Giant urinary tract calculi: A case series

Background: A giant urinary tract calculus is not common in modern urological practice. The bladder has been known to harbour very large stones, weighing hundreds of grams, some with bearable symptoms, for a long time. These giant stones account for less than 1% of all urinary tract calculi. The aim of the present report is to highlight our management of a series of giant urinary tract calculi. Methods: A series of 14 patients were seen over 5 years (2004–2009) with giant urinary tract calculi and were studied in detail using their hospital records. Their biodata, clinical presentation, presence of urinary tract obstruction or infection, diagnostic investigations, operative management, and physical and chemical characteristics of the calculi were reviewed. Results: There were 13 males and one female, and their ages ranged between 4 and 79 years (median 30.5). Ten patients had bladder calculi, one ureteric in combination with a staghorn renal calculus, a second stone in the urethra and two huge staghorn calculi in non‐functioning kidneys. The mean weight of the calculi was 153.3 ± 69.6 (range 25–300 g) and the chemical compositions were mainly calcium oxalate, struvite (triple phosphate) and calcium carbonate. All the stones were radio‐opaque and two were associated with non‐functioning kidneys, and there was no congenital anatomical defect causing obstruction in any of the patients. Conclusion: Giant urinary tract calculi are most common in the male urinary bladder and are managed by open surgery with very good outcome. There were no anatomical abnormalities causing narrowing in the urinary tract in any of the cases.     

ESWL与输尿管镜碎石联合处理上尿路结石

目的：探讨对部分上尿路结石采用ESWI．与输尿管镜碎石联合处理的方法。方法：对70例上尿路结石患者采用ESWI。与输尿管镜下钬激光碎石（URS）联合交替治疗。其中输尿管结石48例,。肾结石22例。结果：结石总排净率为91．4％00（64／70）,其中输尿管结石排净率为95．8％（46／48）,肾结石排净率为81．8％（18／22）。3例治疗失败,其中1例输尿管结石因输尿管狭窄无法入镜;另2例肾结石,1例因交替治疗次数过多中途停止治疗,1例因结石硬度过大ESWI,不佳,均改为PCNL术。结论：ESW[。与URS联合交替进行的疗法处理上尿路结石,避免了创伤性治疗,扩大了ESWI,治疗范围,降低了URS手术难度,缩短了URS操作时间,提高了结石排净率,患者创伤微小、恢复快、并发症少,是治疗上尿路结石,特别是部分复杂性上尿路结石较理想的方法之一。     

Intracorporeal Lithotripsy with the Swiss Lithoclast

Background: In addition to currently available modalities of intracorporeal lithotripsy (ultrasonic, electrohydraulic, and laser), a new ballistic lithotriptor known as the Swiss Lithoclast has recently gained attention. This study reports our experience with the Swiss Lithoclast in the endoscopic management of urinary calculi.
Methods: A total of 51 patients with urinary calculi were treated with the Swiss Lithoclast; one patient with a renal calculus, 28 with ureteral calculi, and 22 with lower urinary tract (bladder, urethra and Kock pouch) calculi.
Results: The Lithoclast successfully fragmented 94% of the calculi, independent of stone composition. Complete failure of fragmentation was not encountered. In six of the 10 upper ureteral calculi, stone fragments were pushed up into the calyces. Adjunctive extracorporeal shock wave lithotripsy for residual fragments was performed in six cases. The stone-free rate at one and three months was 84% and 88%, respectively. There were no intraoperative or long-term complications directly related to the use of this device.
Conclusion: The Swiss Lithoclast is a safe and effective means of intracorporeal lithotripsy. Although suitable for mid and lower ureteral stones, the device has a risk of stone push-up in patients with upper ureteral stones.     

