Urinary bladder stone due to retained indwelling ureteral stent: A case report

RATIONALE

The indwelling ureteral stents is a common procedure in routine urological practice. The double-J (D-J) stent is the most common type of stents used and is indicated mainly for short-term urinary drainage and prevention of obstruction and infection. However, prolonged indwelling stents may result in disastrous complications, such as hematuria, infection, encrustation, and stone formation. In this context, the persistence of stent in situ might play a key role as a nidus in deposition of urinary sediment, then forming calculus. Although the encrustation may become more serious as time goes on, large bladder stones are relatively rare. However, the serious encrustation and giant stone may complicate or exacerbate the conditions in turn.

PATIENT CONCERNS

A 45-year-old female patient who underwent right ureteral stent placement after open ureterolithotomy 6 years ago complained of dysuria, urinary frequency, and urgency over 2 months.

DIAGNOSIS

The kidney ureter bladder (KUB) x-ray showed the presence of a giant stone in the bladder and an entire D-J stent. The computed tomography (CT) urography scans revealed normal left kidney, right hydronephrosis, and an encrusted D-J stent with the significant stone, diameter 4.2 cm with a CT value of 1211.0 ± 221.6 HU, on the vesical coil. On the basis of these auxiliary examinations, the case was diagnosed as cystolith and prolonged-indwelling stents.

INTERVENTIONS

Pneumatic ballistic lithotripsy was used for crushing the bladder calculi followed by the successful extraction of intact D-J ureteral stent.

OUTCOMES

No residual stone was detected on postoperative KUB x-ray and CT urography scans. Patient recovered well and was discharged 10 days after surgery. Semi-annual ultrasound examination was suggested to monitor the effect of therapy.

LESSONS

This case reminds us that it is crucial to take various measures to avoid the forgotten ureteral stent and its unfortunate late complication.

Cystolitholapaxy and laparoscopic sacrocolpopexy in a case of multiple urinary bladder calculi & vault prolapse

Vesical calculi are more common in men than women. The prevalence in women is less than 2%. Multiple vesical calculi in chronic cases of utero vaginal prolapse or vault prolapse is rare. Urinary stasis, urethral kinking along with chronic infection are the probable predisposing factors for stone formation [2]. We report a case of 65 year old female, with mass per vagina since 10 years, who developed acute urinary retention due to impaction of vesical calculus at the external urethra meatus. Subsequently in a span of 12 h she passed 3 more vesical calculi. KUB X-ray failed to show any calculi but Computed Tomography(CT) Kidney Ureter Bladder (KUB) showed 2 vesical calculi. After cystolitholapaxy she underwent laparoscopic sacrocolpopexy for vault prolapse. In cases of chronic uterovaginal prolapse or vault prolapse X-Ray KUB should not miss the prolapsed part of the cystocele as calculi are present in the most redundant part. Chances of missing radiolucent uric acid calculi is high. In such cases CT KUB is essential.

[Multidisciplinary approach in urology. Laser technologies: faster, simpler, more efficient]

Laser technology has taken a place among the methods of treatment of various urological diseases. The new laser devices are being developed in addition to commonly used. Physicists of the russian NTO "IRE Polus" in collaboration with doctors from Sechenov University have developed a new generation laser device - thulium fiber laser. It has been actively used since 2017 for laser enucleation of prostate. Later the laser was used for treatment of bladder tumor, lithotripsy. The device has already managed to prove its efficacy in in-vitro experiments and clinical practice surpassing foreign analogues.

[Initial experience in clinical application of thulium laser contact lithotripsy for transurethral treatment of urolithiasis]

INTRODUCTION

The choice of an effective and safe method of disintegration of stones in upper and lower urinary tract is very important in the context of continuous scientific and technological progress. In current clinical urological practice, various lithotriptors with rigid and flexible probes are used for contact disintegration of stones, having both advantages and disadvantages. This study aimed to analyze the first results of the clinical application of the native Tm: fiber Urolaz laser (STA IRE-Polyus, Russia) for contact transurethral lithotripsy.

MATERIALS AND METHODS

The study comprised 56 patients who underwent transurethral contact thulium laser lithotripsy for 68 stones of the upper and lower urinary tracts between April and September 2017. Forty-four patients had kidney and ureteral stones, and twelve patients had urinary bladder stones. Twenty-four kidney stones were removed by retrograde intrarenal surgery using ureteral casing, flexible ureteropyeloscope and thulium laser, 32 stones in various ureteral segments - by rigid contact thulium laser ureterolithotripsy and 12 bladder stones - by thulium laser cystolithotripsy. The size of the upper urinary tract stones varied from 0.6 to 1.8 cm, bladder stones measured from 1.1 to 3.5 cm. Also, experimental studies were carried out to investigate the effects of the fiber thulium and holmium laser on the stone displacement and temperature environment during lithotripsy.

RESULTS

Full stone fragmentation was achieved in 100% of patients. 47.7% of patients required additional lithoextraction of fragments; there was no retrograde migration of large stones. The mean duration of stone disintegration was 19 minutes. Postoperatively, 15.9% of patients had an exacerbation of pyelonephritis, which was successfully managed by conservative measures. The mean postoperative hospital stay was 2.4+/-1.1 days. At follow-up examination 4-6 weeks after surgery, one patient was found to have a residual symptomatic ureteral stone, which required extracorporeal short-wave lithotripsy. The experimental study showed that fiber thulium laser lithotripsy produced much less propulsion of artificial stone than Holmium laser lithotripsy. With the use of therapeutic power, neither of the lasers resulted in "dangerous" rises of the washing fluid temperature during stone disintegration.

