Multiple giant prostatic urethral stones with an ureteral stone in a young patient

Giant prostatic urethral stones have been reported as a very rare entity, and the etiology of these stones is not clear. We report a case of a 40-year-old man with giant multiple prostatic urethral stones whereby the entire gland was replaced, and a big ureteral stone presented with voiding difficulty and recurrent urinary tract infections. In the literature, to our knowledge, this is the youngest case wherein giant prostatic urethral stones coexisted with a big ureteral stone. Many different-sized stones were observed endoscopically, some protruding into the urethra, and some filling different cavities on the prostate. Following cystoscopy, multiple giant prostatic stones weighing a total of 151 g were removed by the open retropubic route. We treated the big ureteral stone endoscopically.     

The giant calculus within the prostatic urethra

The giant calculus within the prostatic urethra is a rare clinical entity in the young population. Most of the calculi within the urethra migrate from the urinary bladder and obliterate the urethra. These stones are often composed of calcium phosphate or calcium oxalate. The decision of treatment strategy is affected by the size, shape and position of the calculus and by the status of the urethra. If the stone is large and immovable, it may be extracted via the perineal or the suprapubic approach. In most cases, the giant calculi were extracted via the transvesical approach and external urethrotomy. Our case is the biggest prostatic calculus, known in the literature so far, which was treated endoscopically by the combination of laser and the pneumatic lithotriptor.     

Predisposing factors in bladder calculi. Review of 100 cases

One hundred patients, aged twenty to ninety-two years, underwent 111 procedures for removal of bladder calculi. Most patients (88) had some type of bladder outlet obstruction. Two types of stones were identified: those that had apparently formed in the upper tract and been trapped in the bladder (17 cases) and those that appeared to have formed in the bladder in the presence of various types of outlet obstruction. Stone analysis revealed uric acid stones in 50 percent, calcium oxalate stones in 19 percent, and stones of mixed composition in 31 percent. Five patients had metabolic abnormalities predisposing to stone formation; in 2 cases, these abnormalities were discovered during the evaluation for stone disease. Treatment depended on stone characteristics, associated pathology, and the general health of the patient. A review of the literature with regard to the morbidity and mortality of combining treatment of vesical calculi and bladder outlet obstruction secondary to prostatic obstruction is included.     

Open prostatolithotomy for the management of giant prostatic calculi

Giant prostatic calculi are very rare. We present the case of a 45-year-old man with multiple prostatic urethral calculi that replaced the entire gland. He underwent an open "prostatolithotomy," a novel method of stone removal akin to a simple retropubic prostatectomy. Eight stones weighing a total of 59 g were removed from the prostate. For certain patients, adjunctive vesical neck revision and deliberate drainage of the prostatic fossa may be beneficial in addition to stone extraction.     

应用钬激光治疗泌尿外科疾病155例报告

目的：探讨钬激光治疗泌尿系结石、前列腺增生及肿瘤的临床效果。方法：应用钬激光行输尿管镜下碎石29例，膀胱碎石55例，膀胱肿瘤切除45例，前列腺切除16例，腺性膀胱炎8例，尿道狭窄2例。结果：29例输尿管结石中28例碎石成功，55例膀胱结石全部碎石成功；45例膀胱肿瘤均直接汽化；16例前列腺增生中2例行腺体切除，14例直接汽化；8例腺性膀胱亦汽化治愈；2例尿道狭窄病例排尿通畅。无并发症发生。结论：应用钬激光进行输尿管、膀胱碎石，膀胱肿瘤汽化，前列腺腺体切除术或直接汽化等，是安全有效的。     

Transurethral lithotripsy with holmium-YAG laser of a large exogenous prostatic calculus

