Reflux of a Staple after Kock Pouch Urinary Diversion: A Nidus for Renal Stone Formation

Migration of a Hem-o-Lok clip to the renal pelvis after laparoscopic partial nephrectomy: A case report

BACKGROUND

Hem-o-Lok clip (HOLC) has been widely used in laparoscopic surgery due to its ease of application and secure clamping, though the rare complications associated with this technique should not be ignored. The rare complications of laparoscopic partial nephrectomy consist of the clip migrating into the renal pelvis and acting as a nidus for stone formation.

CASE SUMMARY

The case described here involved a 63-year-old woman who was found with stones in the right kidney and upper ureter during a recent reexamination following laparoscopic partial nephrectomy. We performed percutaneous nephrolithotomy for her, but during the operation, it was found that the center of the stone within the kidney was a HOLC, which was removed with forceps. For this reason, we speculate that the HOLC, which was employed to halt tumor wound bleeding, spontaneously drifted into the renal pelvis and formed kidney stones, with the clip being initially misdiagnosed as a kidney stone.

CONCLUSION

By reviewing related case reports, we conclude that in order to prevent complications related to HOLC, loose clips should be actively searched for and retrieved from the wound during urinary tract surgery, while the deployment of clips in close proximity of anastomotic stoma of collecting systems should be avoided.

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.

Stone formation from nonabsorbable clip migration into the collecting system after robot-assisted partial nephrectomy

We describe a case in which a Weck Hem-o-lok clip (Teleflex, Research Triangle Park, USA) migrated into the collecting system and acted as a nidus for stone formation in a patient after robot-assisted partial nephrectomy. The patient presented 2 years postoperatively with left-sided renal colic. Abdominal computed tomography scan showed a 10 millimeter renal calculus in the left middle pole. After using laser lithotripsy to fragment the overlying renal stone, a Weck Hem-o-lok clip was found to be embedded in the collecting system. A laser fiber through a flexible ureteroscope was used to successfully dislodge the clip from the renal parenchyma, and a stone basket was used to extract the clip.

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.

Resorbable clip migration in the collecting system after laparoscopic partial nephrectomy

A complication is reported in which Lapra-Ty absorbable suture clips (Ethicon EndoSurgery) migrated from a laparoscopic partial nephrectomy bed into the collecting system, causing renal colic. During surgery performed with hilar occlusion, visual inspection did not reveal collecting system entry. Transected vessels were oversewn with absorbable suture secured with Lapra-Tys. Absorbable bolsters were placed in the parenchymal bed, and compression sutures secured with Lapra-Tys were placed through the renal capsule. Six weeks postoperatively, the patient developed ipsilateral renal colic, and computed tomography demonstrated several 3-mm opacities within the ureter. After 2 weeks of conservative management, he spontaneously passed several Lapra-Ty clips.