Continent cutaneous diversion pouch calculi
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The present case has been reported in BMJ. A 62-year-old female patient who presented with dull aching right flank pain of 6 months duration. She had a history of radical cystectomy and cutaneous continent urinary diversion (Indiana pouch) done 20 years ago for muscle invasive urothelial carcinoma of urinary bladder.

The patient followed up regularly since operation. However, for last 3 years, the patient was lost to follow-up. On further eliciting the history, she mentioned her inability to perform pouch irrigation and clean intermittent catheterisation regularly during this period.

On examination, a lump was palpable in the right lumbar region in the region of continent pouch. It was firm in consistency around 5×5 cm in size and did not move with respiration. A plain abdominal X-ray revealed multiple radio-opaque shadows in right lumbar region.

Non-contrast CT scan confirmed these findings and showed multiple calculi in pouch with largest measuring 3×4 cm with minimal hydroureteronephrosis in bilateral kidney. Because of presence of multiple large calculi, it was decided to undertake open surgical approach for removal of pouch calculi.

Intravenous metronidazole and third-generation cephalosporin were given on the day of surgery as well as in the postoperative period. A midline infraumbilical transperitoneal incision was taken, and continent pouch was carefully identified and dissected all around. With help of stay sutures, a pouchotomy of around 3 cm was performed at anterior surface, and multiple calculi were delivered out with help of Desjardins stone removal forceps.

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