Experience with the holmium laser as an endoscopic lithotrite

INTRODUCTION: Holmium laser lithotripsy represents an additional option in the management of urinary tract calculi. We report the results of a cohort of patients with ureteric and bladder calculi treated with this modality. METHODS: Twenty-three patients underwent holmium laser lithotripsy to treat ureteric or bladder calculi. Power settings of 0.5 J to deliver 2.5-4.0 watts were used for the ureteric calculi, and up to 30 watts for the bladder calculi. RESULTS: The mean ureteric stone size was 7.3 mm (range 4-10 mm). One stone was upper ureteric, seven were mid-ureter and nine were lower-ureter. Eighteen of the 19 patients with ureteric calculi were free of stones 28 days postoperatively. The remaining patient was clear by 12 weeks. All patients with bladder calculi were completely cleared of stones. There were no intraoperative complications. DISCUSSION: Ureteric stone position can limit the use of extracorporeal shock wave lithotripsy due to imaging difficulties. Ureteric lithotripsy overcomes this problem. The holmium laser has proven to be safe and effective in clearing urinary stone burdens of a variety of sizes, sites and compositions in this cohort of patients.     

Percutaneous removal of upper urinary tract calculi: experience with ultrasonic lithotripsy

From October 1983 to March 1985, the authors removed upper urinary tract calculi percutaneously in 102 patients. In 89 patients, stones required disruption with an ultrasonic lithotriptor before removal. Fifty-two patients had a stone in the renal pelvis and 20 had calyceal stones only; 21 had stones at both sites and 9 had a stone in the upper ureter. Complete removal of all stone material was achieved in 67 of 68 patients with a solitary calculus, in 13 of 26 with multiple calculi and in 6 of 8 with ureteric calculi. Complications were minimal; three patients had pulmonary edema postoperatively as a result of excessive absorption of irrigating fluid, and one patient sustained a perforation of the descending colon. The mean postoperative hospital stay was 6.8 days and patients were able to return to work a few days after their discharge from hospital. Percutaneous stone removal is a safe and effective procedure and is the surgical procedure of choice for the removal of upper urinary tract calculi.     

Urolithiasis in renal and combined pancreas/renal transplant recipients

PURPOSE: Urological complications in renal transplant recipients will become more common with increasing numbers of transplantations as well as increased graft survival secondary to improvements in immunosuppression. Urinary stone disease may be one of those complications. We determine the current incidence of urinary stone disease in renal transplant patients based on contemporary immunosuppressive regimens. MATERIALS AND METHODS: We reviewed the records of 1,730 renal and 83 pancreas/renal transplantations performed during the cyclosporine era and identified 8 recipients (0.4%) with urinary stone disease, including 3 with renal pelvic stones, 1 with multiple ureteral stones and 4 with bladder calculi. RESULTS: Treatment ranged from conservative observation to open pyelolithotomy, and included percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. The ureteral stones were removed with antegrade and retrograde ureteroscopy. The 4 bladder stones were treated with cystolithalopaxy. No case had significant permanent graft damage. Mean followup was 68.6 months. Mean serum creatinine was 1.5 mg./dl. (normal 0.5 to 1.3) at baseline and 2.38 after followup. CONCLUSIONS: While the incidence of upper tract urinary stone disease in renal (0.23%) and pancreas/renal (1.2%) transplant recipients is not statistically significant (p <0.45), the latter have significantly higher rates of bladder stones (4.8 versus 0%, p <0.001). The diagnosis of urinary stone disease in transplant recipients can be challenging because of the lack of symptoms but the treatment approach is the same as in the normal population.     

