Urolithiasis after ileal conduit urinary diversion: a comparison of minimally invasive therapies.

PURPOSE: We report our experience with ureteroscopy, percutaneous nephrolithotomy and shock wave lithotripsy for symptomatic stone disease in patients with ileal conduit urinary diversion. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients treated with cystectomy and ileal conduit urinary diversion from 1982 to June 2010 in whom urolithiasis subsequently developed. RESULTS: We identified 77 patients with urolithiasis requiring surgical intervention after ileal conduit urinary diversion. Average age at treatment was 62.5 years (range 30 to 82). Mean followup was 7.1 years (range 0.1 to 24.3). The primary therapy mode was percutaneous nephrolithotomy in 48 patients (62.3%), extracorporeal shock wave lithotripsy in 20 (26.0%) and ureteroscopy in 9 (11.6%). Average stone size was greater in the nephrolithotomy group than in the ureteroscopy and lithotripsy groups (2.1 vs 0.9 and 1.0 cm, respectively, p <0.0001). Total complication rates were similar, including 29% for nephrolithotomy, 30% for lithotripsy and 33% for ureteroscopy (p = 0.9). The incidence of stone-free status was greater in the nephrolithotomy cohort than in the ureteroscopy and shock wave lithotripsy cohorts (83.3% vs 33.3% and 30%, respectively, p <0.0001). The re-treatment rate did not significantly differ among the groups with 66.7% of the ureteroscopy group requiring subsequent procedures compared to 29.2% of the nephrolithotomy and 45% of the lithotripsy groups (p = 0.08). The change in the mean preoperative and current calculated glomerular filtration rate did not significantly differ among the 3 treatment groups. CONCLUSIONS: Treatment for urolithiasis in patients with urinary diversion is associated with high re-treatment and complication rates. Percutaneous nephrolithotomy achieves a better stone-free outcome than ureteroscopy or shock wave lithotripsy. However, there is no difference in ancillary procedures or complication rates among the 3 treatment modalities.

Transureteroureterostomy revisited: long-term surgical outcomes.

PURPOSE: Transureteroureterostomy is a treatment alternative for ureteral obstruction when more conventionally reconstructive techniques are not feasible. We report on long-term outcomes of patients treated with transureteroureterostomy. MATERIALS AND METHODS: A retrospective chart review of all patients treated with transureteroureterostomy from January of 1985 to February of 2007 was performed. RESULTS: We identified 63 patients who underwent transureteroureterostomy at our institution. Average treatment age was 31.5 years (range 1 to 83). Transureteroureterostomy was performed for 21 (33%) malignant and 42 (67%) benign indications. Reconstructions were 30 right-to-left (47.6%) and 33 left-to-right (52.4%) with 21 concurrent urinary diversions. There were 16 patients (25.4%) who received radiation before transureteroureterostomy. Postoperative complications occurred in 15 (23.8%) patients and were more common in those undergoing diversion for malignancy. Mean followup was 5.8 years (range 0.1 to 22.2) and 5 patients were lost to followup. Of the 56 patients with followup imaging the transureteroureterostomy was patent in 54 (96.4%) and obstructed in 2 (3.6%). Mean preoperative and recent calculated glomerular filtration rate for this cohort were 62.8 (range 13 to 154) and 71.8 (range 22 to 141) ml per minute, respectively (p = 0.04). Stone disease developed in 8 patients, and was treated with percutaneous nephrolithotomy (2), spontaneous passage (2), ureteroscopy (1) and surveillance (3). Subsequent urological intervention was required for obstruction or revision in 6 (10.3%) patients. CONCLUSIONS: We demonstrated the long-term safety and effectiveness of transureteroureterostomy with sustained improvement of renal function compared to preoperative status. Recurrent stricture, distal obstruction and stone disease occur in a small percentage of patients, and can be treated in most with minimal intervention.

Conservative management of upper tract transitional cell carcinoma.

AIM: Our aim was to review the current literature describing the endoscopic management of upper tract transitional cell carcinoma (TCC). MATERIALS AND METHODS: Review of published, peer-reviewed articles relating the primary ureteroscopic or percutaneous management of upper tract TCC was performed using the MEDLINE database. RESULTS: Historically, the gold-standard management for upper tract TCC consists of nephroureterectomy with excision of a bladder cuff. The employment of endoscopic management with these neoplasms was initially instituted in individuals with imperative indications, including bilateral disease, solitary kidney, and/or renal insufficiency. For individuals treated with ureteroscopy, recurrence rates range from 30 to 71% and cancer-specific survival rates from 50 to 93%. Results are dependent primarily on tumor grade and stage. In individuals with low-stage, low-grade tumors treated percutaneously, recurrence rates, and cancer-specific survival rates are 18-33% and 94-100%, respectively. Adjuvant therapy has been employed with thiotepa, mitomycin, and BCG, but none have been able to demonstrate a statistically significant difference in recurrence or cancer-specific survival rates. CONCLUSIONS: Endoscopic management is a safe and effective treatment alternative to nephroureterectomy in the management of upper tract TCC. Survival outcomes are comparable, but renal preservation therapy offers the advantage of reduced morbidity, complications, and the potential for better quality of life. Recurrence and disease progression are not uncommon and underscore the need for strict tumor surveillance.