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

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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 stone risk factors. seen. In the absence of purine overindulgence, becomes indispensible. With the use of In their study, patients with continent urinary the true cause of hyperuricosuria in patients ultrasonography, a small finder needle may be reservoirs, such as the Kock and Indiana with urinary diversions is poorly characterized. advanced into the collecting system and a pouches, were found to have long-term nephrostogram can be taken to identify the increases in urinary excretion of calcium, STONE COMPOSITION best calyx for stone clearance, which can then phosphate and magnesium compared with be targeted fluoroscopically. Alternatively, ileal conduits. It is also well known that the Simplistically, diversion stones may be blind access into the collecting system can be use of long segments of ileum can lead to classified as either metabolic or infectious. obtained using anatomic landmarks, but this enteric hyperoxaluria, thereby increasing the While most patients contain a mix of both is not recommended. risk of stone formation in these patients [15]. types of calculi, the bulk of their stone burden is usually composed of magnesium Another technical challenge in patients with The use of colonic or ileal segments for ammonium phosphate (struvite). Nonetheless, urinary diversions is reduced ureteroscope bladder substitution results in a calcium oxalate, carbonate apatite, hydrogen deflectability. Capacious reservoirs permit

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proximal ureteroscope buckling. More than FIG. 2. Kidney stones Ureteral stones one area of angulation in the course of a Treatment algorithm for upper flexible ureteroscope limits the degree of tip urinary tract stones in patients Retrograde access: Finding neo- deflection. This is caused by a change in the PCNL: Standard of care for ureteral orifice may be with urinary diversions. PCNL, deflecting cables of the ureteroscope. In these large stone burdens, lower pole challenging. Once the access percutaneous nephrolithotomy. cases, small diameter laser fibres and Nitinol calculi, cystine stone disease, gained, the rest of the procedure baskets are recommended since they interfere abnormal renal anatomy and proceeds as in undiverted stones not amenable to less with ureteroscope deflection. patients. ureteroscopy or ESWL. Antegrade access: Considered Both flexible and rigid instruments are often ESWL: Recommended for when retrograde access has needed to render patients stone free. This is stones smaller than 2cm, failed. particularly true in cases of distal ureteric provided no evidence ureteral stones. Stones located within the ureter near obstruction.Significant risk of Combined approach: Combined the uretero-ileal anastomosis, particularly the obstruction and gram negative access may be necessary to segment traversing under the root of the sepsis. render the patient stone free. mesentery, require skill in manoeuvering the flexible ureteroscope to obtain optimal Stone free visualization for lithotripsy and stone Yes/No basketing. In some cases, disintegrating the stone into tiny fragments with the laser fibre Follow-up every 3 months with is advisable when basket extraction is not metabolic evaluation; second stage efficient. intervention as indicated.

STONES IN CONDUITS FIG. 3. Stones in these types of diversions most often Reservoir stones Treatment algorithm for reservoir result from foreign bodies such as staples, stones. sutures, and stones passed from the upper Cutaneous Orthotopic Continent Urinary Diversion Urinary Diversion tracts. Residual urine and stomal stenosis are also risk factors [17,18]. For ureteric stones in Transtomal access: The easiest Retrograde/transurethral patients with loop diversions, a loopogram is approach. Associated with access: Access useful in assessing the patency of the increased risk of stomal stricture gained through native urethra. uretero-intestinal anastomosis. Where and incontinence. Recommended There is a risk of bladder neck successful retrograde access can be achieved, in patients with small reservoir contracture related to this use of a super-stiff guidewire and placement stone burden with the least access. amount of trans-stomal of a ureteric access sheath can greatly manipulations. simplify repeated accessing of the ureter. The super-stiff guidewire and access sheath help Percutaneous access: Image-guided access decreases trans-stomal to straighten out redundancies in the bowel manipulations and potentially avoids damage to the continece loop during the endoscopic procedure. mechanism. Should be considered as a recommended modality with high success rates and acceptable morbidity. Stones removed STONES IN RESERVOIRS AND NEOBLADDERS with either nephroscopy and I Lithotripsy, or laparoscope and forceps. Risk factors for stone formation in continent reservoirs are directly related to residual ESWL: Non-invasive modality for patients urine, build-up of mucus, acidic urine and who want to avoid surgery. Has been shown bacterial colonization. These factors are to be successful within the ileal conduits, Kock and Indiana pouches. May require exacerbated by not irrigating the pouch endoscopic removal of stone fragments. [19,20]. Different methods have been described to manage reservoir and neobladder stones (Fig. 3). Access to stones within the reservoir can be accomplished in many ways. requiring minimal manipulation. In most Percutaneous access is often ideal in The simplest and least invasive is a trans- cases, the stoma should only be used as a neobladder or reservoir patients because stomal approach; however, the continence means of filling the pouch. For orthotopic it allows the greatest flexibility for mechanism in cutaneous reservoirs is often diversions, rigid and flexible instruments can instrumentation. Before access, preoperative fragile, placing the patient at risk of stomal be used via the urethra. The choice of imaging should be carefully reviewed to stenosis or incontinence when a trans-stomal lithotripters (holmium laser, mechanical or delineate the location of adjacent bowel and approach is used. This approach is therefore electro-hydraulic lithotripters) remains the vascular structures that may be encountered discouraged except for very small stones same in these patients. with access and instrumentation. Ultrasound

