顧明軒¹、林子平^{1, 2, 3}、林登龍^{1, 2, 3}、陳光國^{1, 2, 3}

¹臺北榮民總醫院 泌尿部；²國立陽明大學醫學院泌尿學科；³書田泌尿科學研究中心

 

 

Ming-Hsuan Ku¹, Tzu-Ping Lin ^{1, 2, 3} , Alex T.L. Lin ^{1, 2, 3}, Kuang-Kuo Chen ^{1, 2, 3}

¹ Department of Urology, Taipei Veterans General Hospital;

² School of Medicine and ³Shu-Tien Urological Institute, National Yang-Ming University, Taiwan

 

The two most common forms of ureteroenteric anastomosis after radical cystectomy and urinary diversion are the Bricker (separate) and Wallace (conjoined) techniques. The choice usually depends on the surgeon’s preference and experience. Reports had suggested higher stricture rates with the Bricker and increased risks for bilateral renal obstruction with the Wallace. On account of the difficulty of the procedure, ome experts suggested it is easier to perform Bricker methods for ureteroenteric anastomosis in patients with high body mass index.
        An 84-year-old woman with a history of sigmoid colon adenocarcinoma with urinary bladder invasion. Laparoscopic anterior resection and total cystectomy as well as ileal conduit with Wallace (conjoined) ureteroenteric anastomosis were performed on 4^th, August, 1988. Colon cancer remained free of recurrence after the surgery.

An urosepsis episode occurred in October, 2015 and CT showed a 0.8cm stone formation over left upper third ureter. We were consulted for further intervention toward the ureter stone after sepsis subsided. We had performed flexible ureteroscopic lithotripsy via left percutaneous nephrolithotomy (PCN) on 21^st, November, 2015. However, instead of located at left upper third ureter as shown in CT image, the stone was found impacted in right lower third ureter. Due to acute angle of the ureteroenteric anastomosis, we failed to approach to the stone. After the surgery, high fever was noted and later improved after another course of antibiotics. CT was arranged again and confirmed the 0.8cm radio-opaque ureter stone over right lower third ureter. On 2^ND, December, 2015, radiologist had tried antegrade method via previous left PCN to remove the stone. Guiding wire, guiding catheter, balloon catheter and basket catheter were able to pass through the right ureter. However the ureteral stone couldn’t be moved or retrieved despite several times of attempts. Then, the patient was positioned supine, in which another several attempts of stone retrieval were done via the ilieal conduit. The ureteral stone remained still. Guidewires was left in bilateral ureter via ileal conduit by radiologist for guidance of future surgical intervention. Stone located in extraluminal location or diverticular pouch were suspected during the procedure. On 4^th, December, 2015, we performed flexible cystoscopy via ileal conduit alongside guidewires toward bilateral ureters. The scope had reached up to bilateral upper third ureter, but still no stones were seen. We suspected the stone had expelled spontaneously. We arranged another CT and showed the stone was still at the distal site of right ureter. Right PCN was done on 9^th, December, 2015. Radiologist performed antegrade stone removal with basket stone retractor and ureter balloon dilation via right PCN. The stone could not be approached. After discussion with the family and the patient, we performed flexible ureteroscopic lithotriopsy again via right PCN on 12^th, December, 2015, and we succeed stone fragmentation by Holmium LASER this time. The patient tolerated the surgery well. Follow-up KUB showed no residual stones. PCN was removed smoothly.

This is a case of difficult ureter stone, which migrated from left ureter to right ureter in a patient with a history of ileal conduit with Wallace (conjoined)-typed ureteroenteric anastomosis.

 

Conclusion: Wallace-typed ureteroileal anastomosis can lead to stone migration from one ureter to the other. The anastomoses make ureter stone management much more difficult. Flexible antegrade ureterolithotripsy via PCN is a choice in management of ureter stones in these patients.