广东东莞地区416例泌尿系结石成分分析

目的 应用红外光谱法测定东莞地区泌尿系结石化学成分,探讨本地区泌尿系结石患者的尿路结石成分特点,为本地区泌尿系结石的深化治疗、防止结石复发及预防提供科学依据.方法 收集经自行排出、碎石后排出或手术中取出的泌尿系结石标本416例,应用溴化钾压片技术的红外光谱法对其化学成分进行定性分析.结果 416例泌尿系结石患者中男性居多,占66.8%(278/416),女性占33.2%(138/416);上尿路结石占88.2%,下尿路结石(膀胱结石居多)占11.8%;结石成分定性分析共检测出一水草酸钙、二水草酸钙、碳酸磷灰石、无水尿酸、六水磷酸铵镁和尿酸铵6种化学成分.单一成分结石163例(一水草酸钙/无水尿酸/碳酸磷灰石/六水磷酸铵镁:98/56/6/3),占39.2%;混合成分结石253例,占60.8%,其中以草酸钙和碳酸磷灰石的混合结石为主(188/253).所有结石标本中草酸钙检出率最高,占80.5%(335/416),其次为碳酸磷灰石(49.3%)及无水尿酸(17.3%);膀胱结石成分以一水草酸钙或无水尿酸为主.结论 东莞为全国泌尿系结石最高发地区,其结石成分以草酸钙和碳酸磷灰石为主,单一成分结石亦占相当比例.尿路结石成分分析对了解结石成因可提供重要的线索,对临床制定个性化治疗方案、预防结石形成及复发具有重要意义.     

The impact of contemporary bladder management techniques on struvite calculi associated with spinal cord injury.

OBJECTIVE: To evaluate the incidence, risk factors and complications of upper tract struvite calculi, often associated with spinal cord injury (SCI), as such patients have a high incidence of urinary infection complicating their neurogenic voiding dysfunction, by reviewing a large population of patients with SCI in whom modern techniques of bladder management were used. PATIENTS AND METHODS: Between 1982 and 1996, 1669 patients with SCI were admitted to our institution; 1359 of these patients sustained their injuries during the study period. During this time, their bladder management was based on urodynamic and imaging criteria, using techniques such as early intermittent catheterization, sphincterotomy and bladder augmentation where possible to create a catheter-free, low-pressure reservoir. All instances of upper tract struvite calculi in this population were documented. Risk factors for stone development, presentation and complications, management and recurrence rates were assessed. RESULTS: Over the 15 years, 58 patients (3.5% of the SCI population) were treated for a total of 144 episodes of struvite calculi. The incidence of stones in those injured since 1982 was 1. 5%; 67% of these patients had complete spinal cord lesions, 54% had lesions of the cervical cord and 53% developed their first stone >10 years after injury. Only 22% presented within 2 years of injury. The group of patients developing stones had a significantly higher incidence of indwelling catheters (49%), bladder stones (52%) and vesico-ureteric reflux (28%) than those who were stone-free. The development of recurrent urinary tract infections was the most common mode of presentation. The stone-free rate after treatment was 87%. Normal renal function was preserved in 72% of patients. CONCLUSIONS: In a large population of patients with SCI managed using contemporary bladder techniques the incidence of upper tract calculi was 3.5%; 30% of these stones were complete or partial staghorns. Those patients with complete cord lesions, permanent indwelling catheters and vesico-ureteric reflux were at the highest risk. Stone clearance was 87% and recurrent stones occurred in 69% of patients. Struvite renal calculi continue to be a significant problem in the spinal cord injury population.     

经尿道输尿管镜下第三代碎石清石系统治疗婴儿膀胱结石及尿道结石合并急性尿潴留

目的 评价经尿道输尿管镜下第三代碎石清石系统(EMS)治疗婴儿膀胱结石及尿道结石合并急性尿潴留的疗效. 方法应用输尿管镜下EMS治疗三聚氰胺所致膀胱结石及尿道结石合并急性尿潴留患儿10例.男9例,女1例.平均年龄9个月.膀胱结石2例,尿道结石8例,结石直径0.5～1.1 cm,平均0.8 cm.全麻下行经尿道输尿管镜下碎石清石术,采用Wolf 8.0～9.8 F输尿管镜,在电视监视下,从输尿管镜操作通道伸入EMS超声碎石探针将膀胱结石及尿道结石完全粉碎吸出,术中膀胱内保持50～100 ml液体,灌注泵压力为160～210 kPa(1 kPa=10.20 cm H2O),平均180 kPa,超声碎石能量40%～60%,占空比30 0A～70%,平均60%.术后留置8 F双腔气囊导尿管. 结果 10例平均手术时间25 min,均将尿道结石冲入膀胱,在输尿管镜下一次性清除结石,麻醉清醒后拔除导尿管,均能立即顺利排尿.3 d后复查B超.膀胱、尿道内均无残留结石. 结论 对婴儿膀胱结石及尿道结石合并急性尿潴留患儿,应用输尿管镜下EMS清除结石,可以立即解除下尿路梗阻,恢复正常排尿,具有安全、高效、损伤小的优点,可作为膀胱结石及尿道结石合并急性尿潴留患儿手术解除下尿路梗阻的首选方法.     