CONCLUSION

Using the universal thulium laser system "Urolaz" provides a significant improvement in the effectiveness of endourologic upper urinary tract interventions and significantly reduces the likelihood of intraoperative trauma and postoperative complications, which contributes to improving the quality of specialized urological care.

Shockwave lithotripsy with music: Less painful and more satisfactory treatment

INTRODUCTION

The objective of this study was to determine whether listening to music during a session of extracorporeal shockwave lithotripsy (ESWL) improves patients' pain.

MATERIAL AND METHOD

A simple, blind randomisation was undertaken of patients with kidney and ureter stones attending an ESWL session of 7,000 waves for the first time, between September and December 2014. One group was given music and the other was not. The age, gender, location of stones (kidney/ureter) were recorded and 2questionnaires: pre ESWL (questionnaire A) and postESWL (questionnaire B). Each questionnaire contained a question about anxiety and another question on pain on the Likert scale (0-10). Questionnaire B also had a question on satisfaction and comfort (Likert 0-10). Other variables included heart rate, respiratory rate, systolic and diastolic blood pressure on wave 2,000, 5,000 and 7,000, reason for halting the procedure, total pethidine (mg), secondary analgesia, energy (J) and frequency (Hz). Bivariate analysis using the Student's t-test, X²/Fisher test and a multiple linear regression model.

RESULTS

The sample comprised 95 patients, with a mean age of 52 (±13) years, 35 (36.84%) females, 60 (63.2%) males. A total of 25 (26.3%) ureter stones and 70 (73.7%) kidney stones. A number of 42 (44.2%) patients were given music. There were no differences between the demographic variables or questionnaire A scores. Satisfaction and pain were better on questionnaire B with music.

CONCLUSION

Music can reduce pain and improve patient satisfaction in ESWL treatment. More studies are required to confirm this effect.

Giant Bladder Stone in a Healthy Young Female: A Case Report

Giant or massive bladder stone is a rare condition that is usually seen in men with an underlying urologic problem. Hereby we report a large stone in a healthy young female without any predisposing factor and with the minimal urologic complaint.

Surgical removal of a large vaginal calculus formed after a tension-free vaginal tape procedure

Vaginal calculus is a rare disorder which has been reported in association with urethral diverticulum, urogenital sinus anomaly, bladder exstrophy and the tension-free vaginal tape (TVT) procedure. We report a 42-year-old woman who presented with persistent, intractable urinary tract infection (UTI) following a TVT procedure. Cystoscopy demonstrated an eroded tape with the formation of a bladder calculus, and the patient underwent laser cystolithotripsy and cystoscopic resection of the tape. Following this procedure, her UTI completely resolved and she remained asymptomatic for several years. Seven years later she presented with a solid vaginal mass. Pelvic examination followed by transvaginal ultrasonography and magnetic resonance imaging demonstrated a large vaginal calculus located at the lower third of the anterior vaginal wall adjacent to the bladder neck. This video presents the transvaginal excision and removal of the vaginal calculus.

Transurethral Pneumatic Cystolithotripsy: A Novel Approach

OBJECTIVE

Various endoscopic instruments used in treating renal stones have been used in managing bladder calculi. Our aim is to evaluate the use of transurethral ureteroscopic pneumatic cystolithotripsy for the management of large bladder calculi.

PATIENTS AND METHODS

In a retrospective study conducted between May 2005 and July 2011, 53 patients with solitary bladder stones were subjected to our technique, transurethral ureteroscopic pneumatic cystolithotripsy. The mean patient age was 54.3 years. The mean stone size was 4.8 cm. Diagnostic cystoscopy was performed first. A semirigid ureteroscope with a pneumatic probe was introduced through the cystoscope sheath, and pneumatic lithotripsy was performed. The cystoscope sheath works as a draining channel, allowing bladder evacuation. The bladder collapses over the stone and, subsequently, prevents stone migration, which shortens the lithotripsy's duration. Stone immobilization allows the transmission of full pneumatic power to the stone. The stone fragments were removed through periodic bladder irrigation using an Ellick evacuation-irrigation system, and a 16F Foley catheter was placed at the end of the procedure.

RESULTS

Our technique was effective in all cases, including stone-free bladders. No surgical complications were detected. The mean operative time was 83 ± 21.0 minutes, which is comparable to that of standard management. The mean duration of lithotripsy and evacuation was 29.7 ± 18.4 minutes. In the postoperative period, patients were followed up for 18 months, with no urethral stricture being reported in any case.

CONCLUSION

The transurethral ureteroscopic pneumatic cystolithotripsy procedure is a safe technique for the management of large bladder calculi. It allows the bladder to collapse over the stone, leading to stone immobilization and, subsequently, decreasing lithotripsy duration. Our procedure is associated with a minimal chance of postoperative urethral injury because all stone fragments are evacuated through the cystoscope sheath, without contact with the urethral urothelium.

[INTRAVESICAL MIGRATION OF A HEM-O-LOK CLIP AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY: A CASE REPORT]

The Hem-o-lok clips (HOLC) is frequently used for hemostasis of the lateral pedicles in robot-assisted prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP). We report a rare post-operative complication, the migration of a HOLC into the bladder leading to calculus formation after RARP. A 54 year-old man underwent RARP with nerve- sparing procedure with HOLCs in the left neurovascular bundle. Three months later, he was referred to our hospital for pollakisuria and spontaneous hematuria. Abdominal ultrasonographic examination and computed tomography (CT) demonstrated a bladder stone that was 7 mm in diameter. On cystourethroscopy, he was noted to have a yellow-colored stone at 9 o'clock position of vesicourethral anastomosis. A cystolithotripsy for a bladder stone was performed until the surface of it was broken. A HOLC with a calculus was revealed and retrieved by stone forceps through the urethra. Since then, Intravesical migration of a HOLC has not been observed.

