1. CASE REPORT
Urolithiasis Following Formation of a Continent Urostomy:
Case Report and Review of the Literature
Khalid Sait, M.D., Gavin Stuart, M.D., Jill Nation, M.D., and Prafull Ghatage, M.D.
Department of Gynecology, Tom Baker Cancer Centre, and Department of Obstetrics & Gynecology & Oncology,
The University of Calgary, Calgary, Alberta, Canada
Received May 13, 1999
Background. Formation of urinary stones in a continent uros-
tomy (Indiana pouch) has been described as a late complication.
Management of a patient with symptomatic multiple large stones
and review of the literature are outlined.
Case report. A 32-year-old woman presented with recurrent
urinary tract infections and pyelonephritis 6 years after a total
pelvic exenteration and creation of a continent urostomy for cen-
tral recurrent carcinoma of the cervix after radical pelvic radia-
tion. Multiple large stones were found to be the underlying etiol-
ogy. Laparotomy, enterocystotomy, and removal of stones were
performed without apparent complication.
Conclusion. It is recommended that for single calculi or multiple
small stones, electroshock wave lithotripsy or the percutaneous
endoscopic approach be considered. For larger stones the use of
laparotomy and enterocystostomy may be appropriate. © 2000
Academic Press
Key Words: urolithiasis; continent urostomy.
INTRODUCTION
Total pelvic exenteration with formation of a continent
urostomy (Indiana pouch) is used to treat patients with central
recurrent carcinoma of the cervix after radical pelvic radiation
at our center. Formation of urinary stones has been described
as a late complication although the exact frequency is not
known. We are reporting the management of a patient 6 years
after pelvic exenteration with symptomatic multiple large
stones in the Indiana pouch.
CASE REPORT
A 32-year-old G1 P1 woman was diagnosed with clinical
Stage IB2 squamous cell carcinoma of the cervix at the age of
24 years. She underwent a laparotomy with the intent to
perform a Type III radical hysterectomy and was found to have
metastatic microscopic cancer in one left external iliac lymph
node. The radical hysterectomy was abandoned and she was
then treated with radical radiation therapy. This included the
delivery of 45 Gy in 25 fractions using a four-field technique
and 40 Gy total brachytherapy in two sessions. One year after
completion of treatment she developed a localized central
recurrence and underwent a total pelvic exenteration. A neo-
vagina was created using bilateral gracilis myocutaneous flaps.
Urinary diversion was effected through the formation of a
continent urostomy using the technique described by Ahlering
et al. [1]. This was a modified continent Indiana pouch in
which the continent limb used a 12-cm length of terminal ileum
and the low pressure pouch was formed from a detubularized
28-cm segment of right ascending/transverse colon with sub-
mucosal ureteric implantation. The pouch was closed in a
Heineke-Mikulicz fashion with two layers of running 3-O
polyglycolic suture. Serial applications of a 75-mm linear
stapler were used to narrow the lumen of the efferent limb of
the ileum. This was further tapered with interrupted 3-O silk
Lambert sutures at the antimesenteric border at the ileocolic
junction so as to limit intussuception.
The patient remained free of recurrent disease for 6 years
following exenteration. She started experiencing symptoms of
nonspecific abdominal pain 4 years postexenteration. Multiple
large mobile stones were detected in the Indiana pouch by plain
radiographs (Fig. 1) and transabdominal ultrasound. Her symp-
toms were felt to be unrelated to the urolithiasis and no
intervention was recommended at that time. One year later she
experienced recurrent episodes of urinary tract infection and
pyelonephritis. In view of the potential morbidity of further
surgery, conservative measures with prophylactic antibiotics
and oral fluids were instituted. However, over a 12-month
period, six infections were documented. In consideration of the
urolithiasis as a cause of this chronic infection, urologic and
nephrologic consultation was obtained. Although consideration
was given to endoscopic removal or electroshock wave litho-
tripsy (ESWL), an open surgical procedure was recommended
as the best option to remove the stones because of the size and
number of the stones.
Gynecologic Oncology 77, 330–333 (2000)
doi:10.1006/gyno.2000.5750, available online at http://www.idealibrary.com on
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Copyright © 2000 by Academic Press
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2. The patient underwent a laparotomy. The Indiana pouch was
identified and an incision approximately 3 cm in length was
made along a taenia coli (Fig. 2). Ten large stones were
removed, each measuring approximately 2.5–3 cm (Fig. 3).
