PINBALL CALCULUS IN A URETEROSIGMOIDOSTOMY FABRICE MONDET, FEDERICO PASQUI, JENNIFER J. LUCAS, PIERRE CONORT, EMMANUEL J. CHARTIER-KASTLER, AND FRANC¸ OIS RICHARD ABSTRACT We report a complication during the treatment of lithiasis with extracorporeal shock wave lithotripsy in a patient with a ureterosigmoidostomy. This woman presented with renal colic bilaterally and renal insuffi- ciency and was found to have an extremely mobile calculus. A significant gaseous reflux from the sigmoid colon was found to propel the solitary calculus in a retrograde fashion across the ureteroileal anastomosis up the ureter into one kidney, and then later, after re-descent to the level of the anastomosis, up into the opposite kidney. After several days of playing hide and seek with this migrating calculus, using extracorpo- real shock wave lithotripsy, the patient became stone free. UROLOGY 61: 644xiii–644xv, 2003. © 2003, Elsevier Science Inc. T he first case of ureterosigmoidostomy was re- ported by Simon 1 in 1852. This type of urinary diversion has multiple serious mid and long-term complications, including colon cancer (80 to 550 times increased risk compared with the general population) 2 and increased mortality over the long term (48% according to Zabbo and Kay 3 ). Compli- cations, such as lithiasis, that lead to renal insuffi- ciency are responsible for more than one third of deaths. 3 For these reasons, ureterosigmoidostomy is currently rarely performed. Bladder exstrophy remains one of the few indications for ureterosig- moidostomy. We report a highly unusual stone- related complication in a patient with a ureterosig- moidostomy as treatment for bladder exstrophy. CASE REPORT Our patient was a 40-year-old woman presenting with bilateral renal colic and acute renal insuffi- ciency. Her history included bladder exstrophy treated with ureterosigmoidostomy. The uret- erosigmoidostomy was constructed with a segment of ileum interposed between the ureteral Wallace- type anastomosis 4 and the sigmoid colon. The ileo- colic anastomosis was end-to-side with no antire- flux system present. This patient was referred for fever (greater than 39°C), white cell count showing hyperleukocytosis (10,000 cells/mL), and a high serum creatinine level of 400 mol/L. An emergent percutaneous nephrostomy was performed. Non- contrast abdominal computed tomography re- vealed a significant gas pyelogram associated with bilateral upper tract dilation. A solitary 2-cm cal- culus was found at the junction of the two ureters at the Wallace anastomosis (Fig. 1A). Forty-eight hours after the computed tomography scan was obtained, antegrade pyelography revealed that the stone had migrated to the right inferior renal calix (Fig. 1B). This examination ruled out the possibil- ity of any stenosis at the anastomosis. An abdomi- nal plain film obtained 24 hours later (right ne- phrostomy tube spontaneously removed at that time) showed that the solitary stone had migrated once again and was visualized in the left kidney (Fig. 1C). After the patient’s renal function had normalized, we performed extracorporeal shock wave lithotripsy. After searching in vain for the calculus in the left kidney, we were able to localize it to the right kidney and fragment it despite its challenging hypermobility. The patient was stone free at 3 months of follow-up. COMMENT The gaseous reflux from the sigmoid colon across the ileosigmoid anastomosis caused the ex- treme mobility of this solitary calculus and made From the Department of Urology, Pitie-Salpetriere Hospital, Uni- versity Pierre et Marie Curie (Paris VI), Paris, France; Reparto d’Urologia, Universita` Cattolica del Sacro Cuore, Roma, Italia; and University of Kansas School of Medicine, Kansas City, Kan- sas Address for correspondence: Emmanuel Chartier-Kastler, M.D., Ph.D., Department of Urology, G. H. Pitie-Salpetriere, 83 Boulevard de l’Hopital, Paris 75013, France Submitted: February 7, 2002, accepted (with revisions): October 15, 2002 CASE REPORT © 2003, ELSEVIER SCIENCE INC. 0090-4295/03/$30.00 ALL RIGHTS RESERVED doi:10.1016/S0090-4295(02)02409-3 644xiii