Urinary Calculi as a Late Complication of the Indiana Continent Urinary Diversion: Comparison with the Kock Pouch Procedure

Obstructive Uropathy: a retained urethral catheter within an ileal conduit

Following an ileal conduit (IC) urinary diversion for intractable urinary incontinence, a woman in her 50s presented with deteriorating renal function during a routine follow-up. This decline prompted further investigation with an ultrasound scan (USS), which demonstrated bilateral hydroureteronephrosis and an atrophic left kidney. Although the mercaptoacetyltriglycine (MAG-3) renogram was inconclusive in revealing urinary obstruction, a subsequent computed tomography (CT) scan uncovered a calcified tube-like structure within the IC and hydroureteronephrosis extending to this level.To address the obstructive uropathy, a right nephrostomy was inserted, which resulted in improved renal function. A looposcopy was then performed, revealing an encrusted urethral catheter within the IC. Using techniques adapted from percutaneous nephrolithotomy, we were able to endoscopically fragment the encrustation on the catheter and remove it intact through the IC.

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.

A giant neobladder stone with insignificant symptoms: A case report and literature review

Background

Giant neobladder lithiasis after orthotopic bladder replacement is an infrequent but important long-term complication, which should be diagnosed and treated early. If left untreated, it may eventually lead to irreversible acute kidney injury and seriously affect the quality of life of patients. Here, we present a rare case of a patient who presented with a massive neobladder stone after radical cystectomy done with orthotopic neobladder construction, followed by a challenging stone extraction process.

Case presentation

A 70-year-old female patient presented with a massive neobladder stone 14 years after radical cystectomy done with orthotopic neobladder construction. A computed tomography scan showed a large elliptic stone. The patient underwent suprapubic cystolithotomy surgery, which removed her giant-sized stone in the neobladder. The size of the bladder stone that was removed was 13 cm × 11.5 cm × 9 cm, with a total weight of 903 g. To date, the follow-up time of treatment is 4 months, and in our patient, no pain, urinary tract infections, or other abnormalities suggestive of fistula were found.

Conclusion

Imaging examination is useful for detecting neobladder lithiasis occurring after orthotopic neobladder construction. Our experience demonstrates that open cystolithotomy is an appropriate therapeutic method for treating the late-stage complication of a giant neobladder stone.

Current Indications and Techniques for the Use of Bowel Segments in Pediatric Urinary Tract Reconstruction

Today, there are few indications for the use of bowel in pediatric urology. This is in large extent due to the successful conservative therapy in patients with neurogenic bladder and the improved success of primary reconstruction in patients with the bladder exstrophy-epispadias complex. Only after the failure of the maximum of conservative therapy or after failure of primary reconstruction, bladder augmentation, or urinary diversion should be considered. Malignant tumors of the lower urinary tract (e.g., rhabdomyosarcomas of the bladder/prostate) are other rare indications for urinary diversion. Replacement or reconstruction of the ureter with a bowel segment is also a quite rarely performed procedure. In this review, the advantages and disadvantages of the different options for the use of bowel segments for bladder augmentation, bladder substitution, urinary diversion, or ureter replacement during childhood and adolescence are discussed.

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.

Management of neobladder complications: endoscopy comes first

OBJECTIVE

The aim of this study was to report the functional outcome after endoscopic management of neobladder complications.

MATERIALS AND METHODS

Out of 197 patients who underwent radical cystectomy and orthotopic ileal neobladder reconstruction between 2007 and 2013, 30 patients with delayed postoperative complications were enrolled in this study. Complications were in the form of: eight patients with outflow obstruction, 12 with ureteroenteric stricture, nine with neobladder calculi and one with an isolated recurrent papillary tumor inside the neobladder. Patients were followed up regularly to assess the outcomes of endoscopic treatment.

RESULTS

The mean maximum flow rate and postvoiding residual urine after endoscopic treatment of outflow obstruction were 18.2 ± 3.9 ml/s and 28.7 ± 11 ml, respectively. Ten patients with ureteroenteric stricture showed resolution of hydronephrosis after antegrade dilatation and JJ-stent fixation, with two patients requiring open surgery owing to impassable strictures. Complete clearance of neobladder calculi occurred after endoscopic neocystolithotripsy, with two patients requiring two sessions owing to large calculi. Transurethral resection of the neobladder for isolated tumor recurrence was performed in one patient over two sessions, followed by adjuvant chemoirradiation.

CONCLUSIONS

Endourological management of orthotopic neobladder problems is the safest choice. It avoids the difficulties and complications of open surgery and has durable results.

