Urolithiasis After Ileal Conduit Urinary Diversion: A Comparison of Minimally Invasive Therapies

Mini-percutaneous nephrolithotomy versus retrograde intrarenal surgery for the treatment of 10-20-mm kidney stones in patients with ileal conduit: a comparative study

BACKGROUND

Both mini-percutaneous nephrolithotomy (mPNL) and retrograde intrarenal surgery (RIRS) are two major strategies for the endourological management of kidney stones. In the current study, we aimed to compare the efficacy and safety of mPNL and RIRS for the treatment of 10-20 mm kidney stones in patients with ileal conduit.

METHODS

Patients with a history of bladder cancer and ileal conduit who had undergone mPNL or RIRS for unilateral kidney stones 10-20 mm in size between January 2015 and June 2022 were retrospectively included. Baseline characteristics and perioperative outcomes were analyzed and compared between mPNL and RIRS.

RESULTS

The failure rate of the initial surgery was 2.5% and 18.9% for mPNL and RIRS, respectively (P=0.025). In total, 39 and 30 patients were finally included in the mPNL and RIRS groups. One-session stone-free rate (SFR) was higher in the mPNL group than the RIRS group (97.4% vs. 66.7%, P=0.002). However, there was no statistically significant difference between the two groups with regard to operation time, postoperative hospitalization, complications according to Clavien-Dindo classification, as well as the change in hemoglobin, creatinine, procalcitonin, and pain Visual Analogue Scale Score before and after the surgery. Moreover, Results were consistent across subgroup analyses in patients stratified by years (2015-2018 and 2019-2022).

CONCLUSIONS

Both mPNL and RIRS were feasible and safe for the treatment of 10-20 mm kidney stones in patients with ileal conduit. However, mPNL achieved superior SFR outcomes with a similar incidence of complications, and it might be a sensible alternative for selected patients.

Percutaneous Cystolitholapaxy Is Safe and Effective in Adult Patients With Lower Urinary Tract Reconstruction Utilizing Bowel

OBJECTIVE

To investigate the safety, efficacy, and surgical approach of percutaneous bladder calculi removal in adult patients with prior lower urinary tract reconstruction utilizing bowel using a single-institution database.

METHODS

Twenty patients with prior history of lower urinary tract reconstruction (continent cutaneous urinary reservoir, augmentation enterocystoplasty with catheterizable channel, or ileal neobladder) who underwent percutaneous cystolitholapaxy from 2014 to 2020 were identified from an IRB-approved database. Analysis of patient demographics, operative details, stone composition, stone-free rates, recurrence, and associated complications was performed.

RESULTS

Percutaneous access and either ultrasonic lithotripter or laser lithotripsy were utilized to remove bladder stones. Over half of the patients also underwent concomitant renal stone removal via percutaneous removal or retrograde ureteroscopy. Postoperative computed tomography imaging revealed complete bladder stone clearance in 90% of patients. There were no notable complications from percutaneous bladder stone removal and most patients were discharged either the same day or within 24hours. Urine and stone analysis revealed infection was present in the majority of patients. Bladder stones recurred in 45% of patients after more than 2years of follow-up, on average.

CONCLUSION

Percutaneous cystolitholapaxy is a safe and effective approach for the removal of moderate-sized bladder calculi in adults with prior lower urinary tract reconstruction utilizing bowel. Its efficacy and minimally invasive nature make it the approach of choice at our institution.

Ureteroscopy in Patients with Urinary Diversion: Outcomes and Lessons Learned from Two European Centres

Background

Ureteroscopy (URS) in patients with urinary diversion is technically challenging. Common difficulties include anastomotic strictures, tortuosity, and failure to cannulate the ureteric orifice. There are few studies reporting outcomes in this special population.

Objective

Our aim was to report outcomes at two tertiary centres in Europe.

Design setting and participants

A multicentre retrospective cohort study was conducted between 2010 and 2022.

Intervention

URS (antegrade and retrograde) procedures carried out in patients with urinary diversions.

Outcome measurements and statistical analysis

Outcomes of interest included success at cannulating the ureteric orifice, stone-free rate (SFR), and complications. A logistic regression analysis was performed to identify potential predictors for success at cannulating the ureteric orifice and success at completing the intended procedure in a single session.

Results and limitations

Fifty patients underwent 72 URS procedures, with most (86%) undergoing a retrograde approach. The majority (82%) of patients had undergone ileal conduit. Wallace was the commonest anastomosis type (64%). Ureteric anastomosis was cannulated successfully in 81% of cases. The most common reason for cannulation failure was the inability to identify the ureteric orifice (11%). A multivariable analysis revealed that an endourologist performing the case was associated with a significantly greater likelihood of cannulation success compared with consultants (odds ratio 25.9, p < 0.001). The mean operative time and hospital stay were 49 min (range: 11-126) and 1 d (range: 0-10), respectively. SFRs were 75% (zero fragments) and 81% (residual fragments ≤2 mm). No intraoperative complications were recorded. The overall postoperative complication rate was 6%. This study is limited by its retrospective status.