Teaching Evidence-Based Medicine in the Era of Point-of-Care Databases: The Case of the Giant Bladder Stone

In an era where physicians rely on point-of-care databases that provide filtered, pre-appraised, and quickly accessible clinical information by smartphone applications, it is difficult to teach medical students the importance of knowing not only when it is appropriate to search the primary medical literature but also how to do it. This column will describe how librarians at an academic health sciences library use an unusual clinical case to make demonstrations of searching primary medical literature real and meaningful to medical students, and to illustrate vividly the importance of knowing what to do when the answer to a clinical question cannot be found in a point-of-care database.

Safety of percutaneous nephrolithotomy in patients on antithrombotic therapy: a review of guidelines and recommendations

With the expanding use of chronic antithrombotic medical management for coronary artery disease, surgeons face the growing challenge of balancing the risks of postoperative bleeding against perioperative cardiovascular events. Percutaneous nephrolithotomy (PCNL) carries a risk of bleeding and the need for transfusion at baseline, which is further increased in patients on anticoagulation and antiplatelet therapy. Broad perioperative recommendations for risk stratification and antithrombotic management exist for surgical patients, however, they are less clear in those undergoing PCNL. In this review we appraise available literature, guidelines and opinions and present a consensus statement for antithrombotic management in patients undergoing PCNL.

Autonomic dysreflexia during cystolitholapaxy in patients with spinal cord injury

AIM

This study aims to explore the risk factors associated with autonomic dysreflexia (AD) reflex during cystolitholapaxy and increase the awareness of urologists on the dangerous reaction of AD in patients with spinal cord injury (SCI).

METHODS

Data of 89 SCI patients with bladder stone who underwent cystolitholapaxy were retrospectively analyzed. Patients were divided into two groups according to the presence or absence of AD. Risk factors may associated with AD during the endoscopic procedure were analyzed by comparing clinical and operative features between the two groups.

RESULTS

Of the 89 patients, 31 (34.83%) developed AD during the procedure. The patients who developed AD had larger stones (4.58±1.26 cm vs. 3.75±1.15 cm, P<0.01), more stones (2.29±0.86 vs. 1.74±0.81, P<0.01), and greater injury (83.87% vs. 41.38%, above T6, P<0.01) than those who did not develop AD. The patients who developed AD suffered higher irrigation (83.55± 13.05 cm vs. 77.47±10.91 cm, P<0.05) and longer operation time (60.65±17.78 min vs. 49.31±14.31 min, P<0.01) than those who did not develop AD. The AD group also received local anesthetics to a larger extent compared with non-AD group, which more often had spinal anesthesia.

CONCLUSION

The patients who developed AD during the procedure had larger stones, more stone number, injury level more often above T6, higher hydraulic irrigation height, and longer operation time compared with the patients who did not develop AD. Urologists should pay extra care when performing cystolitholapaxy on individuals with these features.

Concurrent stone stabilization improves ultrasonic and pneumatic efficacy during cystolithopaxy: an in vitro analysis

OBJECTIVE

To identify whether stabilization of larger bladder stones would improve the efficacy of combination (ultrasonic/pneumatic) lithotripsy in a phantom bladder stone model for percutaneous cystolithopaxy.

MATERIALS AND METHODS

Using 1cm phantom Bego stones, a spherical model bladder was used to simulate percutaneous bladder access. A UroNet (US Endoscopy, USA) was placed alongside a Swiss Lithoclast probe through the working channel of a Storz 26Fr rigid nephroscope. Using a 30Fr working sheath, the stone was captured, and fragmented for 60 seconds. Resulting fragments and irrigation were filtered through a 1mm strainer, and recorded. Five trials were performed with and without the UN. Durability was then assessed by measuring net defects, and residual grasp strength of each instrument. Descriptive statistics (mean, standard deviations) were used to summarize the data, and Student's t-tests (alpha < 0.05) were used to compare trials.

RESULTS

The mean time to stone capture was 12s (8-45s). After fragmentation with UN stabilization, there were significant improvements in the amount of residual stone (22% dry weight reduction vs 8.1% without UN, p < 0.001), number of fragments (17.5 vs 5.0 frag/stone, p=0.0029), and fragment size (3.6mm vs. 7.05 mm, p=0.035). Mesh defects were noted in all nets, ranging from 2-14 mm, though all but one net retained their original grip strength (36.8N).

CONCLUSIONS

Bladder stone stabilization improved fragmentation when used in conjunction with ultrasonic/pneumatic lithotripsy. However, due to limitations in maneuverability and durability of the UN, other tools need to identified for this indication.

[A case of giant bladder stone in a young man with neither lower urinary tract dysfunction nor foreign body in the bladder]

A 38-year-old man visited our hospital complaining of lower urinary tract symptoms. He had undergone extracorporeal shockwave lithotripsy to remove a right renal stone two times when he was 24 years old. Since examinations revealed right staghorn calculi and a giant bladder stone, vesicolithotomy was carried out. The removed stone measured 95 × 75 × 55 mm and weighed 250 g. We hypothesized that a fragment of the upper urinary tract stone had reached the bladder which could not be discharged spontaneously, and grew in the bladder. After the operation, uroflowmetry and voiding cystourethrography were performed and the results indicated no abnormalities in the lower urinary tract function.

