Management of upper tract calculi in patients with tubularized urinary diversions

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.

Treatment of upper urinary lithiasis in patients who have undergone urinary diversion

Patients undergoing urinary diversion are at high risk for developing stone disease due to the metabolic and structural features intrinsic to the creation of a urinary reservoir. The utilization of shockwave lithotripsy as well as antegrade and retrograde endoscopic techniques in appropriately selected patients affords a relatively safe and effective means of stone removal. This review focuses on the etiology of stone formation in patients with urinary diversion and examines the most relevant and current reports on expulsive techniques and their associated outcomes for patients within this population who develop upper urinary tract calculi.

Preoperative indications for percutaneous nephrolithotripsy in 2009

Abstract Since the first description of percutaneous nephrolithotripsy (PNL) over 30 years ago, the indications for this procedure in the management of upper tract urinary stones has greatly expanded. Despite recent advances in shock wave lithotripsy and ureteroscopic technologies, PNL maintains a dominant role in the management of complex and large volume upper tract stones. The contemporary indications for PNL are reviewed herein.

Third Prize: Contemporary Percutaneous Nephrolithotripsy: 1585 Procedures in 1338 Consecutive Patients

BACKGROUND AND PURPOSE

The approach to urinary-stone disease has changed dramatically over the last three decades with a transition from open surgery to minimally invasive procedures. Percutaneous nephrolithotripsy (PCNL) is a cornerstone of the treatment of kidney and selected upper-ureteral stones and continues to evolve with advances in techniques and instrumentation. The purpose of this study was to assess outcomes and trends prospectively in a large contemporary group of patients undergoing PCNL.

PATIENTS AND METHODS

Between July 1990 and December 2005, all 1338 patients at a single center scheduled for PCNL (N = 1585 procedures) were enrolled. Their mean age was 53 years (range 4-89 years). Data including comorbidities, stone burden, stone location, surgical time, hospital length of stay, rate of secondary procedures, and adverse events were collected prospectively. The primary outcome measures were stone-free rate and complications.

RESULTS

There was a substantial incidence of comorbid medical conditions (48.8%) and anatomic renal abnormalities (25.3%), demonstrating the diverse and challenging patient population in this contemporary series. The overall stone-free rate at 3 to 6 months of follow-up was 94.8%.

CONCLUSIONS

Percutaneous nephrolithotripsy is a highly effective procedure and may be performed in a diverse group of patients with comorbid conditions and renal abnormalities. Improved intracorporeal lithotripters, balloon dilation of the tract, use of flexible instruments, and liberal use of secondary nephroscopy result in excellent stone-free rates with low morbidity.

Percutaneous treatment of large upper tract stones after urinary diversion

OBJECTIVES

To present our experience in percutaneous management of large upper tract stones after urinary diversion.

METHODS

From October 1984 to March 2005, 20 percutaneous nephrolithotomy and 4 antegrade ureteroscopy procedures were performed in 17 men and 7 women, with a mean age of 53.5 years. The urinary diversions were an ileal W neobladder, hemi-Kock pouch, ileal conduit, and rectal bladder in 10, 7, 4, and 3 patients, respectively. The median interval between diversion and stone management was 1.5 years. Success was defined as a stone-free, nonobstructed renal unit at 3 months after the intervention. Follow-up was performed every 6 months with intravenous urography or noncontrast computed tomography for diagnosis of stone recurrence and evaluation of renal morphology.

RESULTS

Renal punctures were guided with ultrasonography in 18 patients (75%) and fluoroscopy in 6 patients. One intraoperative complication (4.16%) and two postoperative complications (8.3%) occurred. All patients with ureteral stones became stone free after one procedure. Auxiliary procedures were needed in 5 patients after percutaneous nephrolithotomy; 2 patients required a second session and 3 needed extracorporeal shock wave lithotripsy. The overall success rate was 87.5% (21 patients). One patient with treatment failure underwent open surgery, and two with small residual fragments were followed up. Long-term follow-up data were available for 15 patients. The stone recurrence rate was 33.3% (5 patients) after a median follow-up of 40 months (range 14 to 132). Recurrent stones were treated with extracorporeal shock wave lithotripsy.

