奇美醫學中心 外科部 泌尿科
Distal Ureteral Stone in a Studer Orthotopic Neobladder: A Case Treated by Antegrade Flexible Cystoscopic and Flexible Ureteroscopic Lithotripsy
Yu-Che Hsieh, Kun-Lin Hsieh, Chien-Liang Liu, Steven K. Huang
Department of Surgery, Division of Urology, Chi Mei Medical Center, Tainan, Taiwan
This 75 y/o male who had urothelial carcinoma of urinary bladder, pT3aN0 s/p radical
cystoprostatectomy with bilateral pelvic lymph node dissection + Studer orthotopic neobladder reconstruction 5 years ago. After the surgery, he was regularly follow up in our GU OPD. This time, some blood tinge in his urine was noted , accompanied with right flank pain. Therefore, he went to our ER for help. Renal function impairment (Cr:2.17) was found. CT revealed that right lower calyceal stone (0.6cm) and right distal ureteral stone (0.7cm) with right hydronephroureterosis. Thus, right side percutaneous nephrostomy (PCN) drainage was done via middle calyceal approach. The right percutaneous nephrolithotomy (PCNL) and antegrade lithotripsy was performed 5 days later after infection controlled and acute kidney injury improved. We dilated previous PCN tract with fascia dilator to 21/22 Fr under fluoroscopic-guided. No obvious bleeding was noted during dilatation. We performed flexible cystoscopy to exam the ureter until lower third ureter. The stone with blood clot was found, so we grasped the blood clot and stone with flexible forceps. Then, we used flexbile ureteroscope to exam the whole ureter until ureter-neobladder junction, and then injected contrast under fluoroscopic-assisted for checking residual stone. No other residual stone was found, and the whole ureter was patent, where the contrast could pass through into neobladder smoothly. Then, we inserted double-J stent(6Fr26cm) with silk tied on renal RD tube. After the surgery, the patient was stable and we kept antibiotics treatment. Two days later, we removed RD with double-J stent without complication. We also follow up KUB and there are no stone-like lesion found on image. The patient was discharged under stable condition, and no discomfort was noted at OPD follow-up.
Stone formation in patients with urinary diversion or orthotopic neobladder is known as a common late complication. Its incidence is reported in 2.6%–15.3% of the patients. In case of small asymptomatic urolithiasis, conservative treatment or medical expulsive therapy may always be the first option. However, in case of symptomatic circumstance, several treatment options have been reported in patient after Studer orthotopic neobladder, including PCNL, ureteroscopic lithotripsy, and shockwave lithotripsy. Treating urolithiasis in Studer orthotopic neobladder is still a challenge. Few cases were reported. As recognizing the neoureteral orifice and traversing through ureteroenteric anastomosis may be extremely difficult.
Thus, we tried using flexible endoscopic antergradely to approach the distal ureter stone. But there still two major difficulties existed. The first one was the angle formed by the calyx, the infundibulopelvic angle, the angle sharpness positively correlated with the difficulty level. The second difficulty was the tortuous ureter caused by hydroureter. This situation could be solved by using flexible cystoscopy firstly, which the view might not distorted due to bigger channel for irrigation. This report shows that antegrade flexible cystoscopy and flexible ureteroscopy via PCN tract is a feasible and minimal-invasive procedure with a low complication rate.