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  1. 1. CASE REPORT Urolithiasis Following Formation of a Continent Urostomy: Case Report and Review of the Literature Khalid Sait, M.D., Gavin Stuart, M.D., Jill Nation, M.D., and Prafull Ghatage, M.D. Department of Gynecology, Tom Baker Cancer Centre, and Department of Obstetrics & Gynecology & Oncology, The University of Calgary, Calgary, Alberta, Canada Received May 13, 1999 Background. Formation of urinary stones in a continent uros- tomy (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 cen- tral recurrent carcinoma of the cervix after radical pelvic radia- tion. Multiple large stones were found to be the underlying etiol- ogy. 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. © 2000 Academic Press Key Words: urolithiasis; continent urostomy. INTRODUCTION Total pelvic exenteration with formation of a continent urostomy (Indiana pouch) is used to treat patients with central recurrent carcinoma of the cervix after radical pelvic radiation at our center. Formation of urinary stones has been described as a late complication although the exact frequency is not known. We are reporting the management of a patient 6 years after pelvic exenteration with symptomatic multiple large stones in the Indiana pouch. CASE REPORT A 32-year-old G1 P1 woman was diagnosed with clinical Stage IB2 squamous cell carcinoma of the cervix at the age of 24 years. She underwent a laparotomy with the intent to perform a Type III radical hysterectomy and was found to have metastatic microscopic cancer in one left external iliac lymph node. The radical hysterectomy was abandoned and she was then treated with radical radiation therapy. This included the delivery of 45 Gy in 25 fractions using a four-field technique and 40 Gy total brachytherapy in two sessions. One year after completion of treatment she developed a localized central recurrence and underwent a total pelvic exenteration. A neo- vagina was created using bilateral gracilis myocutaneous flaps. Urinary diversion was effected through the formation of a continent urostomy using the technique described by Ahlering et al. [1]. This was a modified continent Indiana pouch in which the continent limb used a 12-cm length of terminal ileum and the low pressure pouch was formed from a detubularized 28-cm segment of right ascending/transverse colon with sub- mucosal ureteric implantation. The pouch was closed in a Heineke-Mikulicz fashion with two layers of running 3-O polyglycolic suture. Serial applications of a 75-mm linear stapler were used to narrow the lumen of the efferent limb of the ileum. This was further tapered with interrupted 3-O silk Lambert sutures at the antimesenteric border at the ileocolic junction so as to limit intussuception. The patient remained free of recurrent disease for 6 years following exenteration. She started experiencing symptoms of nonspecific abdominal pain 4 years postexenteration. Multiple large mobile stones were detected in the Indiana pouch by plain radiographs (Fig. 1) and transabdominal ultrasound. Her symp- toms were felt to be unrelated to the urolithiasis and no intervention was recommended at that time. One year later she experienced recurrent episodes of urinary tract infection and pyelonephritis. In view of the potential morbidity of further surgery, conservative measures with prophylactic antibiotics and oral fluids were instituted. However, over a 12-month period, six infections were documented. In consideration of the urolithiasis as a cause of this chronic infection, urologic and nephrologic consultation was obtained. Although consideration was given to endoscopic removal or electroshock wave litho- tripsy (ESWL), an open surgical procedure was recommended as the best option to remove the stones because of the size and number of the stones. Gynecologic Oncology 77, 330–333 (2000) doi:10.1006/gyno.2000.5750, available online at http://www.idealibrary.com on 3300090-8258/00 $35.00 Copyright © 2000 by Academic Press All rights of reproduction in any form reserved.