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FIG. 4. Cystoscopy-guided transillumination access widening the skin incision and removing the area for patency with an antegrade into pouch. bag and stones together (Fig. 5) [21–28]. nephrostogram or retrograde pyelogram before tube removal. Alternatively, a renal Fluoroscopy is a useful adjunct during these scan can be used to assess the efficacy of the cases as it can help detect residual fragments, procedure after drain removal. which often hide within mucosal folds. If intracorporeal lithotripsy is inevitable, PREVENTION OF RECURRENT STONES ultrasonic lithotripters are preferable to the electro-hydraulic variety. The ultrasound Patients with urinary diversions are at high waves cause far less mucosal trauma risk for recurrent stones. Recurrent stones are compared with electrohydraulic lithotripters reported to be as high as 63% over a 5-year [29]. Another distinct advantage of the follow-up period by Cohen et al. [5]. ultrasonic lithotripter is the ability to simultaneously suction out stone fragments, Catheterization alone may not adequately making the process more efficient. Stones as evacuate small stone crystals and mucus large as 5 cm and multiple calculi have been within the reservoir. Both can act as a nidus FIG. 5. Stones placed into an endocatch bag. treated successfully using these techniques for new stone formation. Several authors [21,29]. have investigated the impact of pouch irrigation protocols on stone formation. Laparoscopic ureterolithotomy has been Hensle et al. [35] noted that patients on an described as an alternative to open or irrigation protocol had an overall incidence of endoscopic approaches. Advanced reservoir calculi of 7% vs a rate of 43% in laparoscopic skills are required owing to the those not irrigating their reservoirs. Terai et al. altered anatomy, and the presence of bowel [1,36–38] reported a 12% lifetime risk of adhesions, which pose a significant challenge stone formation in Japanese patients with an to access and dissection. In the right hands, Indian pouch vs 5.4% for patients in the USA. this technique is very successful [30–33]. The only difference noted was that patients in the USA with Indiana pouches were routinely DRAINAGE AFTER STONE REMOVAL placed on standard pouch irrigation protocols. Various options exist for pouch drainage after stone removal. These include ureteric stents, It is also important to completely empty the pigtail nephrostomy tubes, re-entry reservoir of residual urine. Timed voiding and nephrostomy tubes, nephroureteric tubes, and a catheterization schedule can go a long way Foley catheters. Ureteric stents can be used in towards helping to achieve this. Additionally, minor cases where ureteric lithotripsy was this may also aid in reducing the bacterial performed. An extra long ureteric stent should colony count within the reservoir, which is a be used, and if necessary, the string tether risk factor for development of infectious should be left attached to facilitate removal stones [39,40]. guidance is useful as adjacent bowel can be without the need for pouchoscopy. Patients clearly determined when introducing the undergoing percutaneous pouch access Correction of the metabolic abnormalities is percutaneous finder needle. Additionally, should be drained with a Foley catheter for also critical in the management of these placement of a flexible endoscope trans- about 7 days. The tube is then clamped and patients. In addition to hypovolaemia, stomally allows visualization of the access intermittent catheterization of the stoma is hypocitraturia also needs to be addressed and dilation process. Optimal sites for access restarted. If there are no problems, the Foley with oral supplementation in order to further can be transilluminated by deflection of the catheter is then removed from the pouch. decrease the risk of recurrent disease [37,41]. endoscope to visualize the anterior wall of the For patients with infectious stones, antibiotic pouch. One or two Amplatz sheaths may be For renal and antegrade lithotripsy cases, prophylaxis may be indicated, particularly in placed as needed to facilitate stone removal pigtail nephrostomy, nephroureteric and re- patients with recurrent stones. In addition to (Fig. 4). entry nephrostomy tubes are options. antibiotic prophylaxis, acetohydroxamic acid, However, in cases with significant bleeding, a a potent urease inhibitor, can be used. Suby’s As an alternative, laparoscopic trocars can be large bore nephrostomy tube is necessary G solution and Hemiacidrin have been used in used. Again, multiple trocars can be placed, [34]. For cases with significant ureteric dissolution therapy, particularly in cases allowing for separate camera and working oedema, or requiring stricture dilation, a drain where there are tiny residual fragments, ports as needed. To avoid damage to the traversing the compromised area should be which promote new stone formation. Other intestinal mucosa, stones can be placed into a used. This may be accomplished with either a options for medical prophylaxis include laparoscopic endocatch bag. Stone nephroureteric tube or pigtail nephrostomy aluminum hydroxide, which binds phosphate fragmentation can then proceed inside the tube in combination with a ureteric stent. It is in the gut thereby decreasing its absorption bag, or the stone can be removed intact by important to re-assess the questionable [40,42,43].