[Therapeutic approach in urinary tract stones in children]

PURPOSE

Kidney stone disease in children is a rare pathology, with a low incidence in Spain (1/4,500 hospitalized children). The spontaneous expulsion rate is about 34-47% which means that more of 50% of children need active treatment. Paediatric patients forming urinary stones have a high risk of recurrence, therefore, a standard diagnosis and treatment are needed. We present our experience in urolithiasis treatment in children.

MATERIALS AND METHODS

We reviewed retrospectively all the patients ≤ 16 years hospitalized in our hospital with urolithiasis diagnosis from 2000 to 2013, citing treatment modality, stone-free rates and complications.

RESULTS

A total of 69 patients with a mean age of 8,2 years (range 1-16 years) were treated in our hospital during that period. The main clinical presentation was pain (52%). The diagnosis was made by abdominal ultrasounds in all cases. About localization, 21 lithiasis were found in distal urether (UD), 8 in medium urether (UM), 3 in proximal urether (UP) and 13 in renal pelvis (PR). The mean size was 13 mm. 21 (30%) patients had a spontaneous expulsion of the stone, 14 (20%) patients were treated with extracorporeal shock wave lithotripsy and in 22 (32%) patients the elected therapy was ureterosopic stone fragmentation (n = 13) or removal (n = 9). No complications were observed. The overall stone-free rate was 79% (n = 55).

CONCLUSIONS

Kidney stone disease in children is a rare pathology, with its own features about diagnosis and treatment, which requires medical care in a specialized center. The optimal treatment should be considered regarding the age of the patient, localization and size of the stone, as well as the team experience.

[Cystine urolithiasis: recommendations for diagnosis, treatment and recurrence prevention]

Cystine lithiasis is a diagnostic and therapeutic challenge. This consensus document has outgrown of discussion of experts in nephrology and urology. It is our hope that this document will be of use for all physicians who are facing this disturbing type of urolithiasis. So far, in our national literature there have been no comprehensive documents dealing with this entity and we believe that not only nephrologists and urologists will benefit, but also specialists in internal medicine and general practitioners.

[Urology]

This article intended to general practitioners brings an overview on current diseases in urology such as stone disease, benign prostatic hyperplasia, sexual dysfunction and localized cancers of prostate, bladder and kidney.

Jacob Aall's illness and death

Jacob Aall (1773-1844) was one of Norway's most notable nation-builders at the beginning of the 19th century. He owned and operated a large ironworks, participated in political life and was an historian, writer and translator of sagas. In the last 15 years of his life, he suffered greatly from pain attacks. After his death, an autopsy was performed and the doctors found a stone the size of a hen's egg, which weighed more than 90 g. The stone was variously described as a kidney stone and a bladder stone. Aall had travelled to Copenhagen in 1837 and consulted the Danish doctor Ludvig Levin Jacobson (1783-1843), known for his instrument for crushing bladder stones, a new and revolutionary treatment method. But some disagreement appears to have arisen between them about the treatment. A year later Aall consulted Christen Heiberg (1799-1872), a professor of surgery in Christiania (now Oslo). Heiberg also examined Aall's bladder and found «no cause for alarm». Aall adhered to a strict diet, including drinking an Italian «spa water» daily which he obtained in bottles from Trieste. However, he showed no great improvement. To all appearances, it was kidney stones that afflicted him in his last years and which finally ended his life. This article gives a full portrayal of the course of his illness with an authentic description from an age when there were no treatment possibilities for kidney stones.

Safety and efficacy of transurethral pneumatic lithotripsy for bladder calculi in children

OBJECTIVE

To determine the safety and efficacy of transurethral pneumatic lithotripsy for bladder calculi in children.

METHOD

The study included 100 children up to 15 years of age undergoing pneumatic cystolithoclast for bladder stones. The descriptive study was conducted from September 2006 to February 2007 at the Sindh Institute of Urology and Transplantation, Karachi. The inclusion criteria was children up to 15 years of age with a bladder stone of up to 3cm, pre-operative negative urine culture, no coagulopathy and fit for general anaesthesia. An X-ray and ultrasound of Kidney and Urinary Bladder (KUB) was mandatory. The procedure was done under general anaesthesia with a single dose of pre-operative antibiotic. A mini-scope of 4FR or a semi-rigid ureteroscope of 7/8.5 FR with pneumatic wolf lithoclast was used for the fragmentation of stones. Duration of procedure, any per-operative and post-operative complications and the duration of hospital stay were recorded. Post-operatively, the patient underwent ultrasound Kidney and Urinary Bladder at the first follow-up to assess stone clearance after one week.

RESULT

Mean patients age was 4.95 +/- 3.3 years. The male-to-female ratio was 11.5: 1 The mean hospital stay was 9.2 +/- 2.5 hours. The mean operating time was 25 (10 -65) minutes. Ten (10%) patients developed minor complications out of which 5 (5%) developed haematuria and 4 (4%) developed difficulty in passing urine. One (1%) of the patients developed post-operative retention of urine. All the patients were stone-free after the procedure.

CONCLUSION

The transurethral pneumatic lithoclast is very effective and safe in children with bladder stones up to 3cm.

[Extracorporeal shock wave lithotripsy for lower urinary tract stones: complications and the contributing factors]

OBJEVTIVE

To analyze the complications of extracorporeal shock wave lithotripsy (ESWL) for treatment of lower urinary tract stones and identify the factors contributing to the complications.