  2. 2. The patient underwent a laparotomy. The Indiana pouch was identified and an incision approximately 3 cm in length was made along a taenia coli (Fig. 2). Ten large stones were removed, each measuring approximately 2.5–3 cm (Fig. 3). The pouch was irrigated and closed in two layers using a running suture of 2-O chromic catgut for the first layer and a running suture of 3-O polyglycolic acid material in the second layer. Catgut was utilized in the first layer due to its relatively rapid breakdown and minimal chronic foreign body reaction. Blood loss was minimal. A small Foley catheter was inserted in the pouch through the efferent limb and removed 7 days postoperatively. There were no intra- or postoperative compli- cations. Integrated crystallographic analysis of the urinary calculi showed that these calculi were composed of intimately ad- mixed masses of orthorhombic crystals of magnesium ammo- FIG. 1. Plain radiographs demonstrated multiple stones in the Indiana pouch. FIG. 2. Extraction of the stones through an incision in the Indiana pouch. 331CASE REPORT
  3. 3. nium phosphate hexahydrate, subcrystalline ammonium acid urate, and microcrystalline carbonate appetite. Nephrology consultation was obtained. Further investigations determined that the primary etiologic factor was a metabolic urinary defect in citrate excretion (hypocitrituria). The patient was prescribed a daily potassium citrate supplement and encouraged to in- crease fluid intake. Follow-up at 12 months showed no evi- dence of stone formation and there have been no further episodes of urinary tract infection. She remains clinically free of cancer. DISCUSSION In 1950 Gilchrist et al. described a continent reservoir con- structed from the ileocecum in which continence depended upon the ileocecal valve [2]. The different techniques of con- tinent urinary diversion—Kock pouch [3], Mainz pouch [4], Indiana pouch [5], King pouch [6], and Penn pouch [7]—have embraced the same biophysical principles. Continent pouches provide a superior alternative to an ileal conduit as no external appliances are required, thus improving quality of life by enhancing body image and interpersonal relationships. However, the patient must be diligent and me- ticulous in performing self-catheterization. Continent urinary diversion has become increasingly popular for patients requir- ing cystectomy. However, formation of urinary stones is a late complication that has been described [8]. A high incidence was reported in patients with a Kock pouch (17–27%) due to exposed staples and/or foreign material in the reconstructed urinary tract [9, 10]. Stone formation is rare, however, in patients with an Indiana pouch (3–11%) because of the absence of foreign materials [11, 12]. The majority of calculi occurring in Indiana pouches contain struvite and/or carbonate. Ammo- nium, magnesium, and phosphate may also be found [13]. Stone formation may result from nonabsorbed materials used during construction of the pouch. Steel or titanium staples used for linear application may extrude into the pouch. In this particular patient, metabolic factors such as the urinary defect in citrate excretion were likely involved in the formation of stones [14]. The indications used to determine that intervention is war- ranted must be patient specific. In this particular patient, the repeated urinary tract infections with the inherent risk of chronic pyelonephritis provided the specific indication. Gener- ally, infection, pain, and/or obstruction will provide the criteria for intervention. A technique similar to percutaneous nephrostolithtomy and fragmentation of the stone with ultrasonic and electrohydraulic lithotripsy probes is reported to destroy the stones in a conti- nent urinary reservoir. This may be the first choice for inter- vention but it has the added risk of infection, bleeding, and bowel perforation and it can be only performed in selected cases with a qualified urologist [13, 17–20]. Endourological management for urinary stones in the Indi- ana pouch is time consuming and has the potential risk of compromising the continent mechanism because of narrow access, particularly if the stones are large. ESWL has been used to fragment bladder and reservoir stones [15] but it leaves the operator with the problem of removing the stone fragments. An open surgical approach to remove multiple large calculi in an Indiana pouch has been reported in male patients who under- went a pouch formation for urinary diversion because of para- plegia [16]. However, the potential morbidity associated with FIG. 3. Ten large stones were removed, each measuring 2.5–3 cm. 332 SAIT ET AL.
