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Twenty-five-yearFIGURE1. old patient required urinary diversion for treatment of neurogenic bladder secondary to myelomeningocele. Three years after undergoing Kock pouch conversion from ileal conduit patient was found to have massive stone disease. (A) Abdominal radiograph shows two large calculi each with staple in center. (B) Excretory urogram revealed one of the stones was located in afferent limb of diversion and the other in reservoir. (C) Due to fortunate anatomic relationship of ostium of afferent valve it was possible to pass a 21F nephroscope into valve and fragment stone with electrohydraulic lithotripsy. (D) Attention was then directed to the remaining stone in the pouch which was also fragmented and removed. This radiograph shows only the instrument sheath in place after removal of all stone material.

The instruments used are the same as employed for percutaneous techniques for removal of kidney stones. Generally the 24.5F rigid nephroscope was employed to evaluate the pouch and to pass a 9F electrohydraulic lithoIndications for endoscopy of Kock pouch urinary diversion

TABLEI.

Indication for Endoscopy _. Calculi in Kock pouch Calculi in afferent nipple valve Dilation of afferent nipple valve Suspicion of urothelial tumor in ureter or kidney Removal of retained internal stents

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No. of

Pts.

Percent

40 5 3

73 9 5.5

3

5.5

4 55

7 100

tripsy (EHL) probe for fragmentation. After fragmentation, all stone material and the exuded staples were removed. The patients were treated on an outpatient basis under local anesthesia with only intravenous sedation. No patient required a general anesthesia. A suction device was attached to the instrument to drain the pouch intermittently since the pouch is not in a dependent position and does not drain unless suction is applied. A red rubber catheter was used to drain the pouch for at least one or two hours after the procedure. Patients found to have stones or retained stents within the afferent nipple valve or those with suspicion of ureteral or renal pelvic carcinoma present a slightly different problem. In these patients, the afferent nipple valve is cannulated with a flexible-tip guide wire. Occasionally a cobra-tip catheter is required to pass

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the guide wire because of marked angulation of the afferent nipple valve. Once the guide wire is passed into the afferent system, an open end ureteral catheter is passed over the guide wire and the guide wire removed. This provides an exit for irrigant that enters the afferent limb and decreases pressures on the upper urinary tract. Either a rigid or flexible ureteroscope are then passed alongside or over the catheter for observation within the valve. At this point the calculi and stone material are then either removed intact or are fragmented using a 3F or 5F electrohydraulic lithotripsy probe. At the end of this procedure an open end catheter is left in place for the remainder of the patient’s recovery time which averages one to two hours. Patients diagnosed as having a stenotic afferent nipple valve initially underwent endoscopic examination of the ileal reservoir and afferent valve. While monitoring the procedure with fluoroscopy, a floppy-tipped guide wire is passed into the afferent limb or into the renal pelvis if possible. Once the guide wire is in place, a 6-mm balloon dilating catheter is passed coaxially over the wire and positioned across the stenotic valve. Inflation of the balloon is then done slowly at a rate of two atmospheres per minute until all waisting of the balloon is eliminated. This endpoint is a sign of complete balloon expansion and is determined fluoroscopically. After dilation, internal stenting is carried out for six weeks. Results Of the 64 patients found to have stone disease, 45 were subsequently treated by endoscopic methods for stone removal (Table I). Prior to the development of the endoscopic techniques for removal of kidney stones, this technology was not available for use in the continent diversion patient and thus all patients underwent open surgery for stone removal. In no case was it impossible to pass the instrument through the efferent nipple valve system. In each patient all stone material and visible staples were removed with the instrumentation (Fig. 1). The average size of stones removed per patient was approximately 5 cm and the average operating time was 2.5 hours. The patients were able to have the procedures done under intravenous sedation only, and none required. general or regional anesthesia. In patients with afferent limb pathology 4 had retained stents requiring removal in the afferent