微创经皮肾穿刺取石治疗小儿上尿路结石

目的探讨微创经皮肾穿刺取石术（minimally invasive percutaneous nephrolithotomy,MPCNL）治疗小儿上尿路结石的效果。方法回顾分析35例MPCNL治疗小儿上尿路结石的临床资料,男29例,女6例,平均年龄8.5岁（4～13岁）。输尿管上段结石7例,肾结石28例,均为一侧上尿路结石。伴肾盂输尿管连接部（ureteropelvic junction obstruction,UPJ）梗阻2例。结果MPCNL治疗成功31例,成功率88.6%（31/35）,其中一期结石完全清除率87.1%（27/31）,二期结石完全清除率75%（3/4）。2例结石位于UPJ致结石下方狭窄,2例皮肾穿刺失败,改开放手术。结论MPCNL是治疗小儿肾结石和输尿管上段结石安全、有效的方法。     

Urolithiasis in Tunisian children: a study of 120 cases based on stone composition

The composition of urinary stones in children depends on socioeconomic conditions and hygiene, geographical area, and dietary habits. We analyzed urinary stones from 120 consecutive Tunisian children (81 males, 39 females) aged 5 months to 15 years. The stone was located in the upper urinary tract in 91 cases (76%). Stone analysis included both a morphological examination and an infrared analysis of the nucleus and the inner and peripheral layers. The main components of bladder calculi were whewellite (69%) and struvite (22%), whereas the main component of upper urinary tract calculi was whewellite (67%). The nucleus of bladder stones was composed of ammonium urate (45%), struvite (28%), cystine (10%), and carbapatite (7%). The nucleus of kidney and ureteral calculi was mainly composed of ammonium urate (38%), whewellite (24%), carbapatite (13%), or struvite (11%). Based on stone composition, urinary tract infection was involved in the nucleation or growth of a third of calculi. Endemic urolithiasis involving simultaneous nutritional, metabolic, and infectious factors, and defined by its nucleus composed of ammonium urate without struvite, represented 40% of cases. Exclusive metabolic factors – including genetic diseases such as primary hyperoxaluria, cystinuria, and hypercalciuria – were responsible for less than 25% of cases. Received: 6 March 1998 / Revised: 22 March 1999 / Accepted: 22 March 1999     

Urethral calculi managed with transurethral Holmium laser ablation

In situ Holmium laser lithotripsy is a safe, effective procedure for the treatment of impacted urethral stones. This procedure can be performed transurethrally as an outpatient with minimal tissue trauma and render patients stone free. The authors utilized this procedure in 2 patients whose anatomy did not allow the calculi to be manipulated into the urinary bladder in a retrograde manner. Because of its successful use elsewhere in the urinary tract, we believe that Holmium laser lithotripsy may be the treatment of choice for impacted urethral stones.     