CONCLUSIONS

The results of our study have demonstrated that percutaneous treatment of large upper tract stones after urinary diversion offers a high success rate with minimal morbidity. However, regular follow-up after treatment is recommended.

Extracorporeal shock wave lithotripsy of upper urinary tract calculi in patients with cystectomy and urinary diversion

OBJECTIVES

To present our experience with extracorporeal shock wave lithotripsy (ESWL) in the management of upper urinary tract calculi in patients with urinary diversion.

METHODS

Between March 1989 and June 2004, 27 patients with radical cystectomy and urinary diversion were treated using ESWL for upper urinary tract calculi using the Dornier MFL 5000 lithotripter. The mean length of the stones was 11 +/- 3.1 mm and the mean width was 8.8 +/- 3.5 mm. The follow-up protocol included plain abdominal x-ray and renal ultrasonography every 2 weeks until complete stone clearance. All follow-up data were collected and analyzed after 3 months. Success was defined as the absence of residual stones or the presence of insignificant gravel less than 4 mm.

RESULTS

Retreatment was required in 12 patients (44.4%). Failure to disintegrate the stones was recorded in 2 cases (7.4%) and significant residual stones were recorded in 1 (3.7%). Post-ESWL renal obstruction was observed in 2 cases (7.4%). Secondary procedures were needed in 5 cases (18.5%). Two percutaneous nephrolithotomy and one antegrade ureteroscopy were performed for treatment of ESWL failure. One open ureterolithotomy and one antegrade ureteroscopy were performed for treatment of post-ESWL renal obstruction. Thus, the overall success rate of ESWL monotherapy in the treatment of upper urinary tract stones was 81.5% (22 of 27).

CONCLUSIONS

ESWL monotherapy proved to be a valuable option in the treatment of upper tract lithiasis in patients with urinary diversion. However, it may cause renal obstruction, and antegrade endoscopic maneuvers should be available.

Management of ureteric stones

The contemporary management of ureteric stones is reviewed and evidence based recommendations about treatment are made. Stones measuring less than 4mm in diameter have a high chance of spontaneous passage and the main debate for optimum treatment of larger stones centres around the choice of shock wave lithotripsy or endoscopic management combined with laser fragmentation. Treatment recommendations should be based on patient preference, published evidence, local audit (surgeon expertise and availability of equipment) and cost. Artificial Neural Networks could become a useful tool for prediction of treatment outcome for ureteric stones, and further research is needed to clarify this potential. ESWL is less effective than ureteroscopy but it may prevent the need for more invasive treatment in a substantial proportion of patients. It should only be considered as initial treatment in patients with stones less than 10mm in size. The routine use of stents should be avoided as both fragmentation and stone free rates are noticeably lower. For larger stones, initial laser ureteroscopy serves better both for proximal or distal calculi and is more cost-efficient. Provided that no contraindications for general anaesthesia exist, laser ureterolithotripsy should be regarded as an excellent first line treatment modality for ureteric stone especially in greater stone burden. In the best hands, the outcome for endoscopic management of ureteric stone in all sites is better than ESWL and is cheaper, although equipment, expertise and experience are all required to achieve this superior outcome.

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.

Stones in urinary diversions: update on medical and surgical issues

PURPOSE OF REVIEW

Patients who undergo urinary tract diversion are at an increased risk of urolithiasis for various reasons. The purpose of this article is to provide an up-to-date summary of the progress that has been made in the pathogenesis, diagnosis and treatment of stones in patients with urinary diversions. Finally, we will provide recommendations for follow-up in patients with urinary diversions who develop urinary tract calculi.

