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2. Eisner T, Alsop D, Hicks K, Meinwald J. Defensive secretions of millipedes. In: Bettin S (ed.). Arthropod Venoms. Berlin: Springer-Verlag, 1978; 41–72. 3. Shpall S, Frieden I. Mahogany discoloration of the skin due to the defensive secretion of a millipede. Pediatr. Dermatol. 1991; 8: 25–7. 4. Radford AJ. Millipede burns in man. Trop. Geogr. Med. 1975; 27: 279– 87. 5. Mason GH, Thomson HD, Fergin P, Anderson R. Mysterious lesions. Med. J. Aust. 1994; 160: 718–26.

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Abhishek K. Verma,*† BSc (Med), MBBS Bernie Bourke,‡ MBBS, FRACS, DDU *School of Medicine and Public Health, University of Newcastle, †Department of Vascular Surgery, Gosford Hospital, and ‡Department of Vascular Surgery, Gosford Vascular Services Pty Ltd, Gosford, New South Wales, Australia doi: 10.1111/ans.12279

Giant neobladder stone Urolithiaisis is a recognized delayed complication of orthotopic neobladder construction. A stone in the neobladder may be asymptomatic and can be discovered as an incidental finding on a radiological investigation. However, when symptoms occur they may include severe lower abdominal pain, dysuria, haematuria or lower urinary tract symptoms. We describe a rare case of a giant neobladder stone which required open neocystolithotomy and fragmentation with hammer and chisel. A 60-year-old man presented with irritative lower urinary tract symptoms, lower abdominal pain, urinary incontinence and difficulty in self-catherization. Twenty years earlier, he underwent a radical cystoprostatectomy with orthotopic neobladder for urothelial carcinoma at another institution. He lost follow-up with his initial urologist as he has moved to another state. On physical examination, he was morbidly obese and abdominal examination was unremarkable apart from a lower midline abdominal scar. Laboratory investigations were positive for microhaematuria on urine analysis, but urine culture, urine cytology and renal functions were normal. A computed tomography of the abdomen and pelvis revealed a large round 12-cm calculus within the neobladder without evident of hydronephrosis (Fig. 1). He had an endoscopic evaluation for his lower urinary tract symptoms, which revealed a bulbar urethral stricture that was dilated. He proceeded to an open neocystolithotomy via an incision through the lower half of his previous midline scar. With the irrigation via the previously placed indwelling urinary catheter, the neobladder was distended and a vertical neocystolithotomy was performed carefully preserving the mesentery. A very hard 12-cm round stone was noted to be densely adherent to the mucosa of the neobladder and could not be removed intact despite enlarging the neocystotomy. Subsequently it was fragmented into smaller pieces with an orthopaedic chisel (Fig. 2). The neocystotomy was closed in two layers and a pelvic drain inserted. The pelvic drain was removed and patient was discharged with a 22-Fr indwelling catheter on day 2. The stone weighed 860 g (Fig. 3). Biochemical analysis of the stone showed it composed of magnesium ammonium phosphate (60%), calcium phosphate (32%) and calcium oxalate monohydrate (7%). After initially removing the urethral catheter at day 14, there was a continuous urine leak through the lower midline wound and the catheter was reinserted until the incision healed on day 28. Radical cystectomy with urinary diversion remains the standard of care for muscle invasive bladder cancer.1 Calculi are relatively uncommon following orthotopic urinary diversion. Its incidence has

Fig. 1. Coronal view of computed tomography abdomen and pelvis shows large stone in the neobladder.

been reported ranging between 0.5% and 7.0%.2–5 The aetiology of stone formation is multifactorial and includes the presence of infection, metabolic acidosis, stasis, mucus and foreign body. Most stones are composed primarily of struvite (magnesium ammonium phosphate) and are thought to be secondary to infection by urease producing organisms (Proteus, Klebsiella and Pseudomonas). The urease enzyme splits urea into ammonia and bicarbonate, which subsequently cause alkalinization of urine and promote the formation of struvite stone. Furthermore metabolic acidosis can lead to hypercalciuria, hypocitraturia, hyperoxaluria, hyperuricosuria and hyperphosphaturia, which may increase the stone risk. Similarly, urinary stasis, mucus and a foreign body have been implicated in the formation of stones.6–8 The presentation of a neobladder calculus may be asymptomatic. Without appropriate follow-up, these can grow to remarkable dimensions as illustrated in this case. Various surgical approaches have been described, including endoscopic neocystolitholapaxy, extracorporeal shock wave lithotripsy, percutaneous neocystolithotripsy and © 2013 Royal Australasian College of Surgeons

