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Management of Urolithiasis in Patients After Urinary Diversions BJUIBJU INTERNATIONAL Zhamshid Okhunov, Brian Duty, Arthur D

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Management of Urolithiasis in Patients After Urinary Diversions BJUIBJU INTERNATIONAL Zhamshid Okhunov, Brian Duty, Arthur D 2011 THE AUTHORS; BJU INTERNATIONAL 2011 BJU INTERNATIONAL Mini Reviews UROLITHIASIS AFTER URINARY DIVERSIONS OKHUNOV ET AL. Management of urolithiasis in patients after urinary diversions BJUIBJU INTERNATIONAL Zhamshid Okhunov, Brian Duty, Arthur D. Smith and Zeph Okeke The Smith Institute for Urology, North Shore – Long Island Jewish Health System, New Hyde Park, New York, NY, USA Accepted for publication 19 January 2010 After urinary diversion patients What’s known on the subject? and What does the study add? are at increased risk of long-term Patients undergoing urinary diversion are at increased risk of stone formation in the upper complications, including stones of the upper urinary tract and within the pouch. Several studies have reported wide ranging outcomes urinary tract and reservoir or conduit. of the various surgical and non-surgical management options. Advances in instrumentation and techniques have expanded treatment options, while In this article we reviewed risk factors, etiology, and outcomes of surgical and medical minimizing morbidity. Minimally invasive management of diversion-associated urolithiasis. A surgical management algorithm was treatment methods include shockwave developed based on the known literature to serve as a guide to treatment stones in these lithotripsy, antegrade and retrograde patients. The relative effectiveness of various preventive management strategies are ureteroscopic lithotripsy and percutaneous reviewed and summarized. nephrolithotomy. Percutaneous and laparoscopic techniques are applicable to KEYWORDS stones within urinary diversions. Medical management is crucial for avoiding urinary diversion, conduit, neobladder, ileal, recurrent stones in these patients. nephrolithotomy, calculi INTRODUCTION 5.4% of patients with Indiana pouches and of nonabsorbable materials in urinary 26.5% with Kock pouches were found to have diversions has largely been abandoned. Advances in urinary diversion techniques stones. A 16.7% long-term stone formation have greatly improved the health-related rate was noted by Ginsberg et al. [2] in quality of life of patients undergoing radical patients with the Kock pouch. In a study by BACTERIAL COLONIZATION cystoprostatecomy. While most patients do Webster et al. [3] there was a reservoir stone well after surgery, various long-term rate of 5.4% for the Florida pouch. A series of Most patients with urinary diversions become complications can occur, including stomal 800 patients with Mainz pouch diversions, colonized with a multitude of bacteria stenosis, uretero-intestinal anastomotic with a median follow-up of 7.6 years, showed regardless of the type of diversion. stricture, chronic renal insufficiency, vitamin a 10.8% incidence of stones in reservoirs with Colonization rates range from 14 to 96% B12 deficiency, electrolyte abnormalities, an intussuscepted ileal nipple and 5.6% in [9–13]. Nonetheless, most of these patients diarrhoea, and UTIs. These patients are also at reservoirs with an appendiceal stoma [4]. The ultimately remain asymptomatic, despite increased risk of urolithiasis, which can cause incidence of upper tract stones in patients colonization with known uropathogens. In sepsis, pouch infection, pyelonephritis, renal with urinary diversions is comparable with the patients with conduits, the most common insufficiency, haematuria and pouch general population [1,5–8]. colonizers were skin flora such as perforation. This review focuses on the Streptococcus spp. and Staphylococcus etiology and surgical and medical epidermitis [14]. In a study of the prevalence management of diversion-associated OVERVIEW OF RISK FACTORS of asymptomatic bacteriuria in patients with urolithiasis. continent diversions, Suriano et al. [11] Patients with urinary diversions are at published urine culture results from 40 increased risk of upper tract stones as well as patients with orthotopic ileal neobladders. Of INCIDENCE calculi within the diversion segment. Both the samples taken, 57% were positive for continent and incontinent diversions are at bacteria. The most common bacteria isolated The prevalence of urolithiasis in patients with risk. Factors promoting stone formation from these cultures were Escherichia coli, urinary diversions varies from 3 to 43% include bacterial colonization and diversion- Enterococcus feacalis, Enterococcus faecium depending upon the series. Terai et al. [1] from associated urinary metabolic derangements. and Proteus mirabilis [10]. Kyoto University reported a stone formation Other risk factors include urinary stasis, reflux rate of 12.9% in patients with Indiana Pouch of mucus into