Conclusions

Endourological experience increases the likelihood of successful ureteric cannulation and procedural success. A low complication rate can be achieved despite this being a population with often multiple comorbidities.

Patient summary

Patients with previous bladder reconstructive surgery can undergo ureteroscopy with good outcomes. Surgeon experience increases the likelihood of treatment success.

Distal ureteral calculi in a patient with ileal conduit and urinary diversion treated via antegrade ureteroscopic lithotripsy: A case report

Ureteral calculi management in patients with urinary diversion is challenging for most urologists. The surgeon should consider the patient's diversion type, BMI, stone size and location, and his/her experience with the procedure. We report an 85-year-old ileal conduit diversion man presented with ureteral calculi and treated via antegrade ureteroscopic lithotripsy.

Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management

Since their introduction into clinical practice in the 1950s, ileal conduits have been the most common type of urinary diversion used after radical cystectomy worldwide. Although ileal conduits are technically simpler to construct than other forms of urinary diversion, a variety of complications can occur in the early and late postoperative periods. Early complications include urine leakage, urinary obstruction, postoperative fluid collection (eg, urinoma, hematoma, lymphocele, or abscess), and fistula formation. Late complications include ureteroileal anastomotic stricture, stomal stenosis, conduit stenosis, and urolithiasis. Although not directly related to ileal conduits, ureteroarterial fistula can occur in patients with an ileal conduit. Interventional radiologists can play a pivotal role in diagnosis and management of these complications by performing image-guided minimally invasive procedures. In this article, the authors review the surgical anatomy of an ileal conduit and the underlying pathophysiology of and diagnostic workup for complications related to ileal conduits. The authors also discuss and illustrate current approaches to interventional radiologic management of these complications, with emphasis on a collaborative approach with urologists or endourologists to best preserve patients' renal function and maintain their quality of life. ^©RSNA, 2020.

Distal ureteral stone in an ileal conduit: A case treated by antegrade flexible ureteroscopic lithotripsy

Antegrade flexible URSL is a minimal invasive option for treating distal ureteral stones in patient after urinary diversion.

Case report: Treatment of urinary calculi using percutaneous nephrolithotomy in patient with ileal conduit and history of bladder transitional cell carcinoma

Urinary calculi are a frequent complication of urinary diversion following radical cystectomy, including in ileal conduit systems. We report the case of a 38-year-old man with ileal conduit urinary diversion, following radical cystectomy for transitional cell cancer, who presented with symptomatic bilateral kidney stones. By reporting the medical record and management procedure for this patient, we aim to demonstrate the successful management of kidney stones via supine percutaneous nephrolithotomy, using an Alken telescopic metal dilator, under spinal anesthesia. Consistent with most literature, percutaneous nephrolithotomy was the best management procedure in this case.

Risk factors of calculi in upper urinary tract after radical cystectomy with urinary diversion

INTRODUCTION AND OBJECTIVES

The study was conducted to identify the risk factors of upper tract stone formation in patients with diversions after radical cystectomy (RC).

MATERIALS AND METHODS

All patients with diversion after RC were collected in our center from January 2005 to December 2013. Three different common diversions were included: Orthotopic neobladder (ON: 168 patients), Ileal Conduit (IC: 93 patients) or Ureterocutaneostomy (UC: 104 patients). Univariable and multivariable logistic regression analysis were conducted to identify the independent predictors of stone formation in the upper tract.

RESULTS

A total of 365 consecutive patients (316 males, 49 females) were included. At a median follow-up of 48 months (range 12-65 months), 36 patients (9.9%) developed upper tract stone. Among them, 26 (72.2%), 5 (13.9%) and 5 (13.9%) patients underwent ON, IC and UC, respectively. 25 patients had renal stone and 11 ureter stone. Minimally invasive operations (endoscopic laser lithotripsy via the anterograde or retrograde approach in 24 cases, percutaneous nephrolithotomy in 9 cases and shock wave lithotripsy in 3 cases) were carried out successfully in all stone cases. On univariable and multivariable logistic regression analysis, diabetes mellitus, hypertension, urinary tract infection (UTI), anastomotic stenosis and types of diversions (P<.05) were positively associated with upper tract stone formation.

CONCLUSIONS

The variable predictors of upper tract stone may contain diabetes mellitus, hypertension, UTI, anastomotic stenosis and types of diversion.

