A retained ureteral stump with calculi.

Abstract

Augmentation cystoplasty is a commonly used method to treat patients with inadequate bladder capacity. Calculus formation within the altered urinary tract has been a frequent complication. We report the unique finding of calculi within a retained ureteral stump in a patient who had undergone enterocystoplasty. CASE REPORT A 29-year-old female presented with recurrent urinary tract infections that were refractory to treatment. The patient had been born with sacral agenesis and imperforate anus. Neurogenic bladder and vesicoureteral reflux had subsequently developed, and the patient underwent ileal conduit formation for management of progressive bilateral hydroureteronephrosis as a young child. At age 15 years she underwent urinary undiversion with ileocecoplasty to the native bladder. Videourodynamics were repeated at age 28 years and revealed a volume capacity of 700 ml., and bilateral grade V vesicoureteral reflux and reflux into the retained ureteral stumps. The patient performed clean intermittent catheterization every 2 to 4 hours to minimize the post-void residual urine volume. Recurrent urinary tract infections were managed with outpatient oral antibiotic therapy. In addition, in 1999 a bladder calculus had developed in the bowel segment of the bladder. The stone was managed with cystolithotripsy, with complete stone removal. In 2001 urinary tract infections recurred despite appropriate antibiotic coverage for each recurrent infection and antibiotic prophylaxis. Symptoms consisted of painful urethral catheterizations, small urethral catheterized volumes and pyuria. Plain x-ray of the kidneys, ureters and bladder demonstrated multiple calcified densities in the pelvis (see figure). In preparation for cystolithotripsy, cystoscopy of the native and augmented bladder was performed, which showed an absence of bladder calculi. However, a dilated and patulous right ureteral orifice was identified. Retrograde ureterogram revealed several filling defects in the right ureteral stump that correlated with the calcifications seen on x-ray. The ureteral stump measured approximately 8 cm. The calculi were fragmented via semirigid ureteroscopy with holmium laser lithotripsy and basket stone extraction. The bladder was copiously irrigated. The patient was discharged home on the same day with postoperative instructions to perform bladder irrigation twice daily in addition to clean intermittent catheterization. Stone analysis demonstrated calcium phosphate. DISCUSSION