Electrohydraulic lithotripsy for stones in Kock pouch

Metabolic complications of urinary diversions: an overview

Patients with urinary diversions present unique challenges to internists who have an important role in their long-term management. Advances in surgical techniques over the past 30 years have given rise to a number of urinary diversion procedures that use various intestinal segments. In its normal function, the intestine absorbs water and solutes. When placed in contact with the urinary stream, the intestine can create numerous metabolic abnormalities. These include bone disease, hepatobiliary disease, infection, malignancy, neurologic complications, nutritional deficiencies, and a number of electrolyte and acid-base disorders. An overview of these metabolic abnormalities and their causes is provided, as well as recommendations for screening and management of patients.

Endoscopic management of bladder calculi following augmentation cystoplasty

OBJECTIVES

We sought to evaluate the effectiveness and utility of an endoscopic approach to calculi that develop in the bladders of children following augmentation cystoplasty. In addition, we aimed to determine the indications for open vesicolithotomy.

METHODS

We reviewed our experience between 1981 and 1993 with 26 children who formed bladder calculi following augmentation cystoplasty. Data were retrieved retrospectively with respect to management approach and outcome.

RESULTS

Nineteen cases were managed cystoscopically using simple extraction and/or electrohydraulic lithotripsy; 3 cases required open vesicolithotomy and four calculi passed spontaneously. Complete stone extraction was achieved after a single endoscopic treatment in every case approached in this fashion. Every patient resumed preoperative voiding patterns and there were no infections, strictures, or other complications. Calculi reformed in 4 patients and were successfully managed endoscopically.

CONCLUSIONS

An endoscopic approach to bladder calculi is a safe and effective method of managing this increasingly prevalent problem in children following augmentation cystoplasty even in the presence of a reconstructed bladder neck. Open vesicolithotomy should be reserved for the very large stone burden.

Minimally invasive endourologic management of calculi in continent urinary reservoirs

This study was done to determine whether minimally invasive endourologic management of calculi in continent reservoirs can be done effectively without compromise of urinary continence. Four patients with continent urinary diversions (1 Indiana pouch and 3 Kock pouches) were managed with trans-stomal pouchoscopic ultrasonic lithotripsy (n = 2), prone position extracorporeal shock wave lithotripsy (n = 1), or a "sandwich" combination of these (n = 1) for stone burdens up to 20 cm2. Total hospital stay ranged from one to four (mean = 2.6) days. All 4 patients were initially rendered stone free, and, with follow-up as long as twenty-five months, only 1 has had a recurrence. No patient experienced stomal leakage or other complications. This study suggests that minimally invasive endourologic management of calculi in continent urinary reservoirs can be done safely and effectively to obviate the need for more invasive percutaneous approaches or open surgery, even for some patients with large stone burdens.

Percutaneous approach to treatment of Indiana pouch stones

Continent urinary diversions have gained popularity during recent years in the treatment of patients who require cystectomy. The formation of urinary stones remains a possible late complication of urinary diversion. We report the successful use of a percutaneous approach to remove stones from an Indiana pouch after other methods failed.

Histopathological changes in Kock pouch

To investigate whether tumour recurrence or histological changes occur in the Kock pouch, periodic endoscopy with biopsy of the pouch was performed in 15 patients 6 to 66 months after radical cystectomy and urinary diversion for invasive bladder cancer. Endoscopy was undertaken 1 to 4 times in each patient (a total of 37 times in all patients). During endoscopy, random biopsies were taken from the pouch wall, and from the afferent and the efferent nipples. The histological changes were graded as: (1) villous atrophy (grade 0 to 3, 0: nearly normal; 1: shortening, villi/crypt of Lieberkuhn [length] between 1.5 and 4.0; 2: moderate flattening, villi/crypt < 1.5; and 3: almost complete disappearance of villi); (2) fibrosis; and (3) chronic inflammation (grade 0 to 3, based on the amount of fibrous tissue and inflammatory cell infiltration in the lamina propria, respectively). There was no dysplasia or malignant tumour in the Kock pouch in any of the 15 patients. The histology of the ileum changed in terms of villous atrophy, fibrosis and chronic inflammation in the lamina propria and thickening of the muscularis mucosa. The same grade of villous atrophy of the pouch wall, the afferent and the efferent nipples was only found in 3 patients. More fibrosis and less chronic inflammation in the lamina propria were found at the efferent nipple than at the afferent nipple or pouch wall in 8 patients and 5 patients, respectively. Thickening of the muscularis mucosa was found in 13 of 15 patients (86.7%). In conclusion, there was no dysplasia or recurrent tumour in the Kock pouch in patients who were followed for up to 66 months. Various grades of histological changes of the ileum in terms of villous atrophy, fibrosis and chronic inflammation of the lamina propria, and thickening of the muscularis mucosa were found in the pouch wall, and in the afferent and efferent nipples. More fibrosis and less chronic inflammation were commonly observed at the efferent nipple than at the afferent nipple or pouch wall. The degree of histological changes varied even among patients followed over the same period after operation. The time to progression of villous atrophy also varied. The histological changes in some patients were dissimilar even at the same site of the Kock pouch.

