Some patients have recurrent nephrolithiasis that may prove refractory to all known preventive strategies. Such individuals can experience frequent bouts of renal colic that result in narcotic dependency, long-term disability, and depression. As a long-term solution, we offer such patients the option of renal preservation by means of autotransplantation with pyelovesicostomy (ATPV) (Figure 1).
At the Cleveland Clinic, we employ a multidisciplinary approach to deal with such cases. Nephrologists focus on medical and dietary prophylaxis against new kidney stone formation, aiming for correction of any detectable metabolic risk factors plus ensuring adequate hydration and dietary modification. Patients who continue with frequent stone events despite such measures are then considered by the urology department for the above procedure.
This is a complex, lengthy, and highly-technical surgery that can be life-changing in its scope. Hence, all patients considered for ATPV are first screened by our transplant psychiatrist, by a urologist who subspecializes in endourology, and by a second urologist who subspecializes in renal transplantation.
For example, eight years ago, a 31-year-old female patient with cystinuria refractory to optimal medical management, underwent left nephrectomy, ex-vivo removal of all stones, ex-vivo reconstruction for multiple renal arteries, and then transplantation into the ipsilateral iliac fossa. The technique of pyelovesicostomy was modified from that originally described by Boari and utilized the upper third of the transplant ureter incorporated longitudinally into the bladder flap to create a fully-refluxing, large diameter, tubularized connection with the bladder lumen. The opposite kidney was moved in similar fashion four months later. The patient became narcotic-free and rejoined the workforce. She stated that she “had her life back.”
To date, we have mean follow-up of 42 months on 12 such patients and15 renal units (three patients underwent staged, bilateral procedures). Those individuals on whom we performed this procedure averaged nearly four surgical interventions per year for at least two years prior to ATPV. There have been no failures, and renal function has been the same or better in all cases. Narcotic use was statistically significantly reduced in these patients, as were subsequent stone events per year.
Although ileal ureteral substitution provides a large conduit for stone passage and can relieve painful colic, it can result in reabsorption of urea and other solutes, thus placing a greater load on kidneys. Further, ileal ureteral substitution does little to prevent future stone formation, whereas our ATPV technique, with freely-refluxing systems, provides a measure of mechanical prevention due to crystal washout, thus compensating for the failure of metabolic approaches in these difficult cases.
In summary, renal autotransplantation and modified pyelovesicostomy offers patients with intractable stone disease the opportunity to experience improvement in their quality of life by reducing pain and narcotic use and by preventing many stone interventions in this group of individuals.
The authors are affiliated with the Glickman Urological and Kidney Institute of Cleveland Clinic.