Long-term third-party assessment of results after continent cutaneous diversion with Lundiana pouch

OBJECTIVES

To investigate the long-term functional outcomes and complications after continent cutaneous diversion with the Lundiana pouch.

PATIENTS AND METHODS

Complications, re-operations, renal function, and continence were ascertained from patient charts. Outcome variables were validated by a second and independent review of the patient files.

RESULTS

A complication of Clavien-Dindo grade ≥III, including unscheduled re-admissions, occurred in 45/193 patients (23%) at ≤90 days of surgery. At a median follow-up of 13 years, 105/193 patients (54%) had undergone at least one re-operation, with uretero-intestinal stricture being the most prevalent cause [28 patients (15%)]. Re-operations were more prevalent in patients operated during the first half of the study period than during the second half (2000-2007; 62% vs 47%; P = 0.03), and they were also more frequent in patients who underwent surgery for benign causes than in patients who underwent surgery for malignancy (60% vs 51%; P = 0.04). Continence was achieved in 172/188 patients (91%). In all, 16% of all patients required revisional surgery of the outlet to remain continent with an easily catheterisable pouch or to address stomal stenosis. The mean decrease in estimated glomerular filtration rate was more pronounced in patients with benign indications for urinary diversion than in those with malignancies, even after adjusting for younger age at surgery and longer follow-up in the former group (22 vs 11 mL/min/1.73 m² ; P < 0.006). A disinterested third-party assessment revealed 10 postoperative complications, 17 re-operations during follow-up, and seven occasions of hospitalisation due to pyelonephritis (included in data above) not recorded at the primary data review.

CONCLUSIONS

The Lundiana pouch is associated with a high risk of re-operation, although the functional results are good. Independent review by a third party increased the validity of the outcome data.

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.

Characterization of Urolithiasis in Patients Following Lower Urinary Tract Reconstruction with Intestinal Segments

PURPOSE

Urinary diversion and augmentation cystoplasty are associated with long-term complications, including metabolic derangements, infectious complications, and urolithiasis. The aim of this series was to characterize upper and lower urinary tract (LUT) calculi in this population.

METHODS

A retrospective chart review was performed on all patients with a history of urinary diversion or augmentation cystoplasty who subsequently underwent treatment for urolithiasis between January 1998 and May 2015. Data collected included demographics, perioperative characteristics, type of reconstructive procedure, urine culture, stone analysis, and metabolic evaluation. A statistical analysis was performed.

RESULTS

Ninety-nine patients were identified with a history of urolithiasis and incontinent urinary diversion (28), neobladder (21), continent cutaneous diversion (12), and augmentation cystoplasty (38). LUT stones were more common than upper tract stones in all except for incontinent diversions, which only had one lower tract stone (p = 0.0001). Twenty-three percent of stones were metabolic. Several metabolic derangements were noted, including hypocitraturia (100%), elevated urine pH (100%), low urine volume (70%), and hyperoxaluria (35%). There was a 44% rate of recurrent urolithiasis.

CONCLUSIONS

Given the high rate of stone recurrence among patients with a history of urinary diversion and augmentation cystoplasty, all measures should be taken to prevent recurrent stones. In addition to actions aimed to prevent infectious stones such as bladder and pouch irrigation, we recommend these patients undergo a full metabolic workup with targeted dietary changes and medical therapies.

Holmium: Yttrium Aluminium Garnet Laser Lithotripsy for Symptomatic Kock Pouch Calculi

Kock first described continent ileostomy for fecal diversion in 1969 as an alternative procedure to conventional ileostomy. Later, this procedure was replaced by restorative proctocolectomy with ileal pouch anal anastomosis as the procedure of choice. The main reasons for its virtual abandonment include technical difficulty, high morbidity, and the need for a stoma. To our knowledge, this report is the first published case of successful enterolith destruction and retrieval from a Kock pouch, using a Holmium: yttrium aluminium garnet laser. This outpatient procedure can avoid the morbidity and cost of a laparotomy.

Bladder calculi in the augmented bladder: a follow-up study of 160 children and adolescents

INTRODUCTION

Bladder augmentation (BA) has been used for various congenital and acquired conditions to create a low pressure, continent catheterizable reservoir. The prevalence of calculi within the BA have been reported to be from 3 to 52.5%. The present study reports the prevalence and risk factors of bladder calculi in patients with BA.

MATERIAL AND METHODS

A retrospective review of 160 patients was performed from January 1997 through December 2012. The various risk factors for the formation of bladder calculi such as the nature of the anatomical defect, presence of preoperative urinary calculi, type of bowel augmentation, addition of a mitrofanoff and/or bladder neck procedure, prevalence of post-operative urinary tract infections (UTIs), need for mitrofanoff revision due to stenosis/difficulty catheterization, postoperative significant hydronephrosis and bladder calculi were recorded for analysis. The children underwent open removal or endoscopic cystolithotripsy. One hundred and eight males and 52 females (average age 6.3 years) were followed up for a median of 70.5 months. All patients performed daily bladder irrigation with tap or drinking water.