The pouch was irrigated and closed in two layers using a
running suture of 2-O chromic catgut for the first layer and a
running suture of 3-O polyglycolic acid material in the second
layer. Catgut was utilized in the first layer due to its relatively
rapid breakdown and minimal chronic foreign body reaction.
Blood loss was minimal. A small Foley catheter was inserted in
the pouch through the efferent limb and removed 7 days
postoperatively. There were no intra- or postoperative compli-
cations.
Integrated crystallographic analysis of the urinary calculi
showed that these calculi were composed of intimately ad-
mixed masses of orthorhombic crystals of magnesium ammo-
FIG. 1. Plain radiographs demonstrated multiple stones in the Indiana pouch.
FIG. 2. Extraction of the stones through an incision in the Indiana pouch.
331CASE REPORT

3. nium phosphate hexahydrate, subcrystalline ammonium acid
urate, and microcrystalline carbonate appetite. Nephrology
consultation was obtained. Further investigations determined
that the primary etiologic factor was a metabolic urinary defect
in citrate excretion (hypocitrituria). The patient was prescribed
a daily potassium citrate supplement and encouraged to in-
crease fluid intake. Follow-up at 12 months showed no evi-
dence of stone formation and there have been no further
episodes of urinary tract infection. She remains clinically free
of cancer.
DISCUSSION
In 1950 Gilchrist et al. described a continent reservoir con-
structed from the ileocecum in which continence depended
upon the ileocecal valve [2]. The different techniques of con-
tinent urinary diversion—Kock pouch [3], Mainz pouch [4],
Indiana pouch [5], King pouch [6], and Penn pouch [7]—have
embraced the same biophysical principles.
Continent pouches provide a superior alternative to an ileal
conduit as no external appliances are required, thus improving
quality of life by enhancing body image and interpersonal
relationships. However, the patient must be diligent and me-
ticulous in performing self-catheterization. Continent urinary
diversion has become increasingly popular for patients requir-
ing cystectomy. However, formation of urinary stones is a late
complication that has been described [8]. A high incidence was
reported in patients with a Kock pouch (17–27%) due to
exposed staples and/or foreign material in the reconstructed
urinary tract [9, 10]. Stone formation is rare, however, in
patients with an Indiana pouch (3–11%) because of the absence
of foreign materials [11, 12]. The majority of calculi occurring
in Indiana pouches contain struvite and/or carbonate. Ammo-
nium, magnesium, and phosphate may also be found [13].
Stone formation may result from nonabsorbed materials used
during construction of the pouch. Steel or titanium staples used
for linear application may extrude into the pouch. In this
particular patient, metabolic factors such as the urinary defect
in citrate excretion were likely involved in the formation of
stones [14].
The indications used to determine that intervention is war-
ranted must be patient specific. In this particular patient, the
repeated urinary tract infections with the inherent risk of
chronic pyelonephritis provided the specific indication. Gener-
ally, infection, pain, and/or obstruction will provide the criteria
for intervention.
A technique similar to percutaneous nephrostolithtomy and
fragmentation of the stone with ultrasonic and electrohydraulic
lithotripsy probes is reported to destroy the stones in a conti-
nent urinary reservoir. This may be the first choice for inter-
vention but it has the added risk of infection, bleeding, and
bowel perforation and it can be only performed in selected
cases with a qualified urologist [13, 17–20].
Endourological management for urinary stones in the Indi-
ana pouch is time consuming and has the potential risk of
compromising the continent mechanism because of narrow
access, particularly if the stones are large. ESWL has been used
to fragment bladder and reservoir stones [15] but it leaves the
operator with the problem of removing the stone fragments. An
open surgical approach to remove multiple large calculi in an
Indiana pouch has been reported in male patients who under-
went a pouch formation for urinary diversion because of para-
plegia [16]. However, the potential morbidity associated with
FIG. 3. Ten large stones were removed, each measuring 2.5–3 cm.
332 SAIT ET AL.

4. surgical reexploration in a patient who has received megavolt-
age radiation therapy may be significant.