METHODS

We retrospectively analyzed the postoperative complications of ESWL in 83 patients with lower urinary tract stones and their association with the patients' age, height, body weight, body mass index (BMI), stone features, shock wave times, and shock wave energy.

RESULTS

Of the 83 cases treated with ESWL, 72.3% (60 cases) showed gross hematuria, 27.7% (23 cases) complained of pain, and 25.3% (21 cases) had both pain and gross hematuria. None of the patients reported vomiting, skin rash, flatulence, gastrointestinal bleeding or other complications. Patients with postoperative gross hematuria, pain, and both had significantly greater stone length, stone width and more shock body times than those without these complications (P<0.01 or P<0.05). Patients with gross hematuria had significantly lower height than those without complications (P<0.05).

CONCLUSION

The common complications of ESWL for lower urinary tract stones include hematuria and pain. The patient's height, stone length, stone width and shock times are important factors contributing to these postoperative complications.

[Contact laser lithotripsy--an effective minimally traumatic method of treatment of cholelithiasis with calculi of the kidney, ureter and urinary bladder]

An experience with using contact laser lithotripsy is presented in treatment of such actual disease as cholelithiasis. This kind of modern minimally traumatic lithotripsy used in 73 patients has shown it to be effective independent of localization of the calculi: both in the urinary bladder and the kidney and ureter.

[Giant bladder stone nine years after neobladder construction: a case report]

Urinary stone formation after orthotopic neobladder construction is a delayed complication. A giant bladder stone was found in a 67-year-old man who had undergone radical cystectomy and orthotopic neobladder substitution (Hautmann method) in 1998. The stone was removed by cystolithotripsy and weighed 108 g.

Spinal anesthesia in a patient with severe thoracolumbar kyphoscoliosis

Patients with spine abnormalities, present unique challenges to the health care provider responsible for administrating sedation and anesthesia during surgical and technical procedures. Spinal deformities may cause difficulties with both tracheal intubation and regional anesthesia. This report describes the anesthetic management for two urological operations that were performed in a patient with extremely severe thoracolumbar kyphoscoliosis. After examining the risk factors, spinal block by injecting single dose local anesthetic solution to the intratechal space was chosen to provide anesthesia. It has been suggested that hyperbaric solution, which is of high density compared with cerebrospinal fluid, can safely produce blocks for many operations under spinal anesthesia. In the first procedure, intrathecal injection of 6 mg hyperbaric bupivacaine, a local anesthetic solution (1.2 ml total volume), resulted in inadequate motor and sensory blockade, but the successful motor and sensory blockade at the level of Th10 was achieved in a second attempt with 6.25 mg hypobaric bupivacaine (2 ml). Because of this unexpected effect of local anesthetic solution, in the second operation, the technique was changed to intrathecal injection of 12.5 mg hypobaric bupivacaine (4 ml), and the motor and sensory blockade at Th10 was achieved again. The patient reported satisfactory anesthesia each time, and developed no complications. In conclusion, spinal anesthesia can be successful even in cases of severe thoracolumbar kyphoscoliosis.

Encrusted cystitis managed with multimodal therapy

Encrusted cystitis is a rare chronic inflammatory condition of the bladder. The case of a male patient with dysuria and gross hematuria accompanied by the passage of stone fragments is presented. Multimodal therapy was undertaken. He was treated with Renacidin (citric acid mixture) irrigation as an inpatient. One month later, he underwent cystourethroscopy and was determined to have residual stone and fibrosis of the prostatic urethra. The patient was then treated with cystolitholapaxy and visual internal urethrotomy. This multimodal treatment resulted in resolution of his stone burden at follow-up.

Management of pediatric stone disease

Pediatric and adult stone disease differs in both presentation and treatment. Children can present with a wide range of symptoms varying from flank pain and hematuria to nonspecific symptoms such as irritability and nausea. Although ultrasonography and plain radiographs can play a role in diagnosis and follow-up, the standard of care for a child who presents to the emergency department with a history suggestive of a stone is noncontrast spiral CT. Because there is a high yield in identifying predisposing factors in children with urolithiasis and high recurrence rates, metabolic evaluation of every child with a urinary stone should be undertaken and medical treatment should be given if necessary. With recent advances in technology, stone management has changed from an open surgical approach to less invasive procedures such as extracorporeal shock-wave lithotripsy and endoscopic techniques. Herein, we present a review of the recent literature and offer our own preferences to approaches for treatment.

Percutaneous Treatment of Calculi in Reconstructed Bladder

PURPOSE

To report our results with percutaneous removal of calculi from reconstructed bladders.

PATIENTS AND METHODS

Twelve patients with reconstructed bladders who underwent endoscopic cystolithotomy were identified from our departmental database, and retrospective review of case notes and imaging was performed.

RESULTS

Access was gained via an ultrasound-guided new tract in 9 patients (75%). An old suprapubic tract site was used in two patients, and the Mitrofanoff stoma was the route of access in one patient. The procedure was successful, with stone clearance achieved in all 12 cases. No major complications were observed. At a median follow up of 24 months, stone recurrence was observed in 5 patients (42%), 4 of whom underwent repeat procedures. Follow-up showed no change in continence in the patient with a Mitroffanoff stoma.

CONCLUSION

Percutaneous cystolithotomy is a safe and effective minimally invasive option for removal of stones in a reconstructed bladder. We recommend endoscopic removal as the treatment of choice in these patients.

Percutaneous versus transurethral cystolithotripsy and TURP for large prostates and large vesical calculi: Refinement of technique and updated data

BACKGROUND AND PURPOSE

We compare two modalities of treatment; transurethral cystolithotripsy (TUCL) and percutaneous cystolithotripsy (PCCL), for large vesical calculi in patients who underwent simultaneous transurethral resection of prostate (TURP), and present refinements of the technique of PCCL.

