Use of a Duodenoscope in the Management of a Ureteral Calculus in a Patient with Ureterosigmoidostomy (Mainz Pouch II; Rectosigmoid Pouch)

Mainz pouch II (modified ureterosigmoidostomy) is an established technique for permanent urinary diversion in patients with congenital malformations or acquired diseases of the bladder [1]. If urolithiasis occurs, an effective and minimally invasive therapy is mandatory. Extracorporeal shock-wave lithotripsy and surgical procedures are frequently used treatment strategies [2]. Retrograde endoscopic management is an alternative option, which has been reported rarely.

We report here the case of a 24-year-old man, who had undergone ureterosigmoidostomy at the age of 12 months due to bladder exstrophy. The follow-up was unremarkable until the patient’s current presentation with acute right flank pain. The ultrasound examination revealed right-sided hydronephrosis, and computed tomography identified a 6-mm ureteral calculus. During sigmoidoscopy, both ureteral ostia were located at a distance of 15 cm from the anal verge, with a normal macroscopic appearance. Urine drainage was identified only at the proximal ostium (Figure [1]). The ”dry” distal ostium was therefore intubated using a duodenoscope with a conventional endoscopic retrograde cholangiopancreatography (ERCP) catheter. A retrograde ureterogram was obtained by injecting contrast medium, revealing the 6-mm concrement in the distal ureter (Figure [2]). A Dormia basket was inserted and the calculus extracted (Figure [3]).

Figure 1 Endoscopic image of the proximal ureteral ostium, with urine draining into the Mainz pouch II.

Figure 2 The retrograde ureterogram, obtained by injecting contrast medium after intubating the ostium with an endoscopic retrograde cholangiopancreatography catheter, shows the ureteral calculus.

Figure 3 Retrograde ureterogram, showing the Dormia basket in the ureter.

To our knowledge, this is the first reported case of successful extraction of a ureteral calculus using a duodenoscope in a patient with Mainz pouch II. Fitzgerald et al. report successful management of a ureteral calculus in a patient with ureterosigmoidostomy by retrograde sigmoid endoscopy with a 21-Fr cystoscope, in combination with intracorporeal lithotripsy [3]. Costamagna et al. successfully managed 19 of 24 ureteroileal complications in patients with ileal pouches using a duodenoscope. A ureteral calculus was removed in one patient [4].

Retrograde endoscopic management of ureteral calculi is thus a simple technique, which is minimally invasive and provides good access to the distal ureter in patients with ureterosigmoidostomy.

References

• 1 Fisch M, Wammack R, Müller S, Hohenfellner R. The Mainz pouch II (sigma rectum pouch).  J Urol. 1993;  149 258-263
• 2 Cohen T, Streem S B, Lammert G K. Selective minimally invasive management of calculi in patients with urinary diversions.  J Urol. 1994;  152 1091-1094
• 3 Fitzgerald K B, Aslan P, Preminger G M. Endourological management of a large distal ureteral calculus in a patient with ureterosigmoidostomy diversion.  J Urol. 1998;  159 2081-2082
• 4 Costamagna G, Shah S K, Mutignani M. et al . Use of a duodenoscope to manage complications at the ureteroileal anastomotic site after total urinary bladder resection and the Bricker procedure.  Gastrointest Endosc. 2002;  55 242-248