Use of Nonabsorbable Staples for Urinary Diversion: A Step in the Wrong Direction

Abstract

Background: The use of bowel segments incorporated into the urinary tract is well established in urological surgery. Objective: To describe and compare the use of absorbable and nonabsorbable staples for creation of a urine reservoir after radical cystectomy. Materials and Methods: This review is based on a systematic Medline search assessing the period 1950-2010. Results: Use of the autosuture stapling device for the construction of the urinary diversion significantly reduces operating time. Johnson and Fuerst reported its use for the first time to construct a ureteroileocutaneous urinary diversion in 1973. However, many studies demonstrated that exposed metal staples represent a nidus for stone formation when they are in direct contact with urine, particularly in urinary diversions such as Kock pouch and ileal conduit. Stone formation has been attributed in part to the use of nonabsorbable artificial materials, such as metal staples and Marlex mesh, strictures of the pouch and accumulation of mucus. The treatment options for pouch calculi include observation for spontaneous passage, extracorporeal shockwave lithotripsy, percutaneous or endoscopic lithotripsy/lithotomy. Conclusions: Historically, the mean time to stone formation with nonabsorbable material (staples, Marlex mesh) is 34 months. None of the studies on use of nonabsorbable staples in urinary diversion has such a long follow-up. Until further studies with more appropriate observation time are completed, the use of nonabsorbable staples for continent and noncontinent urinary diversion should be discouraged.

Ileal conduit obstruction secondary to tethering of the small bowel anastomosis to the pubic bone

“…Urolithiasis in ileal conduits occurs as a result of mucus production, recurrent bacteriuria, urinary stasis, increased calcium excretion and chronic acidosis 18 19. The presence of foreign bodies, particularly surgical staples, also contributes to the development of stone formation within ileal conduits 20. However, the majority of urolithiasis following radical cystectomy occurs in the upper tracts, rather than the conduit 21.…”

Feasibility of laparoscopic stapled partial cystectomy in canine cadavers

“…Suture penetration into the lumen of the urinary bladder is traditionally avoided as intraluminal suture and material may serve as a nidus for infection or calculogenesis. 20 This raises concern for the use of nonabsorbable staples in the urinary tract. Theoretically, this could predispose to tissue erosion, encrustation, or stone formation along the staple line.…”

“…Theoretically, this could predispose to tissue erosion, encrustation, or stone formation along the staple line. 20 The highly corrosion-resistant nature and biocompatibility of titanium, however, may reduce this risk. 21,22 Furthermore, compression of the urinary bladder walls at the cystectomy site and urothelial proliferation may minimize or eliminate exposure of the staples to the lumen of the urinary bladder.…”

“…This raises concern for the use of nonabsorbable staples in the urinary tract. Theoretically, this could predispose to tissue erosion, encrustation, or stone formation along the staple line 20 . The highly corrosion‐resistant nature and biocompatibility of titanium, however, may reduce this risk 21,22 .…”

Percutaneous neo-cystolithotrity for multiple calculi in Mainz pouch neobladder

“…Struder and associates did not report a single case of neobladder calculi in their twenty-year experience on 482 patients, because all the patients were kept under stringent lifelong follow-up protocol and monitored by a dedicated team (5). Foreign bodies, and use of nonabsorbable staples are other causative factors implicated in the formation of stones and the mean time to stone formation is 34 months (6).…”