A 51-year-old female with a complex urologic history was admitted to our institution
with severe, lower midline abdominal pain radiating into the pelvis. She stated that
the pain was reminiscent of the pain she experienced with prior bladder calculi.
Her history was significant for epispadias status post multiple attempted reconstructions,
which ultimately led to closure of the bladder neck and subsequent urinary bladder-ileum-sigmoid
colon anastamosis. This produced a successful continent urinary diversion, but she
experienced recurrent urinary tract infections and bladder calculi.
On computed tomographic scan of the abdomen and pelvis, a stone was observed in the
bladder ([Figure 1]). Because of her complex surgical history and obesity, a nonsurgical means of stone
removal was sought. A gastroenterology consultation was obtained for possible endoscopic
removal.
Figure 1 Computed tomographic scan of the pelvis, demonstrating a stone in the urinary bladder
(arrow).
In the operating room under general anesthesia and in the dorsal lithotomy position,
a standard upper endoscope was used to perform a flexible sigmoidoscopy. In the distal
sigmoid colon, the anastamosis was identified and dilated using a Microvasive® balloon
(Boston Scientific, Natick, Massachusetts) over a guide wire ([Figure 2] and [Figure 3]). The anastamosis was estimated to have a diameter of approximately 6 mm, and was
subsequently dilated to 10 mm. Following dilation, the endoscope was advanced through
the segment of ileum and into the bladder. In the bladder a 15-mm stone was identified
and retrieved ([Figure 4] and [Figure 5]) with a Roth® retrieval net (US Endoscopy, Mentor, Ohio). The patient tolerated
the procedure well. At 4-month follow-up, the stone had not recurred.
Figure 2 Ileocolonic anastamosis identified in the distal sigmoid colon.
Figure 3 Ileocolonic anastamosis following balloon dilation.
Figure 4 Stone captured with retrieval basket in the urinary bladder.
Figure 5 Stone removed through the ileocolonic anastamosis.
Urinary diversions using a portion of bowel are performed for malignant and benign
disorders of the lower genitourinary tract. Gastroenterologists should be familiar
with urinary diversions, as some are associated with an increased risk of colorectal
adenocarcinoma, such as with ureterosigmoidal anastamoses [1]
[2]. Despite an exhaustive search of medical and surgical literature, the description
of a similar procedure was not found. This case demonstrates the feasibility of removal
of a bladder calculus by gastrointestinal endoscopy in a patient with unusual anatomy,
and highlights the importance of teamwork among specialists in the care of complex
patients.
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