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limb, 5 had afferent limb calculi, and 3 had stenosis of the afferent nipple valve. Two other patients in whom the afferent nipple valve could not be cannulated then underwent open surgery for removal of afferent nipple valve stones. Failure to negotiate this afferent nipple valve was due to direct opposition or retroversion of the ostium of the afferent nipple valve and inability to cannulate it safely. In 4 patients, stents were removed from the afferent limb, and in 3 the afferent nipple valve was dilated with balloon dilating catheters. Two of 3 of these patients did not have long-term results with the dilations and subsequently underwent surgical revision of the afferent nipple valve. One patient continues at fourteen months to have a patent afferent nipple valve following dilation (Fig. 2). Five patients underwent removal of afferent limb calculi. One complication resulted after removal of calculi. This patient suffered a perforation of the afferent limb and required paracentesis for drainage of a large amount of fluid from his abdomen that had extravasated. Irrigation fluid employed was normal saline and thus did not pose a hemodynamic problem for the patient; however, he was hospitalized overnight and an intravenous pyelogram (IVP) done in forty-eight hours. This IVP demonstrated complete healing in the afferent valve. Urinary diversion was also performed with a:n open end catheter left in the afferent limb overnight. All patients were given prophylactic antibiotics prior to the procedure, and these were continued as an oral antibiotic for five days after the procedure. In only 2 patients; has recurrent stone disease developed after rernoval of all initial stone material. In each of these cases stones reformed on staples that had surfaced. Comment Endourologic techniques for removal of stones from continent urinary diversions have made a substantial impact on patient treatment. Abdominal surgery for stone removal is avoided. Potential complications are minimized and anesthesia requirements lessened. Patients are treated on an outpatient basis with substantial lowering of hospital charges. Finally, the patients are able to return to gainful activity very rapidly, possibly even the folloTwing day. The endourologic techniques have been responsible for this improvement in urologic care. These techniques and instruments are the same

2

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Patient with Kock pouch ileal reservoir was found to have FIGURE 2. stenosis ofafferent nipple valve one year after surgical construction. (A) Selected film from excretory urogram shows bilateral hydronephrosis and dilated afferent limb with no contrast material in reservoir. (B) Initial guide wire passage was accomplished by using cystoscope and directing a 0.035 inch Bentson wire through afferent valve while monitoring fluoroscopically. (C) A 6-mm balloon dilating catheter was then passed over wire and positioned across stenotic valve. (D) Balloon tias inflated at 2 atmospheres per minute. Film shows partial inflation of balloon with area of n.arrowing in mid portion of balloon. (E) Full expansion of balloon is shown indicating completion of dilation process. (F) Cystoscope could then be passed through valve. Contrast material was instilled through instrument showing good flow into both upper urinary tracts without extravasation. (G) Two 8F internal stents were then positioned from kidney to reservoir and left in place for six weeks. Follow-up diuresis renogram showed marked improvement in overall renal function without evidence of obstruction.

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as those employed for use for percutaneous renal surger!.. Similar to removal of bladder stones these gigantic stones that form in the pouches of patients with urinary diversion can also be removed with electrohydraulic lithotripsy. The instrumentation and techniques are adaptable exactl!, as they are used in the kidne!; and no new instruments or techniqlles are needed. The afferent limb procedures adapt readily to uret eroscopic instrumentation and techniques. Both rigid and flexible instruments are used in the afferent limb system. The or&, complication in this series occurred in a patient requiring endoscopy of the afferent limb. In this patient, perforation of the afferent system ‘occurred. Subsequent complete recover! occurred in a. very short period of time. The largest disadvantage of this technique is the amount of operative time required to remove completel!, all stone material and visible sta-

pies. The procedure is extremely tedious and all material must be removed so that recurrent stones do not form immediately. A compulsive removal of all stone material and thorough irrigation are required. A suction device attached to the instrument allows the po”lch to be drained more easily and helps protect against overdistention of the pouch with possible damage. Kenneth

Norris Cancer Hospital 1441 Eastlake Avenue Los Angeles. California 90033

Heferencc5 I. Skinner

IX:, 1,ieskovsky GL, and Hoyd SD: l’echnic~ue of creation IIF a continent ileal rcscrvoir (Kock pouchi for urinary di\,ersiclrr, L~rol Clin North .4rn 11: 711 (1984). 2. Skinner I>(:, I.ieskocsky CL, and Doyd SD: Continuing esprirnce 11ith tht, continent ileal reservoir (Kock pouch) as an altwnative to cutaneous urinary diversion An Iqxlatc after 250 c’asc’\. J 1lrol 137: 1 l-10 (1987). 3. Cinsbcq 1). r’t al: Urinary tract stones: a wnlplication of the Kock lxnwh caltincnt urinary diversion. J Ural (in pwss).

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