|Year : 2018 | Volume
| Issue : 1 | Page : 38-40
Endoscopic management of massive stone load in a patient with repaired bladder exstrophy
Varun Vishnu Agarwal, Mukund Gopalkrishna Andankar, Hemant Rangnath Pathak
Department of Urology, BYL Ch. Nair Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||14-Mar-2019|
Dr. Varun Vishnu Agarwal
Department of Urology, 2nd Floor, Office Building, TNMC and BYL Ch. Nair Hospital, Dr. A. L. Nair Road, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
Bladder exstrophy is a rare congenital malformation of the genitourinary system. Patients with exstrophy of the bladder who have undergone augmentation cystoplasty with Mitrofanoff procedure have a tendency of recurrent calculi formation. A 23-year-old female, with bladder exstrophy, underwent Mitrofanoff procedure and developed recurrent vesical calculi thereafter. She presented to us with a very massive stone load, which was managed successfully by endoscopic technique. She was also taught preventive measures thereafter and advised regular follow-up. The importance of the report is that it highlights urolithiasis as a recurrent complication of primary bladder exstrophy closure, which can be managed effectively and safely by modern endoscopic techniques in a hostile abdomen with reconstructed tract and inaccessible urethra.
Keywords: Augmentation cystoplasty, exstrophy bladder, Mitrofanoff, vesical calculus
|How to cite this article:|
Agarwal VV, Andankar MG, Pathak HR. Endoscopic management of massive stone load in a patient with repaired bladder exstrophy. Arch Int Surg 2018;8:38-40
|How to cite this URL:|
Agarwal VV, Andankar MG, Pathak HR. Endoscopic management of massive stone load in a patient with repaired bladder exstrophy. Arch Int Surg [serial online] 2018 [cited 2019 Mar 26];8:38-40. Available from: http://www.archintsurg.org/text.asp?2018/8/1/38/254146
| Introduction|| |
Bladder exstrophy is a rare congenital malformation of the genitourinary system, with an estimated incidence of approximately 1 per 50,000 live births. From a reconstructive point of view, its treatment has faced various challenges to achieve anatomically, functionally, and cosmetically satisfactory results. They are likely to have other congenital conditions such as preterm birth, gastrointestinal anomalies, spina bifida, orthopedic conditions, and cardiovascular anomalies which make them prone to have a higher risk of in-hospital death compared with those without exstrophy. Today, we see more and more adolescent and adult patients who not only have good urinary continence but also have well-preserved upper tracts. However, these patients do continue to face numerous problems in their future lives. Here we present the case of a patient who presented to us with a massive vesical stone load who was managed endoscopically, successfully.
| Case Report|| |
A 23-year-old female, with exstrophy of the bladder, underwent exstrophy closure with B/L iliac osteotomy at an age of 2 months. At 9 years of age, she underwent open cystolithotomy for single vesical calculus. She later underwent augmentation cystoplasty with Mitrofanoff procedure at 10 years of age. Appendix was used as a continent catheterizable channel. She was taught regular clean intermittent self-catheterization of Mitrofanoff for evacuation. However, she developed recurrent multiple bladder calculi after 3 years and underwent percutaneous cystolithotripsy at 13 years of age. Once again at 19 years of age, laser cystolithotripsy was done through Mitrofanoff for a single vesical calculus. An optical laser fiber passed through a flexible cystoscope through Mitrofanoff, thus enabling scarless treatment. Each time complete clearance of calculi was achieved. Now she presented to us with suprapubic pain. X-ray abdomen was done which showed innumerable stones in the region of bladder along with left renal multiple calculi [Figure 1]. Her creatinine was normal and urine culture showed growth of Escherichia More Details coli. She was treated with appropriate antibiotic, and percutaneous cystolitotripsy was done. We used a 22-F nephroscope passed percutaneously through a 30-F Amplatz sheath to fragment the stones with ballistic lithotripter. Ultrasound-guided puncture was taken as the patient had a previously scarred abdomen [Figure 2]. Hundred percent clearance was achieved. Stone analysis revealed struvite calculi. Renal calculi were not managed in the same sitting in view of prolonged operative time and massive stone load, and the patient was asked to follow-up after a month for the same. On discharge, she was taught regular bladder irrigation with an advice of yearly follow-up with an abdominal ultrasound. Currently, she is stone-free at 1-year follow-up.
