The surgical management of stones in patients with urinary diversions

Stones in patients with urinary diversions present unique challenges. Anatomical knowledge of the type of diversion is essential to adequately and safely treat the patient. We will review the anatomical differences between the forms of diversion and helpful maneuvers for successful management of urinary lithiasis in this patient population.

Urology has recently seen a shift toward continent diversion with the most common forms being continent-cutaneous or orthotopic reservoirs. In patients with these forms of diversions, stone management is challenging. In continent cutaneous diversion, for example, trauma to the continence mechanism during stone manipulation can occur. Recently, percutaneous pouch access to facilitate the treatment of upper/lower tract stones has become popular. In patients with upper tract stones, knowledge of ureteral anatomy is essential. There is controversy not only on non-refluxing versus refluxing anastomoses, but also on the mechanism of formation of non-refluxing anastomoses. At the same time, some stone centers have gone back to attempting retrograde management of upper tract stones. In some types of anastomoses, however, this is not possible.

Percutaneous pouch access for large stone burden has become the treatment of choice for most urologists. Percutaneous access may involve placement of an Amplatz sheath or laparoscopic trocars into the pouch, allowing for stone entrapment or intracorporeal lithotripsy. With upper tract stones, retrograde management can be attempted in the setting of a refluxing-ureteral-anastomosis. Laparoscopic management of stones may be on the rise, however, like open stone surgery, the indications are narrow.