Urolithiasis in children following augmentation cystoplasty

Until recently urolithiasis in children following augmentation cystoplasty was an infrequently noted problem. We examined our 10-year experience and found urinary calculi to form in 52% of children and young adults undergoing augmentation cystoplasty. Calculi formed at a median interval of 24.5 months after surgery, predominantly in the lower tract. Urinary tract infection was a statistically significant risk factor, while the use of absorbable staples, intestinal mucus and hypocitraturia were also implicated. Calculus composition was primarily a mixture of apatite, struvite and ammonium urate. Bladder calculi were effectively managed endoscopically in the majority of cases without complication. Upper tract calculi presented an endourological challenge.

Neobladder construction using completely detubularized sigmoid colon after radical cystoprostatectomy

To improve the quality of life of the patient we used completely detubularized sigmoid colon for bladder reconstruction along with radical cystoprostatectomy in 6 men with invasive bladder cancer. Followup was 8 to 20 months. Postoperatively, all of the patients were continent during the day but only 4 (66.7%) were continent at night, although they had to awaken twice to remain dry. Neocystourethroscopy in 4 of the 6 patients revealed no tumor and no stricture at the urethrocolonic anastomosis. However, a stone in the neobladder was found in 1 patients. Urodynamic study of the neobladder showed a low pressure (mean 16.7 cm. water) at the filling phase of water cystometry and an adequate maximal urethral closure pressure (mean 52.0 cm. water) and functional profile length (mean 3.8 cm.). The uroflow rate in all patients was good (1 patient even had a maximal uroflow rate of 31 ml. per second). There was no reflux in any patient. One patient had intestinal obstruction 5 months postoperatively and died 5 months later of widespread metastasis. The remaining 5 patients are alive with a satisfactory quality of life. In conclusion, use of completely detubularized sigmoid colon may be an ideal operation for neobladder construction after radical cystoprostatectomy.

Prospective radionuclide renal function evaluation and its correlation with radiological findings in patients with Kock pouch urinary diversion

In an attempt to understand better the status of renal function after Kock pouch urinary diversion we conducted a prospective evaluation of renal function in 25 patients using the radionuclide 131iodine-hippurate. Studies were done before, and at 1 month and every 6 months for 30 months postoperatively. The radionuclide results were then compared to excretory urography and contrast study of the reservoir. Our renal function study included the determination of individual and total effective renal plasma flow (ml. per minute), the time to maximal radioactivity over the kidney (peak time in minutes) and a renogram. The mean total (both kidneys) effective renal plasma flow rates before (25 patients) and at month 1 (19), month 6 (14), month 12 (12), month 18 (6), month 24 (6) and month 30 (7) after operation were 385.5 +/- 112.2, 310.5 +/- 109.9, 362.7 +/- 69.2, 442.0 +/- 97.5, 468.2 +/- 82.5, 405.7 +/- 70.6 and 414.0 +/- 65.1, respectively. A comparison of individual and total effective renal plasma flow before and after operation revealed that only the change of the flow at each or both sides of the kidney before and at 1 month after the operation reached statistically significant differences, respectively (p less than 0.05, paired t test). Postoperatively 5 of 6 patients with hydronephrosis had abnormal peak time and a third segment on the renogram was performed on the corresponding side of the kidney. No reflux was noted on contrast study of the reservoir of any patient followed for up to 30 months. In conclusion, the radionuclide renal function evaluation showed a significant decrease of renal function 1 month after Kock pouch diversion, then it resumed and remained stable (neither improved nor deteriorated) for 30 months. Also the abnormal peak time and third segment on the renogram usually implicated a dilated upper urinary tract.

Management of upper tract calculi in patients with tubularized urinary diversions

In a retrospective review of patients with urinary diversion who presented to our stone center during a 3.5-year period 9 underwent 20 procedures for suspected stone episodes. Eventual outcome was excellent in all but 1 patient. In particular, all attempts at retrograde trans-stomal manipulation were successful. We present our cases, and note the technical considerations and management principles. Frequently, these patients are best served by a combination of percutaneous antegrade, trans-stomal retrograde and/or extracorporeal shock wave lithotripsy.