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database at our institution. Our patients are educated to follow a strict postoperative protocol following the procedure. Such advice includes: maintaining adequate fluid intake, timed voiding, irrigation regimens as needed, clean intermittent self-catheterization to prevent incomplete voiding and treatment of urinary tract infections. Neobladder calculi are rare, often asymptomatic and may grow to a large size. To our knowledge, this is the largest neobladder stone reported in literature. Open surgical removal may be complicated; however, in this case, it was the only logical approach because of the significant stone burden.

References

Fig. 2. Intraoperative photograph showing the giant stone in the neobladder is fragmented by the chisel.

Fig. 3. A total weight of 860 g of stone debris was removed from the neobladder.

open neocystolithotomy.9,10 The large stone burden and altered anatomy of the neobladder may make open surgical removal a more favourable approach due to the safety and efficacy. Over the last 20 years, there has not been a single case of a neobladder stone being recorded in the radical cystectomy and urinary diversion

1. Stein JP, Lieskovsky G, Cote R et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1054 patients. J. Clin. Oncol. 2001; 19: 666–75. 2. Steven K, Poulson AL. The orthotopic Kock neobladder functional results, urodynamic features, complications and survival in 166 men. J. Urol. 2000; 164: 288–95. 3. Tanaka T, Kitamura H, Takahashi A, Masumori N, Itoh N, Tsukamoto T. Long term functional outcome and late complications of Studer’s ileal neobladder. Jpn J. Clin. Oncol. 2005; 35: 391–4. 4. Hautman RE. Neobladder and bladder replacement. Eur. Urol. 1998; 33: 512–22. 5. Abol-Enein H, Ghonheim MA. Functional results of orthotopic ileal neobladder with serous lined extramural ureteral re-implantation: experience with 450 patients. J. Urol. 2001; 165: 1427–32. 6. Terai A, Arai Y, Kawakita M, Okada Y, Yoshida O. Effect of urinary intestinal diversion on urinary risk factors for urolithiasis. J. Urol. 1995; 153: 37–41. 7. Hensle TW, Bingham J, Lam J, Shabsigh A. Preventing reservoir calculi after augmentation cystoplasty and continent urinary diversion: the influence of an irrigation protocol. BJU Int. 2004; 93: 585–7. 8. Beiko DT, Razvi H. Stones in urinary diversions: update on medical and surgical issues. Curr. Opin. Urol. 2002; 12: 297–303. 9. Paez E, Reay E, Murthy LNS, Pickard RS, Thomas DJ. Percutaneous treatment of calculi in reconstructed bladder. J. Endourol. 2007; 21: 334–6. 10. Bhatia V, Biyani CS. Vesical lithiasis: open surgery versus cystolithotripsy versus extracorporeal shock wave therapy. J. Urol. 1994; 151: 660–2.

Albert Tiu, BSc (Med), MBBS, MMed (Surgery), FRACS (Urology) Mark S. Soloway, MD Department of Urology, University of Miami Miller School of Medicine, Miami, Florida, USA doi: 10.1111/ans.12276

Pseudoaneurysm of the anterior tibial artery after ankle arthroscopy Vascular injuries from arthroscopy are an extremely rare cause of ankle swelling and pain. Arteries are seldom injured intraoperatively in a manner that presents with clinical symptoms due to avoidance tactics adopted or, when insult occurs, it is recognized and managed appropriately immediately. In the situation where damage is not © 2013 Royal Australasian College of Surgeons

recognized, blood can leak into the surrounding tissue, forming a haematoma or a false aneurysm. Undiagnosed injuries may progress to produce a space occupying lesion resulting in ischaemic damage to local tissue and covering skin, and may interfere with distal perfusion.

Giant neobladder stone.

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