Prostatic calculi are classified into two types, endogenous and exogenous calculi, based on their origin. Endogenous calculi are commonly observed in elderly men; however, exogenous prostatic calculi are extremely rare. We report here the case of a 51-year-old man who suffered incontinence and pollakiuria with a giant exogenous prostatic calculus almost completely replacing the prostatic tissue. X-rays and computed tomography demonstrated a large calculus of 65 × 58 mm in the small pelvic cavity. The patient underwent a transurethral lithotripsy with a holmium-YAG laser and a total of 85 g of disintegrated stones was retrieved and chemical stone analysis revealed the presence of magnesium ammonium phosphate. The incontinence improved and the voiding volume increased dramatically, and no stone recurrence in the prostatic fossa occurred at the 2 years follow-up. The etiology of this stone formation seemed to be based on some exogenous pathways combined with urinary stasis and chronic urinary infection due to compression fracture of the lumbar vertebra.     

Giant prostatic urethral calculus associated with urethrocutaneous fistula

Urethral stones in men are rare clinical entity and most of them migrate from the urinary bladder. Urethral stones are rarely formed primarily in the urethra and are usually associated with urethral strictures or diverticula. We report a 41-year-old man with giant prostatic urethral stone (5.9x3.2x2.8 cm) associated with a urethrocutaneous fistula. The etiological factors, pathogenesis, clinical presentation, complications and management of giant urethral calculi are reviewed.     

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.     

Transurethral holmium-YAG laser lithotripsy for large symptomatic prostatic calculi: initial experience

Symptomatic prostatic calculi are a rare clinical entity with wide range of management options, however, there is no agreement about the preferred method for treating these symptomatic calculi. In this study we describe our experience of transurethral management of symptomatic prostatic calculi using holmium-YAG laser lithotripsy. Patients with large, symptomatic prostatic stones managed by transurethral lithotripsy using holmium-YAG laser over 3-year duration were included in this retrospective study. Patients were evaluated for any underlying pathological condition and calculus load was determined by preoperative X-ray KUB film/CT scan. Urethrocystoscopy was performed using 30° cystoscope in lithotomy position under spinal anesthesia, followed by transurethral lithotripsy of prostatic calculi using a 550 μm laser fiber. Stone fragments were disintegrated using 100 W laser generators (VersaPulse PowerSuite 100 W, LUMENIS Surgical, CA). Larger stone fragments were retreived using Ellik’s evacuator while smaller fragments got flushed under continuous irrigation. Five patients (median age 42 years) with large symptomatic prostatic calculi were operated using the described technique. Three patients had idiopathic stones while rest two had bulbar urethral stricture and neurogenic bladder, respectively. Median operative time was 62 min. All the patients were stone free at the end of procedure. Median duration of catheterization was 2 days. Significant improvement was observed in symptoms score and peak urinary flow and none of the patient had any complication. Transurethral management using holmium-YAG laser lithotripsy is a safe and highly effective, minimally invasive technique for managing symptomatic prostatic calculi of all sizes with no associated morbidity.     

Risk factors for renal stone formation in patients with spinal cord injury

To determine factors that may influence kidney stone formation in spinal cord injury patients, the medical records of 893 patients who had been followed up by the Milwaukee Veterans Administration Medical Center from 1970 to 1984 were extensively reviewed. Urography showed that 12 patients had kidney stones. Twenty-four non-kidney stone patients with a similar age range, sex and duration of time since injury were selected as controls. Variables, such as level of spinal lesion, completeness of neurological dysfunction, presence of ureteric reflux etc, were compared and analysed statistically. The results showed that there was no difference between patients with and those without renal stone as far as the level of spinal injury and completeness of spinal cord lesion were concerned. There was no relationship between kidney stone formation and methods of urinary drainage or the presence of ureteric reflux. However, patients with good bladder control had no renal calculi. Serum creatinine, phosphorus, uric acid and calcium levels were similar in both groups of patients. There was a relationship between sepsis, positive urine culture and kidney stone formation. The absence of physical activity was not a risk factor for renal calculi and patients on a high fibre diet had the same incidence of stones as those on a regular diet.     