Treatment of urinary calculi after Yang-Monti ileal ureter reconstruction: a case report

BACKGROUND

The development of ureteral calculi after Yang-Monti ileal ureter reconstruction has not been reported. This study was performed to explore the safety and effectiveness of ureteroscopy combined with laser lithotripsy in the treatment of ipsilateral lower ureteral calculi and lower calyceal calculi after Yang-Monti ileal ureter reconstruction.

CASE PRESENTATION

A 48-year-old man was admitted to our hospital with ipsilateral distal ureteral calculi and ipsilateral lower calyceal calculi. One year prior to this admission, the patient had undergone Yang-Monti ileal ureter reconstruction due to long-segment ureteral stenosis. After conservative treatment failed, we used a rigid ureteroscope with a holmium laser to break up the distal ureteral calculi, and successfully removed the renal calculi with a digital flexible ureteroscope and basket extractor.

CONCLUSION

The successful outcome of the present case suggests that ureteroscopy combined with laser lithotripsy is a valuable option for the management of urinary calculi following Yang-Monti ileal ureter reconstruction.

Endourologic strategies for a minimally invasive management of urinary tract stones in patients with urinary diversion

Objective

To present our experience in minimally invasive management of urinary tract stones in patients with urinary diversion.

Materials and Methods

We retrospectively reviewed 26 patients with urinary tract stones after cystectomy and urinary diversion. The types of urinary diversion were ileal conduit, colon conduit, ileal orthotopic neobladder in 19, 4, and 3 patients, respectively. At postoperative days 2, a plain KUB and urinary ultrasonography were performed in order to assess stone fragmentation or hydronephrosis. According to postoperative imaging, stone free rate (SFR) was defined as complete absence of fragments or residual stones less than 4mm.

Results

19 patients were treated with minimally invasive percutaneous lithotripsy (MPCNL) and 2 patients required second-look MPCNL. Anterograde flexible ureteroscopy was performed in 2 patients, while in 2 patients a combined anterograde and retrograde approach was required. Three reservoir stones were treated by transurethral neo-bladder lithotripsy. Postoperative significant complications occurred in 2 patients (7.7%). The highest percentage of stone composition was struvite, as a result of chronic urinary tract infection (UTI). SFR was 88.5% (23 of 26).

Conclusions

Our experience showed that MPCNL is a safe and effective treatment modality with little morbidity for renal and upper ureteral stones in patients with urinary diversion. For middle and lower ureteral stones, an anterograde approach could be also considered as a first line treatment, but a combined anterograde and retrograde approach was required when the anterograde access alone cannot provide acceptable results.

Symptomatic Distal Ureteral Stone in an Ileal Ureter: Treatment by Combined Supine Ureteroscopy and Mini Percutaneous Nephrolithotomy

Urolithiasis is a well-known and common late complication in patients with urinary diversion. Patients without urinary diversion lead to symptoms such as hematuria and ureteral colic, whereas stones in patients with urinary diversion tend to be asymptomatic and are often diagnosed incidentally during staging examinations of oncologic diseases. We report the case of a 64-year-old male patient with a lower pole kidney stone and a stone in the ileal ureter substitution. He presented with diffuse abdominal and left-sided flank pain. CT revealed the diagnosis of urolithiasis in the ileal ureter substitution and the lower pole of the left kidney. We performed a combined retrograde, flexible ureteroscopy and a mini percutaneous nephrolithotomy (combined intrarenal surgery) without any complications and no residual stone fragments postoperatively. This case presentation demonstrates that in patients with urinary tract diversion, urolithiasis can still cause problems.

Retrograde Endourological Management of Upper Urinary Tract Abnormalities in Patients with Ileal Conduit Urinary Diversion: A Dual-Center Experience

INTRODUCTION

Patients with ileal conduit urinary diversions are at an increased risk of long-term upper urinary tract (UUT) complications, including anastomotic strictures, infections, and urolithiasis. The reconstructed urinary system poses challenges for endoscopic manipulation. We present and describe our dual-center experience in performing retrograde ureteroscopy to treat or diagnose UUT abnormalities in patients with ileal conduit incontinent diversion.

PATIENT AND METHODS

We performed a retrospective analysis of medical records for all patients with previous urinary diversion who underwent retrograde ureteroscopic procedures via the ileal loop in our institutions over a 9 year period (between June 2007 and August 2016).

