more easily accomplished than intermittent urethral catheterization. Thus we r e c o m m e n d the use of an abdominal stoma with the ileoeeeal segment rather t h a n a urethral anastomosis for continent diversion in these patients. Ineontinence has not been a significant problem in our patients. All patients had increased nipple pressures associated with increases in reservoir peristaltic pressures, which m a y be indicative of a coordination that naturally occurs with the use of bowel segments that are in continuity. In all eases this increase in nipple pressure eoineided w i t h the inereased reservoir pressure and prevented ineontinenee. In I patient a slight delay in the onset of increased nipple pressure during peristaltic activity of the reservoir was associated with mild incontinence. This was only noted to occur at reservoir capacity and vcas resolved by shortening the catheterization interval. We conclude that the ileoceeal segment for continent urinary diversion provides a satisfaetory physiologic and functional result and. is assoeiated with a m i n i m a l complieation rate. While t h e long-term results are not yet known, the prelJiminary results are eneouraging. Continent diversion provides the patient an excellent
UROLOGY
/
JUNE 1990
/
VOLUME XXXV, NUMBER 6
alternative to standard conduit diversion, and w h e n questioned all patients expressed a high degree of satisfaction with the results. It is our impression that there is a signifieant improvem e n t in the overall quality of life and patient satisfaction with continent diversion compared with standard conduit diversion relying on external collection devices. Division of Urology Oregon Health Sciences University, L588 3181 S.W. Sam Jackson Park Road Portland, Oregon 97201 (DR. LOWE) Refer~ilces 1. Skinner DS, Boyd SD, and Lieskovsky G: Clinical experience with the Kock continent ileal reservoir for urinary diversion, J Urol 132:1101 (1984). 2. Olsson CA: Continent urinary diversion (editorial), J Urol 132:1157 (1984). 3. Kock NG: The development of the continent ileal reservoir (Kock Pouch) and application in patients requiring urinary diversion, in King LR, Stone AR, and Webster GD (Eds) : Bladder Reconstruction and Continent Urinary Diversion, Chicago, Year Book Medical Publishers, Inc., 1987, pp 269-290. 4. Webster GD, and Bertram RA: Continent catheterizable urinary diversion using the iIeoeeeal segment with stapled intussusception of the fleocecal valve, J Urol 135:465 (1986). 5. Goldwasser B, and Webster GD: Continent urinary diversion. J Urol 134:227 (i985). 6. Hedlund H, Lin&strom K, and Mansson W: Dynamics of a continent caeeal reservoir for urinary diversion, Br J Urot 56" 366 (1984). 7. Goldwasser B, Barret DM, and Benson RC: Complete bladder replacement using the detubularized right colon, in King LR, Stone AR, and Webster GD (Eds): o p c i t . , 3 pp 360-366. 8. Woo&side JR, and McGuire EJ: Clinical evaluation of new urodynamic catheter, Urology 26:95 (1985). 9. Thuroff JW, e t aI: The Mainz pouch (mixed augmentation ileum and cecum) for btadder augmentation and continent diversion, J UroI 136:17 (1986). 1O. Webster GD, and King LR: Further commentary: cecal bladder, in King LR, Stone AR, and Webster GD (E&S): o p cir., 3 pp 206-207. 11. Goldwasser B, and Webster GD: Augmentation and substitution enteroeystoplasty, J Urol 135:215 (1986). 12. Mansson W, Colleen S, and Sundin T: Continent caecal reservoir in urinary diversion, Br J Uro156:359 (1984), 13. Turner-Warwick R: Cystoplasty, in Blandy jP (Ed): UroIogy, Oxford, England, Blackwell Scientific Publications, t976.
547
