Percutaneous cystolithotomy of large urinary-diversion calculi using a combination of laparoscopic and endourologic techniques

Background and Purpose: Patients with urinary diversions are at higher risk for bladder urolithiasis. Often, the stone burden is large, necessitating open stone removal. We describe our technique for removing such stones using a combination of laparoscopic and endourologic instrumentation. Patients and Methods: With the patient in the dorsal lithotomy position or supine, cystoscopy is performed via the native urethra or catheterizable stoma, respectively. With the urinary reservoir distended with normal saline, percutaneous access is obtained under direct vision with a 10-mm trocar introduced through the scar of the previous suprapubic cystostomy. A laparoscopic entrapment bag is introduced through the trocar, into which the calculi are manipulated. The bag is delivered percutaneously through the trocar site with subsequent removal of the trocar. A 30F Amplatz renal dilator sheath (Cook Urological, Spencer, IN) is introduced directly into the bag. An ultrasonic lithotrite passed through a nephroscope is utilized to fragment and evacuate the calculi. Closure of the neocystotomy is not performed. A drainage catheter is left in for 7 days. Results: This procedure has been successful in eight consecutive patients, six with bladder augmentations, one with a bladder reconstruction with appendicovesicostomy, and one with an Indiana pouch. All calculi were radiopaque, having a mean linear size of 4.1 cm (range 1.5-7.0) cm. Several patients had multiple stones. The mean operating room time was 123 minutes (range 48-228 minutes). Two patients had concomitant ureteroscopy with laser lithotripsy for ureteral calculi. All were rendered stone free with one procedure and were discharged within 23 hours after surgery. There were no immediate or delayed complications. Conclusions: Our technique of percutaneous cystolithotomy utilizing laparoscopic and endourologic instrumentation is safe and effective for the removal of large calculi from urinary diversions. It is well tolerated, allows complete stone removal in a single sitting, and obviates an open procedure.