RESULTS

Post-operative bladder calculi were noted in 14 (8.8%) of 160 patients following BA. Median time to stone formation was 37.5 months (11-120 months). Recurrent febrile UTIs were noted in 16 of the 160 patients following BA. The various risk factors and their outcomes are summarized in table. Eight patients underwent open cystolithotomy and four patients were treated by cystolithotripsy. Post-operative recurrent bladder calculi were noted in 2 patients. Multivariate analysis revealed that exstrophy/epispadias (OR 17.2) and recurrent UTI (OR 55.4) were independent risk factors for developing postoperative calculi in bladder augmentations. All other risk factors did not achieve statistical significance.

DISCUSSION

There seemed to be no difference in the prevalence of calculi in the ileal or colonic augmentations. Mucus secreted by the bowel segment blocks catheters leading to incomplete drainage, stagnation and UTIs. Our protocol consists of daily bladder irrigation till the effluents are clear of mucus. This is probably the key to the low prevalence of postoperative calculi (8.8%) in our patients.

CONCLUSION

Bladder exstrophy/epispadias and UTIs are independent statistically significant risk factors for the formation of bladder calculi in BA patients. Other risk factors such as preoperative calculi, bladder neck procedures and the use of mitrofanoff though not statistically significant, may contribute to the overall risk. The performance of daily bladder irrigation is an important part of our management of mucus.

Surgical management of urolithiasis in patients after urinary diversion

OBJECTIVE

To present our experience in surgical management of urolithiasis in patients after urinary diversion.

PATIENTS AND METHODS

Twenty patients with urolithiasis after urinary diversion received intervention. Percutaneous nephrolithotomy, percutaneous based antegrade ureteroscopy with semi-rigid or flexible ureteroscope, transurethral reservoir lithotripsy, percutaneous pouch lithotripsy and open operation were performed in 8, 3, 2, 6, and 1 patients, respectively. The operative finding and complications were retrospectively collected and analyzed.

RESULTS

The mean stone size was 4.5 ± 3.1 (range 1.5-11.2) cm. The mean operation time was 82.0 ± 11.5 (range 55-120) min. Eighteen patients were rendered stone free with a clearance of 90%. Complications occurred in 3 patients (15%). Two patients (10%) had postoperative fever greater than 38.5 °C, and one patient (5%) suffered urine extravasations from percutaneous tract.

CONCLUSIONS

The percutaneous based procedures, including percutaneous nephrolithotomy, antegrade ureteroscopy with semi-rigid ureteroscope or flexible ureteroscope from percutaneous tract, and percutaneous pouch lithotripsy, provides a direct and safe access to the target stones in patients after urinary diversion, and with high stone free rate and minor complications. The surgical management of urolithiasis in patients after urinary diversion requires comprehensive evaluation and individualized consideration depending upon the urinary diversion type, stone location, stone burden, available resource and surgeon experience.

Radical cystectomy with W-shaped orthotopic ileal neobladder constructed with non-absorbable titanium staples-long term follow-up

PURPOSES

We retrospectively assessed our experience with the W-shaped orthotopic ileal pouch, which was constructed with non-absorbable titanium staples. For these purpose, we discuss the results of bladder capacity, urinary continence and early and long-term postoperative complications.

MATERIALS AND METHODS

We included in the study 17 patients who underwent radical cystoprostatectomy followed by construction of an orthotopic W-shaped ileal pouch between October 2000 and November 2009. A 65-70 cm segment of ileum was isolated and prearranged into a W-configuration, leaving two 10 cm intact segments on both sides of the ileal fragment. In our technique we entirely anatomized all adjacent limbs in order to create a sphere-shaped pouch. The ureters were directly anastomized to both intact segments of the ileal division. All our patients underwent pouchscopy 6 months after operation and annually.

RESULTS

Mean operative time for neobladder reconstruction and ureteral anastomoses was 87 ± 7.67 minutes. In one patient a leak from the ileo-ileal anastomosis was confirmed on the 3rd day after operation. In 2 cases unilateral stricture of the ureteral-neobladder anastomosis was documented. Staple lines were mostly covered with ileal mucosa after 6 months. The mean functional bladder capacity was 340 ± 27.6 mL and 375 ± 43.4 mL at 6 and 12 months, respectively. First-year daytime and nighttime continence was good and acceptable in 90% and 78% of patients, while it increased to 95% during the 2nd year.