PATIENTS AND METHODS

Between July 1999 and June 2003, 54 patients were subjected to either TUCL (n = 19) or PCCL (n = 35) along with simultaneous TURP. Inclusion criteria were prostate volume > 50 ml, aggregate stone size > 3 cm with each individual stone > 1 cm, In the TUCL group, calculi were treated with 26F nephroscope, pneumatic lithotripsy and fragment extraction. This was followed by TURP with 26F continuous-flow resectoscope. In the PCCL group, calculi were removed through a suprapubic 30F Amplatz sheath followed by standard TURP with the suprapubic sheath in situ to provide continuous drainage. A 20F two-way Foley catheter was inserted suprapubically and urethrally in cases of PCCL and a 22-24F three-way catheter urethrally after TUCL.

RESULTS

The two groups were comparable in age. The mean prostate size as well as aggregate stone size was significantly larger in PCCL group. The operating time for stone removal was significantly less in the PCCL group while time required for TURP was statistically similar in two groups. In the TUCL arm three patients had residual stones requiring repeat TUCL, and one developed a urethral stricture.

CONCLUSIONS

Combined TURP and PCCL is safe, more effective and a much faster alternative to combined TURP and TUCL in patients with large bladder calculi and large prostates.

Percutaneous Cystolithotomy of Large Urinary-Diversion Calculi Using a Combination of Laparoscopic And Endourologic Techniques

BACKGROUND AND PURPOSE

Patients with urinary diversions are at higher risk for bladder urolithiasis. Often, the stone burden is large, necessitating open stone removal. We describe our technique for removing such stones using a combination of laparoscopic and endourologic instrumentation.

PATIENTS AND METHODS

With the patient in the dorsal lithotomy position or supine, cystoscopy is performed via the native urethra or catheterizable stoma, respectively. With the urinary reservoir distended with normal saline, percutaneous access is obtained under direct vision with a 10-mm trocar introduced through the scar of the previous suprapubic cystostomy. A laparoscopic entrapment bag is introduced through the trocar, into which the calculi are manipulated. The bag is delivered percutaneously through the trocar site with subsequent removal of the trocar. A 30F Amplatz renal dilator sheath (Cook Urological, Spencer, IN) is introduced directly into the bag. An ultrasonic lithotrite passed through a nephroscope is utilized to fragment and evacuate the calculi. Closure of the neocystotomy is not performed. A drainage catheter is left in for 7 days.

RESULTS

This procedure has been successful in eight consecutive patients, six with bladder augmentations, one with a bladder reconstruction with appendicovesicostomy, and one with an Indiana pouch. All calculi were radiopaque, having a mean linear size of 4.1 cm (range 1.5-7.0) cm. Several patients had multiple stones. The mean operating room time was 123 minutes (range 48-228 minutes). Two patients had concomitant ureteroscopy with laser lithotripsy for ureteral calculi. All were rendered stone free with one procedure and were discharged within 23 hours after surgery. There were no immediate or delayed complications.

CONCLUSIONS

Our technique of percutaneous cystolithotomy utilizing laparoscopic and endourologic instrumentation is safe and effective for the removal of large calculi from urinary diversions. It is well tolerated, allows complete stone removal in a single sitting, and obviates an open procedure.

Multiple bladder calculi: a rare cause of irreducible uterine prolapse

BACKGROUND

A vesical calculus in a prolapsed cystocele is rare.

OBJECTIVE

To highlight bladder calculi as a cause of irreducible uterine prolapse.

CASE REPORT

A case of irreducible total uterine prolapse caused by multiple vesical calculi is presented. Bladder stones were removed through vaginal cystolithotomy followed by vaginal hysterectomy.

CONCLUSION

In cases of acute irreducible pelvic organ prolapse, the possibility of bladder stones should be kept in mind and X-ray pelvis including the prolapsed mass should be done to confirm the diagnosis.

Simultaneous transurethral cystolithotripsy with holmium laser enucleation of the prostate: a prospective feasibility study and review of literature

OBJECTIVE

To report experience with holmium laser enucleation of the prostate (HoLEP) simultaneously with transurethral holmium laser cystolithotripsy (HLC) for managing bladder outlet obstruction (BOO) and associated vesical calculi; we also review previously reported cases of managing vesical calculi and associated BOO.

PATIENTS AND METHODS

The high-powered holmium laser is a very efficient multifunctional endourological instrument that effectively fragments calculi of all compositions and is capable of haemostatic cutting of tissue, resulting in minimal bleeding after prostatic resection. A prospective study was conducted from April 2003 that included 32 men who underwent simultaneous HoLEP with transurethral HLC at our institution. Demographic, laboratory, peri-operative and follow-up data were analysed. Complications during and after surgery were identified to assess the morbidity of procedure.

RESULTS

The mean (range) size of bladder calculi was 34.6 (12-70) mm and the preoperative weight of the prostate was 51.9 (11-172) g. Combined HoLEP with transurethral HLC was technically feasible in all patients, and all were stone-free after surgery. The mean operative duration was 97.7 (40-230) min, the weight of prostate tissue removed 34.6 (5-88) g, and the duration of catheterization and hospital stay 29.3 h and 34.8 h, respectively. Complications during and after surgery occurred in 12.5% and 15.6% of patients, respectively; all complication were minor and none caused any residual disability to the patient. No patient required a blood transfusion or developed clot retention.