the upper tract and exposure of Since most patients are reconstructed with diversions vs 43% in patients with the Kock nonabsorbable surgical material, such as refluxing uretero-intestinal anastomoses, the pouch [1]. In a similar study by Arai et al., staples, to urine within the reservoir. The use upper tracts often become colonized with © 2011 THE AUTHORS 330 BJU INTERNATIONAL © 2011 BJU INTERNATIONAL | 108, 330–336 | doi:10.1111/j.1464-410X.2011.10194.x UROLITHIASIS AFTER URINARY DIVERSIONS FIG. 1. Pyelogram showing a matrix stone in the hyperchloremic metabolic acidosis. The urate and calcium phosphate stones have all renal pelvis in a patient with an ileal conduit. etiology of this metabolic abnormality is the been reported [1]. Struvite stones are most ready exchange of bicarbonate and chloride often composed of a matrix core with matrix ions between the urine and bowel surface. The also being interspersed throughout the stone. resulting systemic acidosis causes impaired The usual source of matrix is from the bowel calcium reabsorption from the proximal segment (Fig. 1). tubules and decreased renal production of citrate. There is also an increase in citrate SURGICAL MANAGEMENT absorption by the bowel segments. This complex of events leads to hypercalciuria, Advances in minimally invasive endoscopic hypocitraturia, alkaline urine, abundant techniques have shifted the surgical ammonium and phosphate ions, each of management of upper urinary tract stones which promotes stone formation. away from the realm of open surgery. These advances have resulted in decreased hospital Patients with continent reservoirs are at risk stays and faster recuperation. Despite the for chronic diarrhoea depending on the high success rates associated with these length of ileum resected. With less small newer management techniques, the bowel to absorb fluids, the capacity of the reconstructed urinary tract poses a variety of large bowel to do so is easily overwhelmed, challenges. Given the unique anatomy, cross- leading to an osmotic diarrhoeal state. sectional imaging with CT and other Patients undergoing resection of the ileocecal techniques are indispensible in surgical valve are particularly at risk. The presence of planning. inflammatory bowel disease and previous urea-splitting organisms. These bacteria radiation therapy are additional risk factors. RENAL AND URETERIC STONES include Klebsiella spp., Pseudomonas spp., Roth et al. [15] reported a 15% rate of chronic Proteus spp., Providencia spp., Ureaplasma diarrhoea in 100 patients undergoing Several management options are available for urealyticum, Staphylococcus spp., Citrobacter continent urinary diversion with ileal and upper tract urinary calculi in patients freundii, Streptococcus spp., and ileocecal segments. They noted that patients with urinary diversions (Fig. 2). The initial Enterococcus spp. Urease hydrolyses urea with ileal segments 45–50 cm in length, in management for small diameter ureteric into ammonium and hydroxyl ions. This addition to the usual 15–20 cm of colon, were stones continues to be conservative. For splitting of urea and water into ammonium more likely to have diarrhoea unresponsive to patients requiring intervention, ESWL is a and bicarbonate ions has a dual purpose. medication. Leonard et al. [16] reported a 20% good initial treatment option given the Firstly, it creates an abundance of rate of chronic diarrhoea in their group of potential difficulty in endoscopically ammonium ions and phosphate ions. paediatric patients after continent reservoirs. accessing the ureter in patients with Secondly, the bicarbonate ions serve to reconstructed urinary tracts. alkalinize the urine. These conditions allow Bile salts are irritative to the intestines, the ready precipitation of magnesium causing a secretory diarrhoea. In the absence In general, ureteric access is more easily ammonium phosphate crystals of adequate ileum to absorb bile salts and achieved in ileal conduits than in reservoirs ((NH4)MgPO4·6H2O) and carbonate apatite fatty acids, they transit into the large bowel owing to the lack of an afferent limb. crystals (Ca10 (PO4) 6•CO3) in the presence of where they undergo saponification by binding Regardless of diversion type, the main alkaline urine (pH > 7.2). calcium. An absorptive hyperoxaluria occurs difficulty lies in locating the neo-ureteric because there is less calcium available to orifices, which are often not clearly visualized. DIVERSION-ASSOCIATED METABOLIC complex with oxalate in the gut, resulting in This also creates difficulties when attempting DERANGEMENTS more ionized oxalate being available for to gain percutaneous renal access because absorption. In chronic diarrhoeal states, contrast cannot be infused into the collecting Terai et al. [7] evaluated the impact of urinary hyperuricosuria and hyperuricaemia are also system. In these cases, ultrasound guidance diversion type on metabolic
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