CONCLUSIONS

The long term follow-up shows that non-absorbable titanium staples can be safely used for creation of an orthotopic ileal neobladder. However, these data should be further validated in a larger series of patients.

Neobladder long term follow-up

One of the commonest forms of orthotopic bladder substitution for bladder cancer survivors, used in our institute, is the use of ileocecal segment. Sometimes, the need for Indiana pouch heterotropic continent diversion arises.

AIM

To compare the long-term effect of orthotopic ileocecal bladder and heterotropic Indiana pouch following radical cystectomy in bladder cancer patients.

PATIENTS AND METHODS

Between January 2008 and December 2011, 91 patients underwent radical cystectomy/anterior pelvic exentration and orthotopic ileocecal bladder reconstruction (61 patients) and Indiana pouch (30 patients), when orthotopic diversion could not be technically or oncologically feasible.

RESULTS

Convalescence was uneventful in most patients. All minor and major urinary leakage cases, in both diversions groups, where successfully conservatively treated. Only one patient in the ileocecal group with major urinary leak required re-exploration with successful revision of uretro-colonic anastomosis. Only one patient in the Indiana pouch group had accidentally discovered sub-centimetric stone, which was simply expelled. The overall survival proportion of ileocecal group was 100% compared to 80% in the Indiana pouch group (p<0.001). The disease free survival proportion of ileocecal group was 90.8% compared to 80% in the Indiana pouch group (p=0.076). Effective comparative daytime and nighttime urinary continence as well as renal function deterioration were not statistically significant between both reconstruction types.

CONCLUSION

Both ileocecal bladder and Indiana pouch are safe procedures in regard to long-term effects over kidney function following radical cystectomy.

Use of nonabsorbable staples for urinary diversion: a step in the wrong direction

BACKGROUND

The use of bowel segments incorporated into the urinary tract is well established in urological surgery.

OBJECTIVE

To describe and compare the use of absorbable and nonabsorbable staples for creation of a urine reservoir after radical cystectomy.

MATERIALS AND METHODS

This review is based on a systematic Medline search assessing the period 1950-2010.

RESULTS

Use of the autosuture stapling device for the construction of the urinary diversion significantly reduces operating time. Johnson and Fuerst reported its use for the first time to construct a ureteroileocutaneous urinary diversion in 1973. However, many studies demonstrated that exposed metal staples represent a nidus for stone formation when they are in direct contact with urine, particularly in urinary diversions such as Kock pouch and ileal conduit. Stone formation has been attributed in part to the use of nonabsorbable artificial materials, such as metal staples and Marlex mesh, strictures of the pouch and accumulation of mucus. The treatment options for pouch calculi include observation for spontaneous passage, extracorporeal shockwave lithotripsy, percutaneous or endoscopic lithotripsy/lithotomy.

CONCLUSIONS

Historically, the mean time to stone formation with nonabsorbable material (staples, Marlex mesh) is 34 months. None of the studies on use of nonabsorbable staples in urinary diversion has such a long follow-up. Until further studies with more appropriate observation time are completed, the use of nonabsorbable staples for continent and noncontinent urinary diversion should be discouraged.

Metabolic changes after urinary diversion

Urinary diversion is performed on a regular basis in urological practice. Surgeons tend to underestimate the metabolic effects of any type of diversion. From the patient's perspective, diarrhea is the most bothersome complaint after urinary diversion. This might be accompanied by malabsorption syndromes, such as vitamin B12 deficiency. Electrolyte abnormalities can occur frequently such as hyperchloremic metabolic acidosis, or less frequently such as hypokalemia, hypocalcaemia, and hypomagnesaemia. Bone health is at risk in patients with urinary diversion. Some patients might benefit from vitamin D and calcium supplementation. Many patients are also subject to urinary calculus formation, both at the level of the upper urinary tract as in intestinal reservoirs. Urinary diversion can affect hepatic metabolism, certainly in the presence of urea-splitting bacteria. The kidney function has to be monitored prior to and lifelong after urinary diversion. Screening for reversible causes of renal deterioration is an integral part of the followup.

Chapitre A - Lithiase et vessie neurogène

Stones of the upper and lower urinary tract are frequently observed in spinal cord injury patients. In this article, the authors reviewed the literature to identify the most reliable tools for diagnosis and follow-up. A review of recently published series demonstrated an excess risk of kidney and bladder stones in this population. The authors discuss the possible measures of prevention and identification of high-risk groups likely to benefit from more intensive follow-up.