延安地区泌尿系结石成分分析的研究

目的利用红外光谱法测定延安大学附属医院泌尿外科手术获得的泌尿系结石成分,探讨延安地区泌尿系结石成分与年龄、性别等关系,比较上、下尿路结石成分特点,分析延安地区泌尿系结石发生的流行病学情况,为临床制定有效的个体化治疗及预防措施提供参考依据。方法收集2013年1月至2017年1月在延安大学附属医院泌尿外科治疗1984例尿路结石患者的年龄、性别、结石部位等临床资料,对比分析延安地区泌尿系结石在不同年龄、不同性别、不同解剖部位的分布特点。结果在1984例泌尿系结石的患者中,按每10岁年龄大小分组排序,统计各年龄阶段泌尿系结石发病情况,男性患者有1346例,女性患者有638例,男性年龄(50.23±14.48)岁,女性年龄(47.87±14.51)岁,男、女患者比例约2.11∶1。在66~75岁年龄段,尿路结石发病率性别差异具有统计学意义(P<0.05)。结石成分以混合性结石为主,以混合性结石为主,共1582例,占79.76%。其中1665例(83.92%)为上尿路结石,上、下尿路结石的比例为5.22∶1,其余为肾结石合并膀胱结石。上尿路结石中男性1062例,女性603例,男女比例为1.76∶1;下尿路结石中男性284例,女性35例,男女比例为8.11∶1。青壮年(年龄≤45岁)泌尿系结石患者草酸钙为主结石、感染性结石多见;中老年(年龄>45岁)泌尿系结石者草酸钙为主结石、尿酸类结石多见。感染性结石患者性别差异具有统计学意义(P<0.05)。结论在延安地区男性较女性更容易患泌尿系结石。同时,不同年龄段结石构成成分具有差异。对于年龄≤45岁患者,主要以草酸钙为主结石、感染性结石多见,这与结石整体发病率基本一致;而对于年龄>45岁患者,主要以草酸钙为主结石、尿酸性结石多见。表明对于不同年龄段的结石患者,可以根据上述结果在结石的预防和治疗上综合考量,给予明确而更加合理的治疗。     

Management of impacted urethral stones in children

Objective: To find out the clinical presentation, site of impaction, management and outcome of children presenting with urinary retention due to urethral stone. Study Design: Case series. Place and Duration of Study: Surgical Unit B of National Institute of Child Health (NICH), Karachi, from April 2009 to January 2010. Methodology: All the patients under the age of 12 years, who presented with urinary retention due to impacted urethral stones were included. Urinary retention due to other causes like trauma, stricture, pelvic masses etc. were excluded. Diagnosis was made on clinical examination (palpable stone in penile urethra) and with the help of radiology. Surgical procedure was tailored according to the site of impaction in urethra. All stones were sent for chemical analysis and patients were followed in Nephrology OPD (stone clinic) for further work-up. Results: There were a total of 19 patients with mean age of 3.94 ± 2.27 years. All were males. Twelve patients (63.1%) had stones impacted in anterior urethra while 7 (36.9%) were found in posterior urethra. Stones in penile urethra were removed in emergency either by meatotomy (when impacted at urethral meatus, n = 3) or following initial supra-pubic decompression of urinary bladder (using wide bore cannula) by urethrolithotomy (n = 6). Stones in bulbous (n = 3) and posterior urethral (n = 7) locations were pushed back into bladder and later removed on elective list by supra-pubic vesicolithotomy. No patient had proximal urinary tract calculi on further work-up. All patients remained well except one who developed retention of urine after a week of discharge. He had urinary tract infection and was treated with antibiotics. All the stones were of calcium oxalate type. Conclusion: Urethral stones must be kept in differential diagnosis in a child who presents with acute urinary retention. Clinical examination can identify causes in significant number of cases. Simple procedures like meatotomy, supra-pubic bladder decompression and urethrolithotomy can relieve the misery in these children.     

Bacteriology of upper urinary tract stones

Extensive cultures of stones and urine were performed in 215 patients who underwent an operation for upper urinary tract calculi. Microorganisms could be cultured from the stone in 1 of every 3 patients. Despite the extended culture technique urease-producing microorganisms could be cultured from the stone in only 48% of the patients with calculi that contained magnesium ammonium phosphate. This finding suggests that an infection with urease-producing microorganisms is not obligatory for the formation of this type of stone. Of the patients with calcium oxalate phosphate stones 32% had positive stone cultures, which distinguished them from patients with pure calcium oxalate stones, only 8% of whom had a positive stone culture (p less than 0.001).     

