|Year : 2016 | Volume
| Issue : 3 | Page : 98-99
A Giant Ileal Conduit Calculus after Radical Cystectomy
Mukesh Chandra Arya, Rajeev Kumar, Mayank Baid, Lalit Kumar
Department of Urology, S.P. Medical College, Bikaner, Rajasthan, India
|Date of Web Publication||4-Aug-2016|
Mukesh Chandra Arya
Department of Urology, S.P. Medical College, Bikaner, Rajasthan
Source of Support: None, Conflict of Interest: None
Radical cystectomy with ileal conduit is one of the treatment options for patients with muscle invasive carcinoma bladder. Giant ileal conduit calculus is a very rare complication. A 60-year-old male had undergone radical cystectomy with ileal conduit about 12 years back and now presented left gross hydrourereteronephrosis with perinephric collection and features of renal failure. We performed drainage of perinephric collection followed by left sided percutaneous nephrostomy and patient's condition improved gradually. Later on, we performed contrast-enhanced computed tomography (CT) intravenous urogram and nephrostogram which revealed a huge calculus of size 9 cm × 5 cm in the ileal conduit. Calculus was removed by open surgery by incising the conduit over antimesenteric border. Above presentation is a sequel of a huge ileal conduit calculus obstructing left ureter. Calculus formation can result from stomal stenosis, metabolic acidosis, small bowel syndrome, recurrent infection, any foreign body like a staple or nonabsorbing suture material. These patients require close surveillance with X-ray kidney, ureter, and bladder for a longer period after the urinary diversion. In doubtful cases, helical CT may be useful. Giant ileal conduit calculus is a very uncommon presentation after radical cystectomy.
Keywords: Huge calculus, ileal conduit, radical cystectomy
|How to cite this article:|
Arya MC, Kumar R, Baid M, Kumar L. A Giant Ileal Conduit Calculus after Radical Cystectomy. J Integr Nephrol Androl 2016;3:98-9
| Introduction|| |
Radical cystectomy with ileal conduit is one of the treatment options for patients with muscle invasive carcinoma bladder. Various long-term complications are known for this procedure. Among the complications that mentioned, stoma complications, bowel complications, urinary tract infection, stone formation, and deterioration of renal functions.  However, giant ileal conduit calculus is a very rare complication. Rarity and management problems warrant this presentation.
| Case report|| |
A 60-year-old male had undergone radical cystectomy with ileal conduit about 12 years back. He was asymptomatic and leading normal life till recently. He presented with low urine output through conduit site along with fever, loss of appetite, nausea, painful swelling left flank, bilateral lower limb swelling, and breathlessness. There was no history of hematuria and flank pain of prolonged duration. On general examination, patient was anemic and febrile. Abdominal examination revealed normal stomal opening without any evidence of stomal stenosis. Left flank and left renal angle fullness were noted, it was a renal lump and soft in consistency with ill-defined margin. Laboratory examination showed hemoglobin 9 g% with white blood cell count of 17,000/μL. Blood urea and serum creatinine were 156 mg/dl and 3.2 mg/dl, respectively. Ultrasonography (USG) revealed left gross hydroureteronephrosis with the perinephric collection. We performed drainage of perinephric collection followed by left-sided percutaneous nephrostomy and patient's condition improved gradually. Perinephric drain was dry after 5 days and it was removed after USG revealing no perinephric collection. Percutaneous nephrostomy was draining well with about 600 cc of clear urine daily. Two weeks later, the general condition of the patient improved and his hemoglobin was 10 g% and his leukocyte count and renal function test were within normal limits. Urine culture was sterile. We performed contrast enhanced computed tomography of the abdomen with both oral and intravenous contrast, but unfortunately, the noncontrast film was not provided so that we missed the calculus. As we had a high suspicion of the left uretero-enteric anastomotic stricture so that we did nephrostogram which revealed a huge calculus of size 9 cm × 5 cm in the ileal conduit. Then, we took the patient for endoscopic removal of calculus by the rigid endoscope through stoma site, but we could not negotiate the endoscope up to calculus. Then, we performed open surgery through midline intraperitoneal approach by incising the conduit over the antimesenteric border and total removal of calculus was done by pneumatic lithoclast fragmentation. During exploration, we found nonstenotic normal left ureteric opening without any evidence of foreign body or growth in the conduit. Postoperative recovery of the patient was uneventful, and percutaneous nephrostomy was removed on the 4 th postoperative day. Stone was sent for analysis, and it was mixed stone containing calcium oxalate, calcium phosphate, and uric acid.
| Discussion|| |
The primary goals in the selection of a urinary diversion are to ultimately provide the patient with diversion that results in the best local cancer control, the lowest potential for complications in both short- and long-term, and the best quality of life.  The ileal conduit urinary diversion was one of the most commonly used techniques.
The various complications manifest at different times, and one of the long-term complications noted after urinary diversion is urolithiasis and its related problems. The incidence varies from 4.9%  to 15.3%  worldwide, but in Indian scenario, Rajaian and Kekre  reported a large bifid ureteric calculus in both the ureter from ileal conduit following radical cystectomy. The stones related to urinary diversion could either be in the upper tracts or in the conduit itself. However, the majority of the cases, calculus formation occurred in upper urinary tract after conduit diversion. The incidence of conduit calculus has been reported with forgotten Double J stent but a huge conduit calculus after more than 10 years of follow-up is not reported till date in our knowledge.
Our patient presented with upper tract changes with left-sided hydroureteronephrosis with perinephric urinoma and septicemia with detoriorated renal function. Possibly, all these things are the sequele of such a huge ileal conduit calculus obstructing left ureteric opening.
The possible reason for such a huge calculus may be due to metabolic complications of diversion. Hypocitraturia as a result of metabolic acidosis and hyperoxaluria due to short bowel syndrome may be contributory factors.  Bacterial colonization with recurrent infection of the conduit may form infection stones. Another possibility, the stapler used for the creation of conduit may act as a nidus for the stone formation. Dropped stone from upper tract which enlarged in size gradually with time is another possibility. We have already ruled out stomal stenosis as one of the causes for conduit calculus.
To avoid delay in diagnosis, patients require close surveillance for a longer period after the urinary diversion.  Patel and Bellman  recommended annual kidney, ureter, and bladder (KUB) X-ray and flexible lower-tract endoscopy to look for urolithiasis. A plain X-ray of the KUB region should suffice to diagnose urolithiasis in those who have undergone urinary diversion. In doubtful cases, helical computed tomography may be useful.
| Conclusion|| |
Giant ileal conduit calculus is a very uncommon presentation after radical cystectomy, but it requires close annual surveillance to avoid delay in diagnosis. Metabolic acidosis, short bowel syndrome, and recurrent infection probably were the contributory factors in our case.
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Conflicts of interest
There are no conflicts of interest.
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