Laparoscopic-assisted radical cystectomy with U-shaped orthotopic ileal neobladder constructed using nonabsorbable titanium staples

INTRODUCTION

Recently, nonabsorbable staples have been safely used in a variety of urologic open and laparoscopic extirpative and reconstructive procedures. We report the surgical steps of our technique of U-shaped orthotopic ileal neobladder created with titanium staples.

TECHNICAL CONSIDERATIONS

Using stay stitches, a 45 to 50-cm ileal segment is arranged in a U shape with two segments of approximately 20 cm and an afferent limb of 5 or 10 cm. An opening is made at the lowest point of the U-ileal segment on its antimesenteric border. The jaws of the 80 x 3.5-mm nonabsorbable mechanical stapler are accommodated within the bowel loop and fired twice, bringing together and detubularizing approximately 15 cm of each arm of the U. To complete the pouch detubularization, another small opening is made at the bottom of the chimney on its medial border. After this, a third nonabsorbable mechanical stapler had its jaws introduced through this opening and through the open end of the bowel segment on the right side and the stapler is fired, completing the U pouch. Subsequently, the open ends of the U segment and the opening made at the base of the afferent limb are closed with absorbable running sutures.

CONCLUSIONS

Our technique is feasible and may represent an alternative to expand the spectrum of continent urinary reservoirs that could be expeditiously created with nonabsorbable staples. Continued surveillance is mandatory to determine the lithiasis-inducing potential of these titanium staples within the urinary tract.

Metabolic factors in the causation of urinary tract stones in patients with enterocystoplasties

Stones are a common complication of the storage of urine in intestinal reservoirs. Previous studies have identified predisposing physical characteristics in the reservoirs. Biochemical and dietary factors have been little investigated. Fifteen patients (6 males and 9 females) who had undergone various enterocystoplasty operations and who had subsequently formed either upper or lower urinary tract stones were investigated. The programme has been previously described and included stone, blood and urine analysis and dietary review. Comparison was made with 15 age- and sex-matched idiopathic stone formers with normal bladders. Stones were infective in origin in 86% of cases, and 14% were sterile. Metabolic screen showed that 80% of enterocystoplasty patients had risk factors for at least three different types of stone. All patients had raised pH (mean 6.93) and hypocitraturia. Five had a raised alkaline phosphatase. Raised serum and urinary calcium, hyperoxaluria and hyperuricosuria were found in 33% of patients. Five had a 24-h urine volume below 1.6 l/day. All patients had a high risk index (PSF) for phosphatic stones and 12 also for calcium oxalate stones. Compared to age-and sex-matched idiopathic stone-formers, the urine had a higher pH, sodium and protein excretion and a lower calcium and citrate excretion. Although the patients were already selected as stone-formers, the data show that metabolic and dietary factors are present. They may be as important in the aetiology of the stones, as the already recognised factors of infection and poor reservoir drainage. Investigation should include such factors, the presence of which may be taken into account in a prophylactic regime.

Intestinal oxalate absorption in patients with continent urinary diversion

The objective of the study is to evaluate the post-operative effect of an orthotopic ileal neobladder or a Mainz pouch I bladder replacement on the extent of intestinal oxalate absorption. Gastrointestinal oxalate absorption was measured in six patients with an orthotopic ileal neobladder and in six patients with a Mainz pouch I bladder replacement. The function test applied was the [13C2]oxalate absorption test. With a range of 5.1-12.4%, the oxalate absorption of these patients was well within the reference range for healthy volunteers. The results from our small study indicate that such continent urinary diversions present no hazard for oxalate hyperabsorption and subsequent calcium oxalate urolithiasis.

Medial thigh pain: neurology or urology?

Flank pain, irritative urinary symptoms, and hematuria are traditional symptoms of urolithiasis. We report a case of urolithiasis in a neobladder in a patient with a chief complaint of medial thigh pain.

Sigmoid impaction secondary to urinary stones: case report and review of literature

BACKGROUND

This is the first case report of a Miami pouch sigmoid fistula developing passage of urinary stones resulting in the presentation of constipation secondary to impaction.

CASE REPORT

A 49-year-old woman who developed a recurrence of invasive squamous cell cervical carcinoma 1 year after pelvis radiation. She then underwent anterior pelvic exenteration and creation of a Miami pouch. Approximately 14 years after the primary radiation therapy and 13 years after the creation of the exenterative procedure, the patient developed a Miami pouch sigmoid fistula. The decision was made at this time to repair the fistula and remove the urinary stones from the sigmoid colon. Postoperatively, the patient remained continent using intermittent catheterization of the pouch and there was no evidence of recurrence of the cancer.

CONCLUSION

Conservative management of urinary reservoir complications should always be considered before surgical intervention is attempted. When indicated, surgical management should not be delayed.

