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