CONCLUSIONS

Managing bladder stones and BOO with simultaneous transurethral HLC and HoLEP should be considered the treatment of choice for such cases. Stones of any size and composition, and prostates of practically any size can be treated endoscopically using the holmium laser, with acceptable morbidity once the technique is mastered. The review of previous reports suggested a need for a prospective study comparing endoscopic management of BOO and associated bladder stones, with medical management of BOO and extracorporeal shock wave lithotripsy/endoscopic lithotripsy for bladder stone.

Extracorporeal shock wave lithotripsy in the management of pediatric urolithiasis

The main objective of this paper was to evaluate the efficacy and safety of the management of pediatric urolithiasis by extracorporeal shock wave lithotripsy (ESWL). Between November 1988 and July 2000, 165 renal stones, 53 ureteral stones, and 5 bladder stones were treated in 126 pediatric patients using Siemens Lithostar lithotriptor. The ESWL treatments ranging from 1 to 7 were needed per patient (mean: 2.1). One ESWL session was performed for 49.6% of stones, two for 24.6%, three for 13.0 %, four for 5.6% and > 4 for 8.2%. The success rate for renal stone units (asymptomatic fragments less than 4 mm) was 88.2%, stone-free rate was 49.0%. The stone-free rate for ureteral stone units was 87.5%, but was 75% for bladder stones. The overall results of ESWL treatment in 126 children was satisfactory: the success rate was 90.5%, stone-free rate was 51.6%, residual fragments > 4 mm were 9.5%. General anesthesia was required in 65 children (136 treatments) under the age of 10, and only in 18 children (40 treatments) in the age 11-14. Auxiliary procedures, such as double J stent and percutaneous nephrostomy (PCN) were used in 19 and 7 patients, respectively. Perirenal hematoma in one patient and hematomas in enteric wall in another one patient were the only major complications managed conservatively without consequences. Low energy lithotripsy with the Siemens Lithostar in our series of pediatric patients was safe and relatively effective.

Bladder calculi: did the clinical picture change?

OBJECTIVES

Recent improvements in socioeconomic conditions have changed the clinical picture of urinary stones, including bladder calculi. With the ongoing changes in these predisposing factors, it is possible that the clinical picture of bladder calculi will show additional changes. Nevertheless, few contemporary series of bladder calculi in published English reports have addressed these issues.

METHODS

We retrospectively reviewed the records of 328 patients who underwent surgical therapy for bladder calculi at our institution from January 1995 to June 2005.

RESULTS

Acute urinary retention was the most common presenting symptom (n = 221, 67%). Patients who presented with urinary retention were younger (37 versus 48 years, P <0.001), had a greater incidence of recent renal colic (40% versus 19%, P <0.01), and had a lower incidence of bladder outlet obstruction (14% versus 37%, P <0.001) compared with the nonretention group. However, previous stone passage did not influence the probability of presenting with urinary retention. Small bladder stones were associated with a greater likelihood of presenting with urinary retention. The retention group had greater incidence of stones less than 1 cm in diameter compared with the nonretention group (72% versus 39%, P <0.001). Finally, calcium oxalate was found in 78% of patients with bladder calculi.

CONCLUSIONS

Acute urinary retention was the main mode of presentation in patients with bladder calculi. Younger age, a history of recent renal colic, and smaller stones appeared to increase the likelihood for patients to present with urinary retention.

Percutaneous suprapubic cystolithotripsy under local anesthesia

OBJECTIVES

To assessed the feasibility and effectiveness of percutaneous cystolithotripsy under local anesthesia in selected patients.

METHODS

Thirty-one patients with bladder stones of different etiologies underwent percutaneous cystolithotripsy under local anesthesia. Suprapubic access was obtained with ultrasound guidance, and fragmentation of the stone was performed using the Swiss lithoclast. Suprapubic and transurethral catheters were placed postoperatively.

RESULTS

No major intraoperative complications occurred. The whole procedure was well tolerated, and no significant differences were found in the mean pain score between the percutaneous suprapubic cystolithotripsy group and a group of male patients who underwent rigid cystoscopy under local anesthesia (P = 0.35). Complete stone clearance was achieved in all but 1 patient (96.78%). Bladder irrigation because of gross hematuria was needed in 5 patients, but no blood transfusion was required. Fever developed in 1 patient and was treated with intravenous antibiotics. The average hospitalization was 2.3 days (range 2 to 5). After a mean follow-up of 10 months, no recurrent stone developed.

CONCLUSIONS

Percutaneous suprapubic cystolithotripsy under local anesthesia is a safe and effective technique to remove bladder calculi. Thus, it may be used as an alternative treatment option in selected patients.

Intravesical migration of an intrauterine contraceptive device complicated by bladder stone: a report of six cases

Intrauterine contraceptive device is the most popular method of reversible contraception in developing countries due to its efficiency and low cost. However, this device is often inserted by paramedics of variable skills, and follow-up evaluations are irregular or absent which can be the source of major complications. The authors report six cases of intravesical migration of intrauterine contraceptive devices complicated by bladder stones. All the six cases were managed endoscopically with excellent outcome. The authors demonstrate that this major complication can be managed endoscopically with decreased morbidity for the patient.