Urolithiasis in enterocystoplasties

The incidence of stones in patients with enterocystoplasty is reported as 12-52.5%. Most patients will have multiple physical factors such as immobility, need for self catheterisation and poor urine drainage, so that it is not certain that an intestinal reservoir is the cause of stones on its own. There is little or no evidence that mucus is an aetiological factor. Foreign bodies in the reservoir, such as staples, increase the risk of stone formation from 13% to 43%. Stones require surgical removal. Minimally invasive techniques may be used for small stones. A low velocity disintegrator is required so that fragments are not propelled into the intestinal mucosa. Stones are infective in origin in 86% of cases, but 14% are sterile. Metabolic screen shows that 80% of patients have risk factors for at least three different types of stone. All patients have raised pH (mean 6.93) and hypocitraturia. Raised serum and urinary calcium, hyperoxaluria and hyperuricosuria are found in up to 33% of patients.

Surgical complications of urinary diversion

We comprehensively reviewed the published literature on urinary diversion, specifically examining the surgical complications associated with conduit, continent cutaneous diversion and orthotopic urinary diversion. Appropriate patient selection and adherence to proper surgical technique are of paramount importance in preventing surgical complications of urinary diversion. Complications can be broadly divided into those related to bowel, conduit or reservoir, stoma and ureterointestinal anastomosis. Each type of urinary diversion has unique characteristics predisposing to certain surgical complications as well as similarities related to intestinal surgery. With conduit urinary diversions, problems related to the stoma such as stomal stenosis and parastomal hernia present not uncommonly. With continent cutaneous diversion, complications include difficulties with catheterizing of the efferent limb, formation of pouch stones and urinary leakage. With orthotopic neobladder formation, voiding dysfunction manifesting as incontinence or hypercontinence may present unique challenges in patient management. Increased surgical experience and technical refinements have led to decreasing surgical complication rates for all types of diversion in contemporary series.

The surgical management of stones in patients with urinary diversions

PURPOSE OF REVIEW

Stones in patients with urinary diversions present unique challenges. Anatomical knowledge of the type of diversion is essential to adequately and safely treat the patient. We will review the anatomical differences between the forms of diversion and helpful maneuvers for successful management of urinary lithiasis in this patient population.

RECENT FINDINGS

Urology has recently seen a shift toward continent diversion with the most common forms being continent-cutaneous or orthotopic reservoirs. In patients with these forms of diversions, stone management is challenging. In continent cutaneous diversion, for example, trauma to the continence mechanism during stone manipulation can occur. Recently, percutaneous pouch access to facilitate the treatment of upper/lower tract stones has become popular. In patients with upper tract stones, knowledge of ureteral anatomy is essential. There is controversy not only on non-refluxing versus refluxing anastomoses, but also on the mechanism of formation of non-refluxing anastomoses. At the same time, some stone centers have gone back to attempting retrograde management of upper tract stones. In some types of anastomoses, however, this is not possible.

SUMMARY

Percutaneous pouch access for large stone burden has become the treatment of choice for most urologists. Percutaneous access may involve placement of an Amplatz sheath or laparoscopic trocars into the pouch, allowing for stone entrapment or intracorporeal lithotripsy. With upper tract stones, retrograde management can be attempted in the setting of a refluxing-ureteral-anastomosis. Laparoscopic management of stones may be on the rise, however, like open stone surgery, the indications are narrow.

[Giant stone in a Bricker urinary diversion. Obstruction uropathy as the presenting form]

Bowel is used in urological surgery to replace the bladder, either as a conduit to drain urine to the abdominal wall as a urinary stoma or refashioned to form a substitute bladder. Many factors contribute to stone formation, being urinary stasis, mucus production and bacteriuria the most important. Metabolic changes induced by exposure of segments of the alimentary tract to urine promote struvite, calcium oxalate and calcium phosphate stone formation. Generally, the majority of patients with stones in a urinary diversion can be treated with minimally invasive techniques. Open surgical removal is considered when other modality of treatments cannot be accomplished safely and expeditiously.

Shockwave lithotripsy for urinary stones in patients with urinary diversion after radical cystectomy

BACKGROUND AND PURPOSE

During recent years, survival of patients with invasive bladder cancer has been improved by early diagnosis and radical treatment. Urinary lithiasis is not rare in patients who have been submitted to radical cystectomy and urinary diversion. We have demonstrated the effectiveness and safety of SWL for these patients.

PATIENTS AND METHODS

We studied 11 patients who presented to our lithotripsy department suffering from urinary lithiasis after radical cystectomy. They were all cancer free at the time of treatment, and all underwent SWL on the Dornier HM-3 lithotripter as a first-line treatment. The mean stone burden was 1.85 cm(2), and the stone-to-patient ratio was 1:1.