Renal calculi in spinal cord-injured patient: association with reflux, bladder stones, and foley catheter drainage

Renal units associated with reflux in the spinal cord-injured (SCI) patient have a greater incidence of kidney stones developing than in the nonrefluxing units. It is logical to assume that SCI patients with persistent reflux and bladder stones treated with cystolitholapaxy would be at even higher risk for kidney stones developing. Of the 898 SCI patients studied (1,793 renal units), in 14.8 percent kidney stones developed. Kidney stones occurred in 161 of 1,517 (10.6%) of nonrefluxing units. Of the 276 renal units with reflux, in 104 (37.7%) an ipsilateral stone developed. Of the 198 patients in whom a kidney stone formed, 56.6 percent managed their bladder with a Foley catheter whereas only 28 percent of 700 patients in whom a stone did not form used a Foley catheter. On evaluating 261 patients (520 renal units) with bladder stones treated with cystolitholapaxy, 62.5 percent of these patients were managed with a Foley catheter. The association between cystolitholapaxy treatment, reflux, and the formation of kidney stones was (1) in 22 of 111 (19.8%) refluxing units, an ipsilateral stone formed; (2) in 70 of 409 (17.1%) units that were nonrefluxing, stones developed; and (3) overall, in 92 (17.7%) renal units, kidney stone developed. We concluded that kidney stone development is significantly increased in the SCI patient with reflux and/or Foley catheter drainage. From these data cystolitholapaxy treatment in the presence of reflux does not appear to increase the development of kidney stones.     

Urethral calculi.

The diagnosis and management of 34 men and 13 women with urethral calculi are reviewed. A majority of patients presented with dysuria, weak stream and perineal pain. Diagnosis was made radiographically in only 42 per cent but was confirmed in all patients who underwent cystourethroscopy. All patients had lower urinary tract lesions or previous prostatic operations and 47 per cent were infected. Migrant urethral calculi were encountered 10 times more often than were native stones and a metabolic cause was found in 10 of 18 patients studied. In men penile urethral calculi were removed transurethrally and all bulbous and most posterior urethral stones were guided endoscopically into the bladder. Most of these stones were irrigated out or removed by transurethral litholapaxy; the remaining few, together with vesical calculi, required cystolithotomy. In all 13 women calculi were removed at the time of urethral diverticulectomy. A majority of 17 men (76.5 per cent) and the 4 women who were followed for an average of 5.3 years have remained free of trouble.     

A study on bacteria within stones in urolithiasis

The bacteria in 37 stones obtained from 37 patients with urinary stone diseases, that is, 11 renal stones (containing 2 staghorn calculi), 21 ureteral stones, 4 bladder stones and 1 urethral stone, were studied, according to the Nemoy & Stamey's method. The stones were collected by partial nephrectomy (1 case), nephrolithotomy (1 case), pyelolithotomy (1 case), percutaneous nephrolithotripsy (PNL) (6 cases), 12 ureterolithotomies, transurethral ureterolithotripsy (2 cases), cystolithotripsies (4 cases) and spontaneous deliveries (10 cases). According to a stone analysis by infrared spectrophotometer revealed 30 were noninfection stones (81.1%) and 7 infection stones (18.9%). Of these 37 stones, 5 stones (13.5% of 11 stones) had bacteria within them. These stones consisted of 4 infection stones (57.1% of all infection stones) and 1 noninfection stone (3.3% of all noninfection stones). Out of 4 patients having bacteria within their stones, urine culture of whom were carried out before stones were collected, only one patient (25%) had the same species of bacterium (E. coli) both within the stone and in urine. The E. coli within the stone and that in urine, however, showed quite different reactions to some antibiotics. The fact that all organisms within stones cannot be detected by urine culture before collecting stones of the patients in our present study, suggests that patients undergoing endourological surgery, such as extracorporeal shock wave lithotripsy and PNL, may have a risk of complications, such as severe urinary tract infection and urosepsis, if the possibility of the presence of organisms within stones is not taken into consideration.     

