|Year : 2023 | Volume
| Issue : 1 | Page : 73-74
Giant pouch stones as a surgical challenge decades after a continent ileal pouch
Adil Abdulla, AV Venugopalan, TC Farzana
Department of Urology, Government Medical College, Kozhikode, Kerala, India
|Date of Submission||16-Oct-2022|
|Date of Decision||15-Nov-2022|
|Date of Acceptance||10-Dec-2022|
|Date of Web Publication||29-Dec-2022|
Department of Urology, Government Medical College, Kozhikode, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Continent cutaneous urinary diversion pouches are prone to complications like stoma blockage by mucus, metabolic derangements, infection, renal derangements and urolithiasis. Pouch urolithiasis is not uncommon, but presentation of a huge stone burden is rare. We report a case of giant pouch stones in a continent pouch which was a surgical challenge. We also highlight the need for adequate hydration, pouch irrigation and drainage by clean intermittent catheterization and regular follow-up, to prevent such a condition from arising.
|How to cite this article:|
Abdulla A, Venugopalan A V, Farzana T C. Giant pouch stones as a surgical challenge decades after a continent ileal pouch. Indian J Urol 2023;39:73-4
| Introduction|| |
Continent urinary diversions are created after radical cystectomy for urine storage and drainage. Patients with such continent pouches may develop early complications like stoma blockage by mucus, metabolic derangements, infection and renal derangements. Pouch stones are a late complication, usually years after the procedure. Pouch urolithiasis is not uncommon but presentation of a huge stone burden is rare. We report a case of giant pouch stones in a continent pouch two decades after surgery.
| Case Report|| |
A 63-year-old male, with muscle-invasive urothelial carcinoma of the urinary bladder, had undergone radical cystectomy and a continent diversion with cecum, ascending colon, and terminal ileum (Indiana pouch) with a catheterizable stoma (Mitrofanoff procedure) 26 years prior to presentation. He had been lost to follow-up for 20 years and was not diligent in his stoma care and bladder irrigation during this time. He presented with a hard, nontender, swelling of around 12 cm × 8 cm over the right lower quadrant of his abdomen which did not move with respiration. His hemogram, serum electrolytes, renal, and liver function tests were normal. X-ray abdomen erect showed radio-opacities in the right lower abdomen which suggested multiple large stones [Figure 1]. The findings were confirmed by a contrast-enhanced computed tomography scan. The patient underwent open surgery for stone retrieval. The pouch was approached by a midline laparotomy incision and dissected all around. A 6 cm pouchotomy incision was placed on the anterior aspect avoiding injury to the appendicular stoma. The stones were cleared completely. A total of 23 stones were removed weighing 880 gms. The pouch was closed in two layers with a pouch Foley catheter and an abdominal drain in situ. During the immediate postoperative period, the patient developed abdominal distension and surgical site infection, which was managed conservatively. The patient improved and pouch irrigation was started. The pouch drain and Foley catheter was removed on the 4th and 16th postoperative day, respectively. The stone analysis revealed it to be a struvite stone (triple phosphate). The patient was discharged in a stable condition after education regarding bladder irrigation. Follow-up X-ray revealed no residual stones. On last follow-up, the patient was asymptomatic.
|Figure 1: An erect X-ray abdomen shows radio-opacities in the right lower quadrant suggestive of multiple large stones|
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| Discussion|| |
Urinary diversions are prone to various complications such as stoma blockage by mucus, metabolic derangements, infection, renal derangements, and urolithiasis. An incidence of 4%–43% of pouch stones is reported after the Koch pouch and a corresponding incidence of 2.9%–13% after the Indiana pouch diversion. Regardless of the diversion, most of these stones are secondary to infection. Recurrent infections or pouchitis, metabolic derangements, excess mucus retention, and urinary pH are risk factors for pouch stone formation. Despite a huge stone burden, derangement of renal function may not be present.
| Conclusion|| |
Continent pouch urolithiasis with a large stone burden is preferably treated with open pouchotomy and stone clearance. These patients must be kept on regular lifelong follow-up and be educated regarding the risk of pouch stones, in addition, to the need for pouch irrigation and the risk for metabolic derangement.
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|| |
Turk TM, Koleski FC, Albala DM. Incidence of urolithiasis in cystectomy patients after intestinal conduit or continent urinary diversion. World J Urol 1999;17:305-7.
Agarwal S, Sharma D, Gupta A, Sankhwar S. Continent cutaneous diversion pouch calculi. BMJ Case Rep 2018;2018:r-226447.