RESULTS

The stone-free rate 1 month after SWL was 63.7%. Patients who were not stone free underwent a second SWL, and the stone-free rate after the second SWL session was 81.8%. We performed percutaneous nephrolithotripsy in one patient after the second SWL session because of the large stone burden remaining (3.2 cm(2)). The remaining patient was submitted to ureterolithotomy.

CONCLUSION

Application of SWL gives very good results in the treatment of urinary lithiasis in patients with a urinary diversion. Indeed, the results are equivalent to those achieved in patients without urinary diversion.

A modified intussuscepted nipple in the Kock pouch urinary diversion: assessment of perioperative complications and functional results

OBJECTIVE

To assess the complications and continence of a modified intussuscepted nipple in Kock pouch urinary diversions.

PATIENTS AND METHODS

From February 1992 to December 2000, 40 patients (mean age 55.8 years, range 21-74) with bladder cancer (24), gynaecological tumours (eight) or previous lower tract reconstructive surgery (eight) underwent cystectomy and cutaneous continent urinary diversion using the Kock pouch procedure. The first 23 procedures (group I) used Henriet's technique, whereas a modified fixation of the intussuscepted efferent limb was applied in the last 17 (group II). Complications and functional results (focused on continence and the upper urinary tract) were reviewed.

RESULTS

The median (range) follow-up was 47.6 (10-124) months; one patient died 4 weeks after surgery. Early complications occurred in 11 (28%) and re-operation was required in two (5%). Of the late complications reported (38%), extussusception (8%) and efferent nipple prolapse (3%) only occurred in group I and required surgical revision. Late complications were minor (15%) including two asymptomatic refluxes and four with stoma sclerosis. The continence rate at 6 months in groups I and II were 78% and 94%, respectively (P = 0.13).

CONCLUSION

Efferent limb prolapse and extussusception of the Kock pouch were the main complications requiring surgical revision. Applying the modified nipple fixation the complications can be reduced and reservoir continence improved.

Functional outcomes and complications of continent urinary diversions in patients with gynecologic malignancies

OBJECTIVE

The purpose of this study was to review our experience with continent urinary diversions in patients with gynecologic malignancies and evaluate the presentation and management of early and late complications.

METHODS

A retrospective chart review was performed of all patients who underwent a continent urinary diversion on the Gynecologic Oncology Service at The University of Texas M. D. Anderson Cancer Center during the period January 1988 to March 2001. We analyzed our data to evaluate potential risk factors for complications. Renal status, conduit integrity, and overall patient outcomes were also studied.

RESULTS

We identified 40 patients who underwent a continent urinary diversion using an ileocolonic segment (Miami pouch technique). All patients had a history of gynecologic malignancies. The median age at the time of the procedure was 50 years (range 24 to 76 years), and the median weight was 69.6 kg (range 47 to 125 kg). A total of 39 patients (98%) had a history of radiotherapy. Continent urinary diversion was performed as part of an anterior pelvic exenteration in 12 patients (30%), in conjunction with a total pelvic exenteration in 18 patients (45%), and as the main procedure in 10 patients (25%). The median estimated blood loss was 2100 ml (range 200 to 8500 ml). The median length of hospitalization was 19.5 days (range 7 to 56 days). A total of 24 patients (60.0%) had a postoperative complications unrelated to the reservoir. Complications directly related to the continent urinary diversion were seen in 26 (65.0%) of 40 patients. None of the patients in this study group developed chronic renal failure, and there were no perioperative deaths. At last evaluation, 36 (90%) of 40 patients reported normal continent conduit function.

CONCLUSIONS

Continent urinary diversion using an ileocolonic segment is a reasonable alternative to the ileal and transverse colon conduit in bladder reconstruction in patients undergoing radical pelvic surgery. The routine use of postoperative total parenteral nutrition, the chronic use of antibiotics after discharge from the hospital, and the routine use of imaging studies remain controversial. In this group of patients, the majority of complications may be successfully managed conservatively.

Urolithiasis following formation of a continent urostomy: case report and review of the literature

BACKGROUND

Formation of urinary stones in a continent urostomy (Indiana pouch) has been described as a late complication. Management of a patient with symptomatic multiple large stones and review of the literature are outlined.

CASE REPORT

A 32-year-old woman presented with recurrent urinary tract infections and pyelonephritis 6 years after a total pelvic exenteration and creation of a continent urostomy for central recurrent carcinoma of the cervix after radical pelvic radiation. Multiple large stones were found to be the underlying etiology. Laparotomy, enterocystotomy, and removal of stones were performed without apparent complication.