RESULTS

Fifty-four procedures were performed in 36 patients. Mean age was 61 (28-90) years. Average time from diversion to ureteroscopic procedure was 13.0 (0.08-53) years. Stone disease was the most common indication for intervention in 35.2% (19/54) of cases, with a stone-free rate of 78.9% (15/19). Other indications included surveillance of transitional-cell carcinoma in 22.2% (12/54), diagnostic flexible ureteroscopy (fURS) in 20.4% (11/54), stricture management in 11.1% (6/54), removal of encrusted stent/nephrostomy in 7.4% (4/54), urine leak after diversion in 1.9% (1/54), and miscellaneous in 1.9% (1/54). Successful retrograde access was possible in 74% (40/54) of cases. A long and tortuous ileal segment, too difficult to negotiate, was the most common cause of failure to access the UUT. In 13 out of 54 (24.1%) cases, retrograde fURS was combined with simultaneous percutaneous antegrade access. Six patients (11.1%) developed postprocedural pyrexia requiring additional antibiotic therapy, and one (1.9%) patient required embolization of the renal artery for ongoing bleeding. Median length of stay was 1 day (0-55), with 13 (24%) being performed as day-case procedures.

CONCLUSIONS

Retrograde ureteroscopy in patients with ileal conduits can be technically challenging due to distorted anatomy. This procedure can be safely performed in experienced hands with standard endourological equipment. An antegrade approach can be carried out simultaneously, which may be required in a small number of patients.

Stones in special situations

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

Percutaneous Nephrolithotomy in a Patient with Mainz Pouch II Urinary Diversion: A Case Report

Mainz pouch II is a reliable and viable technique of continent urinary diversion. Patients are at increased risk of long-term complications including urolithiasis of the upper urinary tract and reservoir. We report the case of a 67-year-old male with prior Mainz pouch II due to invasive bladder cancer treated for a large renal calculus. Percutaneous nephrolithotomy (PCNL) was successfully performed. Stone management in these type of patients is of increased interest due to existed "anatomical challenges" concerning the access and safety during the procedure. To our knowledge this is the first case of PCNL in a patient with Mainz pouch II that has been reported in the literature.

Retrograde ureteroscopy via a continent urinary diversion: surgical techniques and common pitfalls

PURPOSE

We assessed our experience performing retrograde ureteroscopy (URS) in patients with a continent urinary diversion.

METHODS

A retrospective review was performed of patients with a continent urinary diversion necessitating URS for diagnostic or therapeutic purposes from 2002 to 2013.

RESULTS

We identified 11 male and 1 female patients with a continent urinary diversion with a mean age of 62.5 years (27-77) who underwent 13 procedures on 17 renal units. Indication for URS was diagnostic in 10 (77%), stone disease in 2 (15%), and stricture in 1 (8%). URS was attempted a median of 6.2 years (1.3-14.5) after diversion creation. Retrograde URS was attempted in 17 renal units with 10 (59%) accessed successfully. One procedure was staged with antegrade wire access obtained before retrograde URS. Inability to identify the afferent limb or ureteral orifice one (20%), tortuosity of afferent limb two (40%), angulation one (20%), and length of the afferent limb one (20%) were causes for unsuccessful retrograde URS. Of the successfully attempted retrograde URS, 75% occurred within the past 5 years. There were no complications in the successful retrograde URS group. Ureteral stents or nephrostomy tubes were left in place postprocedure in six (50%) patients.

CONCLUSION

While technically challenging, retrograde URS can be performed successfully in patients with an orthotopic neobladder once the learning curve for the procedure is overcome.

Antegrade percutaneous flexible endoscopic approach for the management of urinary diversion-associated complications

PURPOSE

We present our experience in the minimally invasive management of postoperative complications associated with urinary diversions using an ureteral access sheath (UAS) in an antegrade approach.

PATIENTS AND METHODS

From 2005 to 2011, 21 antegrade flexible ureteroscopies (F-URS) were performed in 17 patients with a urinary diversion. Urinary diversions in this population consisted of ileal conduits, orthotopic neobladders, catheterizable pouches, and an ureterosigmoidostomy in 9, 5, 2, and 1 patients, respectively. The most important reason for treatment was recurrent upper urinary tract infection. The indication for intervention was stone disease in 15 procedures and strictures in 6 cases. In two patients, "staged-therapy" was performed. Using UAS in an antegrade approach was the main concept.

RESULTS

A nephrostomy tube was already in place in 14 (66.6%) procedures, which was the access route used. Successful puncture was performed in all other patients. Eighty percent of patients were rendered stone free after the first antegrade session. Moreover, all strictures were successfully managed by dilation. In two sequential procedures in a patient, there was an inability to perform stone treatment because of abnormal position of the ureter (kinked), which did not allow the ureterorenoscope to pass. All other procedures were uneventful. Postoperative complications were reported in four procedures. There was significant urinary tract infection in two patients as well as an obstructed nephrostomy tube in two patients.

CONCLUSION

An antegrade endoscopic procedure using UAS in patients who present with stones or ureterointestinal stricture as late complications of urinary diversion is a feasible, well-tolerated technique, especially when using smaller access sheaths.