Bilateral percutaneous nephrolithotomy after radical cystectomy and ileal conduit

Amit Tuli; Idha Sood; Kim Mammen

doi:10.4103/cjhr.cjhr_1_18

CASE REPORT

Year : 2018 | Volume : 5 | Issue : 2 | Page : 149-151

Bilateral percutaneous nephrolithotomy after radical cystectomy and ileal conduit

Amit Tuli¹, Idha Sood², Kim Mammen¹
¹ Department of Urology, Christian Medical College, Ludhiana, Punjab, India
² 2nd Year MBBS Student, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication

9-Apr-2018

Correspondence Address:
Kim Mammen
Department of Urology, Christian Medical College, Vellore - 632 004, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cjhr.cjhr_1_18

Abstract

Urinary stones are one of the most common complications of urinary diversions. We report the case of a 40-year-old man with renal and ureteric stones after radical cystectomy and ileal conduit. Normally renal stones are fragmented and removed through the ureters and urethra. However, in this patient with ileal conduit, the neo ureteric orifices being extremely narrow and because of the delicate wall of the ileum percutaneous nephrolithotomy has become the best option of treatment.

Keywords: Ileal conduit, percutaneous nephrolithotomy, radical cystectomy, renal stones

How to cite this article:
Tuli A, Sood I, Mammen K. Bilateral percutaneous nephrolithotomy after radical cystectomy and ileal conduit. CHRISMED J Health Res 2018;5:149-51

How to cite this URL:
Tuli A, Sood I, Mammen K. Bilateral percutaneous nephrolithotomy after radical cystectomy and ileal conduit. CHRISMED J Health Res [serial online] 2018 [cited 2022 May 23];5:149-51. Available from: https://www.cjhr.org/text.asp?2018/5/2/149/229573

Introduction

Radical cystectomy is the removal of the entire bladder, pelvic lymph nodes (lymphadenectomy), surrounding fat and fascia, lower ureters, prostate, prostatic urethra, and seminal vesicle that may contain cancer cells, done in patients with muscle-invasive carcinoma bladder. To make a new passage for urine, an ileal conduit which uses a portion of the distal ileum is made. This allows urine to pass from the kidneys through the conduit and out through an opening on the skin of the abdomen into an appliance attached to the anterior abdominal wall. These patients are at an increased risk of development of stones in the upper urinary tract, largely due to metabolic derangements and sepsis. Percutaneous nephrolithotomy (PCNL) is the standard of treatment for large stone burdens. Other methods include extracorporeal shockwave lithotripsy and antegrade or retrograde ureteroscopic lithotripsy.

Case Report

A 48-year-old man was diagnosed with a case of carcinoma of the bladder, and he underwent transurethral resection of bladder tumor. Biopsy revealed it to be transitional cell carcinoma and inverted papilloma. He had progression of tumorn after 8 years and underwent radical cystectomy and urinary diversion.

Four years later, he had right flank pain and was diagnosed to have bilateral nephrolithiasis and bilateral ureteric calculi with right pyelonephritis and bilateral hydroureteronephrosis on ultrasound abdomen for which he was admitted. His serum creatinine level was 3.7, and bilateral percutaneous nephrostomy (PCN) under ultrasonography guidance was done. Once serum creatinine levels were normal, computed tomography urogram showed bulky right kidney with multiple calculi seen in the middle and lower calyx and the largest one at the level of the upper ureter (L3 level) measuring 20 mm × 8 mm along with right pyelonephritis. Left nephrolithiasis with left upper ureteric calculus measuring 9 mm along with mild hydronephrosis was seen [Figure 1] and [Figure 2].

Figure 1: Coronal view of computed tomography urogram. Arrow indicates bilateral nephrolithiasis and bilateral upper ureteric calculi

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Figure 2: Axial view of computed tomography urogram. Arrow indicates bilateral nephrolithiasis and bilateral upper ureteric calculi

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He underwent bilateral PCNL, and complete stone clearance was achieved [Figure 3]. Intraoperatively few fragments went down the ureter for which 6/7.5 Fr rigid ureteroscope was used to retrieve fragments from upper ureter [Figure 4].

Figure 3: Bilateral flank incisions for bilateral percutaneous nephrolithotomy

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Figure 4: Rigid ureteroscope inserted through Amplatz sheath for removal of fragments in the upper ureter

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Discussion

The urinary stone formation is one of the most common adverse events out of the myriad of complications in patients with urinary diversions.^[1] These stones form in the upper urinary tract or in the diversion itself. The diversions that form a reservoir are more prone to develop stones within the pouch. The patients with an ileal conduit that only provides a passage but not a reservoir have upper urinary tract dilatation and urinary stasis contributing toward the urinary stone formation. Hyperchloremic metabolic acidosis because of increased reabsorption of solutes across intestinal mucosa is mainly responsible for calculus formation.^[2]

After radical cystectomy and ileal conduit, this patient also presented with renal and upper ureteric stones along with hydronephrosis and right pyelonephritis. The advent of minimally invasive endoscopic techniques has reduced hospital stay and has hastened recovery postoperatively. These techniques include PCNL, extracorporeal shock wave lithotripsy (ESWL), antegrade or retrograde ureteroscopic lithotripsy.^[3]

PCNL is the standard of care for renal stones, abnormal renal anatomy, and stones not amenable to ureteroscopy.^[4] ESWL is a good treatment option in patients with urinary tract reconstruction because of difficulties in endoscopically accessing the ureter.^[5] In patients with ileal conduit, neo ureteric orifices being narrow are difficult to visualize, and it is difficult to gain percutaneous renal access since contrast cannot be infused into the collecting system.

In this patient, with the combined guidance of ultrasound and fluoroscopy PCN was done and later, PCNL was done through the same tract for successful stone clearance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Turney BW, Reynard JM, Noble JG, Keoghane SR. Trends in urological stone disease. BJU Int 2012;109:1082-7.
2.	Sullivan JW, Grabstald H, Whitmore WF Jr. Complications of ureteroileal conduit with radical cystectomy: Review of 336 cases. J Urol 1980;124:797-801.
3.	Zhong W, Yang B, He F, Wang L, Swami S, Zeng G, et al. Surgical management of urolithiasis in patients after urinary diversion. PLoS One 2014;9:e111371.
4.	Guliev BG. Ultrasound guided percutaneous nephrolithotripsy. Urologiia 2014:111-5.
5.	El-Assmy A, El-Nahas AR, Mohsen T, Eraky I, El-Kenawy MR, Shaban AA, et al. Extracorporeal shock wave lithotripsy of upper urinary tract calculi in patients with cystectomy and urinary diversion. Urology 2005;66:510-3.