CONCLUSION

It is recommended that for single calculi or multiple small stones, electroshock wave lithotripsy or the percutaneous endoscopic approach be considered. For larger stones the use of laparotomy and enterocystostomy may be appropriate.

Secondary and miscellaneous urolithiasis. Medications, urinary diversions, and foreign bodies

Secondary stones, those with no "classic" cause, provide unusual diagnostic and treatment challenges to the urologist. Stones related to medications, to urinary diversions or augmentation, or to presence of foreign bodies within the urinary tract occur rarely. Nevertheless, they represent situations that may be corrected fully by appropriate conservative or procedural therapy, and therefore they must be included in the differential diagnosis of many patients who present with symptoms of urolithiasis.

A prospective randomized study comparing absorbable and nonabsorbable staples in constructing antireflux valves of urethral hemi-Kock pouches

OBJECTIVE

To determine the long-term complications associated with constructing an antireflux nipple valve using absorbable or nonabsorbable staples in the urethral hemi-Kock pouch.

PATIENTS AND METHODS

Fifty patients (all men, median age 47 years, range 28-73) undergoing construction of a urethral hemi-Kock pouch were randomized prospectively into two equal groups. In group 1, absorbable (polyglyconate) staples were used for the construction, and in group 2 nonabsorbable (metal) staples were used but omitting the staples applied at the tip of nipple valve. Assessment during the follow-up of 6-88 months comprised urine analysis, culture and sensitivity, measurement of serum creatinine, electrolytes and blood gases, and plain abdominal radiography, intravenous urography and micturating pouchography.

RESULTS

In group 1, 21 patients were evaluable; a pouch stone was detected in one, extussusception of the valve in one and valve stenosis in one. In group 2, 20 patients were evaluable; pouch stones were detected in six, extussusception of the valve in three and valve stenosis in one.

CONCLUSION

Compared with nonabsorbable (metal) staples, the use of absorbable (polyglyconate) staples significantly decreased the incidence of pouch stone formation and improved valve stability in patients with a urethral hemi-Kock pouch.

Pediatric urinary tract reconstruction using intestine

OBJECTIVE

To analyse the outcome of urinary tract reconstruction in children.

MATERIAL AND METHODS

Fifteen children with bladder exstrophy or neurogenic bladder, 4-18 years old, were followed in accordance with a predetermined program for bladder augmentation (13 pat) or continent urinary reservoir (2 pat). The follow-up time was 1.7-6.3 years, median 3.7 years.

RESULTS

All were dry, though one case had occasional leaks. Three bladder neck reconstructions, two artificial sphincters, one sling plasty and one fistula closure with subsequent bladder neck injection were required. Bladder volumes were adequate for age at low pressures. Reflux resolved in 12/13 ureters. A boy with preoperative renal insufficiency was transplanted. Total renal function remained otherwise stable despite acidosis in one case and some glomerular impairment in all. Progressive parenchymal lesions were seen in combination with abundant mucus, infections and calculi only. Growth and bowel function was unaffected. Bone mineral density showed overall increase; some low values were not consistent between investigations.

CONCLUSIONS

Urinary tract reconstruction in children results in continence and regression of reflux. Growth, bone mineralization and renal function are unimpaired during the first years, but irrigation of the bladder is essential to minimize the risk of urinary tract infection. However, glomerular function might be affected and the possible risk of metabolic complications in later life can only be determined by continuous close monitoring over an extended period of time.

ABBREVIATIONS

Voiding cystourethrogram (VCUG), dimercapto-succinic acid (DMSA), Chrome51-Ethylenediaminetetraacetic acid (Cr-EDTA), single photon absorption (SPA), bone mineral content (BMC), bone mineral density (BMD), dual photon x-ray absorption (DEXA), glomerular filtration rate (GFR), urinary tract infection (UTI), immunoglobulin G (IgG), clean intermittent catheterization (CIC) and subureteral teflon injection (STING).

The Kock pouch urinary reservoir

The use of detubularized ileum for the Kock pouch produced a low pressure, high capacity system superior to large bowel segments that provided excellent continence and protection of the upper urinary tracts. The early enthusiasm was tempered, however, by the technically demanding aspects of the construction of the nipple valves, the early and late complications, and occasional catheterization problems. With simple modifications in the fixation of the intussuscepted nipples, limiting use of staples and mesh collars, and tapering of the stoma, much of those problems have been resolved. The nipple valve is reliable and superior to the tunneled implant for the dilated ureter. With more widespread indications for continent neobladders, the hemi-Kock reservoir remains one of the most dependable and stable neobladders.