These authors recommend that in the creation of a continent
urostomy, every effort must be made to utilize nonreactive,
absorbable material in the pouch construction. Screening for a
metabolic predisposition to stone formation should be consid-
ered if there is any significant history of renal disease or
urinary tract calculi. Either an infused CT scan or intravenous
pyelography should be used preoperatively in all patients un-
dergoing a planned continent urostomy. It is likely that the
recurrent infections in this patient were a sequelae of the
urolithiasis, rather than a cause. It may still be appropriate to
maintain long-term prophylactic antibiotics as a preventive
strategy. It is recommended that, for single calculi or multiple
small stones, ESWL or the percutaneous approach be consid-
ered. For larger stones, the use of laparotomy and enterocys-
tostomy may be one of the therapeutic options to be consid-
ered.
REFERENCES
1. Ahlering TE, Weinberg AC, Razor B: Modified Indiana pouch. J Urol
145:1156–1158, 1991
2. Gilchrist RK, Merricks JW, Hamlin HH, Rieger IT: Construction of
substitute bladder and urethra. Surg Gynecol Obstet 752:90, 1950
3. Kock NG, Nilson AE, Nilson LO, Norlen LJ, Philipson BM: Urinary
diversion via a continent ileal reservoir: clinical results in 12 patients.
J Urol 128:469–475, 1982
4. Thuroff JW, Alken P, Engelmann U, Riedmiller H, Jacobi GH, Hohen-
fellner R: The Mainz pouch for bladder augmentation and continent
urinary diversion. J Urol 136:17–26, 1986
5. Rowland RG, Mitchell ME, Bihrle R, Kahnoski RJ, Piser JE: Indiana
continent urinary reservoir. J Urol 137:1136–1139, 1987
6. McDougal WS: Metabolic complication of urinary intestinal diversion.
J Urol 147:1199–1208, 1992
7. Ginsberg D, Huffman JL, Lieskovsky G, Boyd SS, Kinner DG: Urinary
tract stones a complication of the Kock pouch continent urinary diversion.
J Urol 145:956–959, 1991
8. Arai Y, Kawakita M, Terachi T, Oishi K, Okada Y, Takeuchi H, Yoshida
O: Long term follow-up of the Kock and Indiana pouch procedure. J Urol
150:51–55, 1993
9. Rowland RG, Kropp BP: Evolution of the Indiana continent urinary
reservoir. J Urol 152:2247–2251, 1994
10. Arai Y, Schichiri Y, Miyakawa M, Ueda T, Terai A, Terachi T, Takeuchi
H, Yoshida O: Evolving experience with continent urinary diversion using
the Indiana pouch. Int J Urol 1:241–245, 1994
11. Terai A, Ueda T, Kakehi Y, Terachi T, Arai Y, Okada Y, Yoshida O:
Urinary calculi as late complication of the Indiana continent urinary
diversion. J Urol 155:66–68, 1996
12. Terai A, Arai Y, Kawakita M, Okada Y, Yoshida O: Effect of urinary
intestinal diversion on urinary risk factors for urolithiasis. J Urol 150:
726–731, 1993
13. Boyd SD, Everett RW, Schiff WM, Fugelso PD: Treatment of unusual
Kock pouch urinary calculi with ESWL. J Urol 139:805–806, 1988
14. Khatri VB, Walden T, Pollack MS: Multiple large calculi in a continent
diversion pouch. J Urol 148(pt 2):1129–1130, 1992
15. Hollensbe DW, Foster RS, Brito CG, Kopecky K: Percutaneous access to
a continent urinary reservoir for removal of intravesicle calculi. A case
report J Urol 149:1546–1547, 1993
16. Thomas R, Lee S, Salatore F, Blank B, Harma E: Direct percutaneous
pouch cystotomy with endoscopic lithotripsy for calculus in a continent
urinary reservoir. J Urol 150:1235–1237, 1993
17. Seaman EK, Benson MC, Shabasigh R: Percutaneous approach to treat-
ment of Indiana pouch stones. J Urol 151:690–692, 1994
18. Roth S, Van-Ahlen HS, Emjonon A, VonHeyden-Bhertle L: Percutaneous
pouch lithotripsy in continent urinary diversions. Br J Urol 73:316–318,
1994
333CASE REPORT