Clinical observation of urolithiasis in Mie University Hospital

The urinary tract calculus patients seen at our Department between January, 1974 and December, 1983 were reviewed to determine the trend of urolithiasis. The urinary tract calculus patients accounted for 10.1% of all the outpatients. Recurrent calculus diseases were seen in 16.9% of male patients and in 12.1% of female patients. The frequency of recurrence was very high in the patients in their forties. Upper urinary tract calculi were seen most frequently in the patients in their forties. We could expect spontaneous passage of stone for at least 6 months in the case of a middle-sized stone (less than 6 X 10 mm). The percentage of calcium oxalate-containing stone was 73.2% in male patients and the percentage of phosphate-containing stones was 81.6% in female patients. Hypercalciuric patients were seen in 34.0% of the calculus inpatients. Urinary bacterial culture revealed positive in 33.0% of the calculus inpatients.     

The aetiological and clinical pattern of childhood urolithiasis in Saudi Arabia

The clinical and aetiological pattern in 85 stone-forming children presenting to an integrated nephrourological service in Riyadh is reviewed. All patients were below the age of 15 years, the male to female ratio being 2∶1. Only 2 children presented with bladder calculi. The remaining all had upper tract stone and, in 12 cases, these were bilateral. Of 34 calculi recovered for analysis, one-third was predominantly calcium oxalate and a further third was composed of uric acid or urate. Four patients had cystine stones and the remaining 7 presented mixed calcium stones, 6 (17.6%) being struvite and infection-related. Of the 85 patients 55 were treated successfully with extracorporeal shock wave lithotripsy, 16 underwent surgery and 7 had their stones removed by endourological procedures. In the remaining 7 children, stones dissolved or were passed spontaneously during medical therapy. Nine children (10.6%) showed a primary metabolic defect leading to their stone formation, 10 (11.8%) had a predisposing anatomical anomaly and 15 (17.6%) presented with urinary tract infection. Of the remaining 51 patients (60%) with idiopathic disease, 6 showed hypercalciuria on investigation and 2 children may have formed their stones due to prolonged recumbency.     

泌尿系结石成分450例分析

目的分析泌尿系结石患者的发病年龄及性别特点,探讨结石部位与患者年龄及性别的关系,根据结石不同成分采用不同预防措施。方法应用化学分析法对450例尿路结石做成分分析,结合临床资料,对尿路结石患者发病年龄、性别、结石部位及结石成分做对比分析。姑杲男性患者321例,高发年龄21～60岁;女性129例,高发年龄41～60岁;男性发病率是女性的2．49倍。发病部位肾脏结石319例（70．8％）,输尿管结石115例（25．6％）,膀胱结石16例（3．6％）;单一成分结石275例（61％）,其中单纯草酸钙结石260例（57．7％）,两种及以上混合成分结石175例（39．0％）。结论尿路结石的发病率及发病年龄存在着明显的性别差异;尿路结石发病部位主要为上尿路结石;单一成分结石以草酸钙为主,约40％的尿路结石为两种及以上混合成分结石。     

以结石成分分析为基础的个体化指导方案在结石术后患者中的应用价值研究

目的探讨以结石成分分析为基础的个体化指导方案在结石术后患者中的应用价值。方法选取2016年1月至2017年1月在本院收治300例经内镜手术治疗的尿路结石患者为研究对象(观察组),所有患者均采取红外光谱自动分析法对尿结石标本进行化学成分分析,并以结石成分分析为基础给予个体化预防指导方案;另选取同期本院未进行结石成分分析的40例尿路结石患者为对照组,对比两组术后结石复发率。结果尿路结石标本中多为混合成分结石,2种成分混合结石占比38.67%,3种成分混合结石占比34.00%,单一成分结石占比27.33%。单一成分结石、混合成分结石及不同结石发生部位(上、下尿路结石)中,草酸钙结石均占比最高,其次为尿酸结石。术后3个月,两组结石复发率比较差异无统计学意义(P>0.05);术后半年、1年,观察组结石复发率低于对照组,差异有统计学意义(P<0.05)。结论红外光谱可简便、快速获取结石成分信息,结石成分复杂,多为草酸钙类结石与尿酸结石,结石成分分析是提出个体化预防指导方案的基础,可有效降低术后结石复发率。