  4. 4. surgical reexploration in a patient who has received megavolt- age radiation therapy may be significant. These authors recommend that in the creation of a continent urostomy, every effort must be made to utilize nonreactive, absorbable material in the pouch construction. Screening for a metabolic predisposition to stone formation should be consid- ered if there is any significant history of renal disease or urinary tract calculi. Either an infused CT scan or intravenous pyelography should be used preoperatively in all patients un- dergoing a planned continent urostomy. It is likely that the recurrent infections in this patient were a sequelae of the urolithiasis, rather than a cause. It may still be appropriate to maintain long-term prophylactic antibiotics as a preventive strategy. It is recommended that, for single calculi or multiple small stones, ESWL or the percutaneous approach be consid- ered. For larger stones, the use of laparotomy and enterocys- tostomy may be one of the therapeutic options to be consid- ered. REFERENCES 1. Ahlering TE, Weinberg AC, Razor B: Modified Indiana pouch. J Urol 145:1156–1158, 1991 2. Gilchrist RK, Merricks JW, Hamlin HH, Rieger IT: Construction of substitute bladder and urethra. Surg Gynecol Obstet 752:90, 1950 3. Kock NG, Nilson AE, Nilson LO, Norlen LJ, Philipson BM: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Urol 128:469–475, 1982 4. Thuroff JW, Alken P, Engelmann U, Riedmiller H, Jacobi GH, Hohen- fellner R: The Mainz pouch for bladder augmentation and continent urinary diversion. J Urol 136:17–26, 1986 5. Rowland RG, Mitchell ME, Bihrle R, Kahnoski RJ, Piser JE: Indiana continent urinary reservoir. J Urol 137:1136–1139, 1987 6. McDougal WS: Metabolic complication of urinary intestinal diversion. J Urol 147:1199–1208, 1992 7. Ginsberg D, Huffman JL, Lieskovsky G, Boyd SS, Kinner DG: Urinary tract stones a complication of the Kock pouch continent urinary diversion. J Urol 145:956–959, 1991 8. Arai Y, Kawakita M, Terachi T, Oishi K, Okada Y, Takeuchi H, Yoshida O: Long term follow-up of the Kock and Indiana pouch procedure. J Urol 150:51–55, 1993 9. Rowland RG, Kropp BP: Evolution of the Indiana continent urinary reservoir. J Urol 152:2247–2251, 1994 10. Arai Y, Schichiri Y, Miyakawa M, Ueda T, Terai A, Terachi T, Takeuchi H, Yoshida O: Evolving experience with continent urinary diversion using the Indiana pouch. Int J Urol 1:241–245, 1994 11. Terai A, Ueda T, Kakehi Y, Terachi T, Arai Y, Okada Y, Yoshida O: Urinary calculi as late complication of the Indiana continent urinary diversion. J Urol 155:66–68, 1996 12. Terai A, Arai Y, Kawakita M, Okada Y, Yoshida O: Effect of urinary intestinal diversion on urinary risk factors for urolithiasis. J Urol 150: 726–731, 1993 13. Boyd SD, Everett RW, Schiff WM, Fugelso PD: Treatment of unusual Kock pouch urinary calculi with ESWL. J Urol 139:805–806, 1988 14. Khatri VB, Walden T, Pollack MS: Multiple large calculi in a continent diversion pouch. J Urol 148(pt 2):1129–1130, 1992 15. Hollensbe DW, Foster RS, Brito CG, Kopecky K: Percutaneous access to a continent urinary reservoir for removal of intravesicle calculi. A case report J Urol 149:1546–1547, 1993 16. Thomas R, Lee S, Salatore F, Blank B, Harma E: Direct percutaneous pouch cystotomy with endoscopic lithotripsy for calculus in a continent urinary reservoir. J Urol 150:1235–1237, 1993 17. Seaman EK, Benson MC, Shabasigh R: Percutaneous approach to treat- ment of Indiana pouch stones. J Urol 151:690–692, 1994 18. Roth S, Van-Ahlen HS, Emjonon A, VonHeyden-Bhertle L: Percutaneous pouch lithotripsy in continent urinary diversions. Br J Urol 73:316–318, 1994 333CASE REPORT