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TABLE 1 Selected papers on the surgical management of stones

Median (range) Author/ No Stone follow- up, study Diversion type/Configuration patients location months Stone type Success rate Notes Breda et al. n/r 74 Reservoir: 74 n/r n/r 95% Percutaneous access under [44] fluoroscopic guidance. 12% minor postoperative complications. Stone-free rate confirmed at 14 days with a plain abdominal film. Lam et al. Indiana pouch: 1, bladder 8 Ureters: 2 n/r n/r 100% Removal of a large burden [45] augmentation: 6, Reservoir: 6 diversion stones with appendicovesicostomy: 1 combination of laparoscopic and endourological techniques. No intra/postoperative complications. Hyams Indiana pouch: 2, 15 Kidneys:5 n/r n/r n/r Assessment of different access et al. [46] ileal conduit: 8, methods in the management of orthotopic neobladder: 5 urolithiasis in patients with urinary tract reconstruction. El-Nahas Ileal neobladder: 10, 24 Kidneys: 20 40 50% struvite; 87.5% Percutaneous management of et al. [47] ileal conduit: 4, Ureters: 4 (14–132) 41.7 calcium; large burden kidney and ureteric hemi-Kock pouch: 7, 8.3 urine acid stones; 12.5% complication rectal: 3 rate; recurrent stones treated with ESWL. Paez et al. n/r 12 Reservoir: 12 23.6 n/r 58% Ultrasound-guided percutaneous [48] access. No intra/postoperative complications. Five (42%) stone recurrences with the mean time to recurrence of 18 months. Roberts Bladder neck reconstruction: 11, 60 Reservoir: 60 48.7 n/r Intact stone Intact vs fragmented extraction; et al. [49] bladder augmentation: 4, extraction: 103 stone episodes in 60 bladder augmentation + 57.6%; patients found no difference in catheterizable channel: 25, fragmented: extraction methods. Average catheterizable reservoir: 15, 56.1% time from reconstruction to neobladder: 2 stone formation or recurrence was 37 months. Natalin Indiana pouch: 5 5 Reservoir: 5 32.5 (9–61) n/r 100% Combined endolaparopscopic et al. [50] double-percutaneous method for large burden reservoir stones. No intra/postoperative complications. Deliveliotis S-pouch: 3, Bricker: 8 11 Kidneys: 7 4.5 years Struvite, urine 81.8% ESWL for upper tract calculi in et al. [51] Ureter: 5 (1–9 years) acid with patients with urinary diversion. calcium Four patients failed; two deposits patients received repeated ESWL and two underwent percutaneous nephrolithotomy and ureterolithomy; no complications recorded. El-Assmy Ileal W neobladder: 11, 27 Kidneys: 21 3 n/r 81.5% Repeated ESWL in 12 (44.4%) et al. [52] Bricker conduit: 8, Ureter: 3 patients; eight (29.6%) required Kock pouch: 6, two sessions, four (14.8%) rectal bladder: 2 required three sessions. Two patients required percutaneous nephrolithotomy. 7.4% minor postoperative complications.

n/r, not recorded.

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World J Urol Stone entrapment during percutaneous endourological equipment and techniques 1999; 17: 305–7 removal of infection stones from a have greatly reduced the morbidity of this 9 Bishop RF, Smith ED, Gracey M. continent diversion. J Urol 1999; 162: common problem (Table 1, [44–52]). Bacterial flora of urine from ileal conduit. 775–6 Prevention of recurrent stones with J Urol 1971; 105: 452–5 24 Cain MP, Casale AJ, Kaefer M, Yerkes E, correction of metabolic abnormalities, 10 Suriano F, Gallucci M, Flammia GP et al. Rink RC. Percutaneous cystolithotomy in increased fluid intake, pouch irrigation Bacteriuria in patients with an orthotopic the pediatric augmented bladder. J Urol protocols, and prophylaxis against recurrent ileal neobladder: urinary tract infection or 2002; 168: 1881–2 infections are critical steps in avoiding asymptomatic bacteriuria? 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