Bladder lithiasis: from open surgery to lithotripsy

Bladder calculi account for 5% of urinary calculi and usually occur because of bladder outlet obstruction, neurogenic voiding dysfunction, infection, or foreign bodies. Children remain at high risk for developing bladder lithiasis in endemic areas. Males with prostate disease or relevant surgery and women who undergo anti-incontinence surgery are at a higher risk for developing vesical lithiasis. Open surgery remains the main treatment of bladder calculus in children. In adults, the classical treatment for bladder calculi is endoscopic transurethral disintegration with mechanical cystolithotripsy, ultrasound, electrohydraulic lithotripsy, Swiss Lithoclast, and holmium:YAG laser. Novel modifications of these treatment modalities have been used for large calculi. Open and endoscopic surgery requires anesthesia and hospitalization. Alternatively, extracorporeal shock wave lithotripsy has been demonstrated to be simple, effective, and well tolerated in high-risk patients. Recently, simultaneous percutaneous suprapubic and transurethral cystolithotripsy has been tested as well as percutaneous cystolithotomy by using a laparoscopic entrapment sac.

[Brief history of vesical lithiasis management]

Stones of the bladder are one of the oldest illness that we know. History of its treatment has been cause of discussion in different moments. Since first treatments in Egypt or India, until our extracorporeal shock waves lithotritia (ESWL), there have been many intermediate treatments. The objective of this work is to know a little about some of these advances and their authors, as well as the instruments that have made it possible.

Endoscopic treatment of multiple prostatic calculi causing urinary retention

Although prostatic calculi are relatively common, the etiology of these stones is not clear. We report a case with multiple prostatic calculi causing urinary obstruction and a concomitant bladder stone. We treated these stones endoscopically. We found a lot of different sized stones endoscopically, some protruding into the urethra, some filling different cavities on the prostate. So these cavities suggest prostatic calculi may occur related to intraprostatic reflux in the congenital or acquired diverticulum of the prostatic tissue. In addition, the stone composition of the bladder and prostatic stones was the same. All of these results show that the origin of bladder and prostatic stones can be the same. This case also supports a theory of intraprostatic reflux and urine stasis.

Use of resectoscope to aid in bladder stone extraction

We describe a modified technique of standard cystoscopic manipulation to facilitate bladder stone extraction. This technique decreases the overall time required for stone manipulation by allowing larger size stone fragments to be removed from the urethra under direct visualization.

Extracorporeal shock wave lithotripsy monotherapy for treatment of patients with urethral and bladder stones presenting with acute urinary retention

OBJECTIVES

To present our experience with extracorporeal shock wave lithotripsy (ESWL) monotherapy for the treatment of patients with urethral and bladder stones presenting with acute urinary retention.

METHODS

A total of 64 patients (62 male and 2 female) with urethral or bladder stones underwent ESWL monotherapy. All patients presented to the emergency department with acute urinary retention. The mean patient age was 40 +/- 13.2 years (range 11 to 74). The exclusion criteria were urethral strictures, associated bladder growths detected by pelvic ultrasonography, and bladder stones larger than 25 mm in the largest diameter. After fixation of a Foley catheter, ESWL monotherapy was performed with a Storz SL 20 lithotriptor. The catheter was removed after confirmation of stone fragmentation.

RESULTS

Fine fragmentation was obtained and uncomplicated spontaneous evacuation occurred without the need for adjuvant procedures in 60 patients. Four patients developed acute urinary retention due to urethral stone impaction. In 3 patients, the urethral catheter was successfully refixed, and an additional session of ESWL resulted in fine fragmentation of the stones, with spontaneous evacuation after catheter removal. In the remaining patient, the stone could not be pushed into the bladder and crushing was performed endoscopically.

CONCLUSIONS

ESWL monotherapy is safe and effective for the treatment of urethral and bladder stones in patients with no other causes of infravesical obstruction.

Holmium laser cystolithotripsy in children: initial experience

INTRODUCTION

Management of vesical calculi in children poses an interesting challenge to the urologist. The treatment options currently available include open surgery, transurethral pneumatic cystolithotripsy, percutaneous suprapubic cystolithotomy and shockwave lithotripsy (SWL). Holmium: YAG (Ho: YAG) laser cystolithotripsy represents a novel modality of treatment that is minimally invasive.

MATERIALS AND METHODS

From July 1999 to January 2003 we treated 23 children with vesical calculi using transurethral Ho: YAG laser lithotripsy. The indications for cystolithotripsy were stone size < or = 4 cm (N=19), or multiple stones with combined stone burden < or = 4 cm (N=4). The mean patient age was 7.8 (range 2-12) years and the mean stone size was 2.7 (range 0.9-4) cm. Access was obtained with an 8F ureteroscope and holmium laser energy (0.6-1.8 J/pulse at 5-12 Hz) was applied through a 550-mum. end-firing fibre under video guidance. The calculi were pulverized to tiny fragments about 2-3 mm in size. An 8F urinary catheter was placed for one night in all patients. Post-operatively the children were evaluated at 3 and 18 months with radiological imaging and uroflowmetry to confirm stone-free status and exclude urethral stricture formation.

RESULTS

The mean duration of the endoscopic procedure was 38 (range 19-62) minutes while the mean length of hospital stay was 2.2 (range 2-3) days. All the children were rendered stone-free following a single operative session. Laser-induced major complications were not observed in any of the children. At the mean follow-up of 42 (range 26-69) months none of the children developed stone recurrence, urinary tract infections or urethral strictures.

CONCLUSIONS

Transurethral Ho: YAG laser lithotripsy was found to be an efficient and safe modality for the treatment of vesical calculi in children.

Use of Amplatz sheath in male urethra during cystolitholapaxy of large bladder calculi

Large-burden bladder stones often require percutaneous cystolithotomy or an open procedure. These approaches may not be feasible in certain patients who are at increased risk of operative complications. We present a novel technique for transurethral cystolitholapaxy using Amplatz sheath in the male urethra.