title: Renal autotransplantation and modified pyelovesicostomy for intractable metabolic stone disease.
abstract: OBJECTIVE
  Some patients with intractable metabolic stone disease experience narcotic dependence, which cannot be managed with standard treatments. We offered these patients renal autotransplantation with a modified pyelovesicostomy as an alternative solution.
  
  
  METHODS
  Renal autotransplantation with pyelovesicostomy was performed for 15 kidneys in 12 patients (3 bilateral, 2 solitary), 9 female and 3 male, with a mean age of 33.8 years (range 16 to 55). The etiology of metabolic stone disease was calcium oxalate (40%), cystinuria (33%), type 1 renal tubular acidosis (14%), calcium oxalate/urate (7%) and medullary sponge kidney (7%). Patients reported that lifetime stone events ranged from 10 to more than 70, that underwent an average of 3 to 4 surgical interventions per year in the previous 2 years and that they were dependent on daily oral narcotics for stone related pain.
  
  
  RESULTS
  All 15 kidneys were successfully autotransplanted with a mean followup of 41.8 months (range 3 to 74). We used a modified pyelovesicostomy with ureteral strip in 13 and standard Boari tube in 2 cases. All patients continued to pass small stone debris per urethra with minimal symptoms. Of 12 patients 11 (92%) were weaned off daily narcotics. There have been 17 stone episodes in 4 patients (3 cystinuria) for which medical intervention and pain medication was required. The number of urological procedures/patients before (155/12 [12.9]) and after (8/12 [0.66]) autotransplantation was dramatically reduced (paired t test p = 0.0001). The preoperative mean estimated glomerular filtration rate was 77.2 cc/minute, and 73.5, 71.9, 79.2 cc/minute at 12, 36 and 60 months, respectively.
  
  
  CONCLUSIONS
  Renal autotransplantation and pyelovesicostomy offer patients with intractable metabolic stone disease the opportunity to improve quality of life and to decrease daily narcotic use.
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio 44195, USA. flechns@ccf.org
authors.forename: Stuart M
authors.initials: SM
authors.lastname: Flechner
authors.forename: Mark
authors.initials: M
authors.lastname: Noble
authors.forename: Ho Yee
authors.initials: HY
authors.lastname: Tiong
authors.forename: Kathy L
authors.initials: KL
authors.lastname: Coffman
authors.forename: Alvin
authors.initials: A
authors.lastname: Wee
mesh_terms: D000293:Adolescent; D000328:Adult; D000714:Anastomosis, Surgical; D003404:Creatinine / Q000097:blood; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007669:Kidney Calculi / Q000737:chemistry / Q000601:surgery*; D016030:Kidney Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000379:methods; D014182:Transplantation, Autologous; D014513:Ureter / Q000601:surgery; D055815:Young Adult
chemical_list: D003404:Creatinine