RECENT FINDINGS

In contemporary studies, the incidence of urolithiasis in patients with urinary diversion appears to be decreasing. Computed tomography scanning has been shown to be superior to ultrasound in the diagnosis of calculi in such patients. Endourological procedures have become the mainstay of therapy for stones in patients with urinary diversions. Since the introduction of extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy and ureteroscopy, the need for open surgery has decreased, even in this anatomically unique and surgically challenging patient population.

SUMMARY

Urolithiasis is an established long-term complication of urinary diversion. In recent years, significant advances have been made in the pathogenesis, diagnosis and treatment of such stones. As a result of potential stone-related complications, we recommend lifelong surveillance for all patients with urinary stones and diversions, with medical therapy when indicated, in order to minimize these complications.

Percutaneous nephrostolithotomy. What is its role in 1997?

PNL is a challenging and satisfying part of endourologic practice. Although more invasive than SWL or ureteroscopy, it offers a high chance of success in many different situations. The selective and appropriate application of PNL requires the consideration of many factors, especially stone location and size, patient habitus, and the anatomy of the upper urinary tract (Table 5). For the urologic surgeon in the last decade of the twentieth century, complete stone therapy entails judgment and skill with myriad modalities: SWL, ureteroscopy, PNL, and open or laparoscopic stone surgery.

Complications in radical cystectomy and their prevention

We wish to dedicate this review article on radical cystectomy, its complications and their prevention to the memory of Prof. Luciano Giuliani. The article is based on a work written originally by Jim Montie and many other authors for the consensus meeting on bladder cancer held in Antwerp in 1994 and recently published in a booklet entitled “Global strategy for bladder cancer” (1). With the consent of Montie and the other co-authors, we have prepared on updated Italian version, inserting some parts (such as vascular complications) which were treated more superficially in the preliminary text.

Selective minimally invasive management of calculi in patients with urinary diversions

We evaluate the efficacy of selectively applied minimally invasive management of calculi in 30 patients with urinary diversions (ileal/jejunal conduit in 23, cutaneous ureterostomy in 2, nonrefluxing colon conduit in 4 and ureterosigmoidostomy in 1). Upper tract calculi in 38 renal units were managed with extracorporeal shock wave lithotripsy or endo-urologically. Patients were divided into 3 treatment groups determined primarily by stone size and location: group 1-25 renal units with a mean stone burden of 1.78 cm.2 treated with extracorporeal shock wave lithotripsy alone, group 2-7 renal units with a mean stone burden of 12.75 cm.2 treated with percutaneous nephrostolithotomy alone and group 3-6 renal units with a mean stone burden of 19.03 cm.2 treated with a combination of both procedures. Stone-free results were 92%, 100% and 67% in groups 1 to 3, respectively. Total hospital stay averaged 4.3, 11.1 and 13.7 nights, while complications occurred in 1, 3 and 2 patients, respectively. We conclude that selective application of contemporary techniques for minimally invasive management of calculi in patients with a urinary diversion can provide acceptable results, even with progressively large and complex stone burdens, and that these results will be equivalent to those achieved in patients without urinary diversion.

Extracorporeal shock wave lithotripsy and endoscopic management of renal calculi with urinary diversions

A total of 12 patients with urinary diversions had calculi in 15 kidneys managed initially by extracorporeal shock wave lithotripsy (ESWL) in 12 kidneys and percutaneous nephrolithotripsy in 3. After 15 treatments with ESWL only 3 of the 12 kidneys (25%) became stone-free. Endoscopic procedures were used in 5 kidneys with fragments remaining after ESWL, and comprised percutaneous ultrasound lithotripsy in 2 and transstomal retrograde manipulations in 3. The 3 initial and 5 subsequent endoscopic procedures resulted in 6 of the 8 kidneys (75%) being stone-free. The poor results with ESWL are due to preexisting dilated upper urinary tracts and to immobility in obese myelomeningocele patients. Endoscopic procedures are the preferred method of treatment in these patients.