|Figure 1: Preoperative X-ray abdomen showing entire bladder studded with multiple calculi|
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| Discussion|| |
In a study involving 530 patients with exstrophy of the bladder, Silver et al. noted that 15% developed stones, mostly in the urinary bladder whether native or augmented by enterocystoplasty; risk factors were urinary infection, vesicoureteral reflux, foreign bodies, and urinary stasis. About 39% patients had stone recurrence associated with urinary tract infection of struvite composition. Bladder augmentation or urinary diversion requires intermittent catheterization, which introduces infection. The use of bowel for augmentation cystoplasty results in mucous secretion into the bladder, which combines with infection and stasis, increasing the risk of stone formation.
Our patient underwent augmentation by enterocystoplasty and has been on regular intermittent catheterization for 9 years which explains the role of mucus secretion and repeated infection in the etiology of recurrent stone formation. In addition, she had struvite stones which further support infection as the cause of recurrent stones.
Urolithiasis in a healthy adult or child usually develops in the upper urinary tract. However, urolithiasis in the exstrophy of the bladder almost always occurs in the lower urinary tract, usually in the bladder, whether the bladder has been augmented or not. Our patient had an unusual presentation of calculi, both in the upper and lower urinary tract.
These stones can be managed using either a transurethral shockwave lithotripsy or percutaneous approach. The first suprapubic combined approach to bladder calculi was described by Gopalakrishnan et al. in 1988. Transurethral approach could not have been used in our patient in view of obliteration of bladder neck at the time of Mitrofanoff procedure.
Pietro et al. described a technique in a patient with a Mitrofanoff diversion and a renal transplant using a flexible ureteroscope, an amplatz sheath, and combination of ballistic and ultrasound lithotripsy. Hubsher and Costa inserted a 30-F Amplatz sheath through an existing suprapubic tract and then introduced a combination of either ultrasound or holmium laser for calculi removal under direct vision with a nephroscope. We achieved complete clearance with a ballistic lithotripter passed percutaneously through nephroscope through a 30-F Amplatz sheath. Laser could not have been used in view of massive stone load [Figure 3].
Various methods have been used to prevent stone formation in augmented bladder including irrigation to maintain drainage and remove mucus, diligent catheterization, and prudent use of antibiotics. Hensle et al. suggested that high-volume bladder irrigation (>240 mL) significantly reduced the incidence of reservoir calculi whenever bowel was used as a part of urinary tract reconstruction.
Barroso et al. suggested close follow-up with regular imaging or cystoscopy. We have taught our patient regular bladder irrigation and advised follow-up with abdominal ultrasound yearly. This would enable earlier detection of stones when they are small and amenable to treatment by endoscopic laser which would be of limited use in larger and massive stone load.
| Conclusion|| |
The need for surgical procedures in exstrophy of the bladder continues through adolescence and into adulthood. Bladder stones in exstrophy–epispadias complex are related to risk factors associated with surgical reconstruction of this condition.
Bladder irrigation is an effective method of preventing urolithiasis as it prevents penting up of mucus and secretions. Serial follow-up with annual ultrasound of patients with the exstrophy bladder is necessary for early detection of bladder stones which enables early treatment by endoscopic laser when the stone load is very less. The importance of the report is that it highlights urolithiasis as a recurrent complication of bladder exstrophy closure, which can be managed effectively and safely by modern endoscopic techniques in a hostile abdomen with reconstructed tract and inaccessible urethra.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]