Bladder calculi in children who perform clean intermittent catheterization

OBJECTIVE: To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients. PATIENTS AND METHODS: The records of 403 patients who were using a regimen of CIC between January 1981 and March 1998 were reviewed to identify those forming bladder calculi; stones were diagnosed in 28 patients. The patients were categorized as: group 1, patients with no bladder augmentation who catheterized urethrally (227, group 1a) or via a Mitrofanoff conduit (18, group 1b); group 2, patients with augmented bladders who catheterized urethrally (100, group 2a) or via a Mitrofanoff conduit (58, group 2b). The incidence of bladder calculi in each group was determined and compared statistically where applicable. The success of the treatment options for stone management was reviewed. RESULTS: Bladder calculi developed in 5% of patients in group 1a, 8% in group 2a, 11% in group 1b, and 10% in group 2b; the incidence of calculi was not significantly different among the groups. Of these patients, 18 (64%) were asymptomatic at the time of diagnosis and significant bacteriuria was found in 23 (88%). Difficulty in catheterizing either the Mitrofanoff conduit or the native urethra was reported in 14 (50%) of these patients. Calculi were more often solitary (71%) and typically composed of struvite or apatite. Calculi were managed by open cystolithotomy in 15 patients (54%) and endoscopically in 13 (46%). Stones recurred in nine patients (32%) after treatment, comprising four of six patients treated endoscopically with electrohydraulic lithotripsy and in five of 15 after open cystolithotomy. The mean interval to recurrence was 22.8 months. CONCLUSION: These results suggest that patients on a regimen of CIC are at risk of developing bladder calculi but the incidence of calculi is not influenced by bladder augmentation. The presence of a Mitrofanoff conduit was associated with a slightly increased incidence of calculus formation. Open cystolithotomy was associated with a lower stone recurrence rate but there were too few patients to draw definitive conclusions.     

Extracorporeal shock wave lithotripsy monotherapy for bladder stones with the second generation lithotriptors

Between June 1987 and April 1989 a total of 4,500 extracorporeal shock wave lithotripsy treatments was performed in our department with the Siemens Lithostar lithotriptor. Renal (pelvic, caliceal and staghorn stones), ureteral and even bladder calculi can be treated by means of a system of fluoroscopic detection and electromagnetic shock wave generation. The treatments are performed without the use of anesthesia and on an outpatient basis. Hospitalization is indicated whenever underlying infectious stone disorders are suspected (associated urinary tract infection or infected calculi). Initial experience in the first 10 patients with bladder stones treated by electromagnetic extracorporeal shock wave lithotripsy monotherapy is reported. All stones disintegrated after 1 treatment, except in a patient with 2 bladder stones who required 2 sessions. Mean treatment duration was 53 minutes. Mean number of shock waves was 3,600 and electrical discharge averaged 20.2 kv. per shock wave. Minute fragmentation was obtained and uncomplicated evacuation occurred without the need for adjuvant procedures, even in the presence of prostatic hypertrophy (2 patients) or neurogenic bladder dysfunction (3). No morbidity during or after treatment was encountered in these 10 patients.     

电切镜下同期治疗BPH并发膀胱结石疗效观察

目的：探讨BPH并发膀胱结石更为有效的治疗方法.方法：采用TURP联合电切镜下钬激光碎石术同期治疗BPH并膀胱结石患者23例,即通过电切镜电切攀通道置人经过裁剪的输尿管导管及钬激光光导光纤行膀胱结石钬激光碎石,冉行TURP.结果：23例均一次性手术成功,取石率100%,手术时间30～80 min,平均56 min,其中碎石时间3～20 min,平均9 min 术中无膀胱穿孔、膀胱出血、TURS 术后留置导尿3～5天,术后住院时间4～9天,平均5.6天 术后随访3～18个月.无结石复发,无尿道狭窄.结论：采用TURP加电切镜下钬激光碎石术治疗BPH并膀胱结石具有手术时间短、创伤小及安全等优势,能够治疗膀胱较大结石、多发结石,对治疗伴有膀胱出血患者更显优势.     

The vesical calculus

Bladder calculi account for 5% of urinary calculi and usually occur because of foreign bodies, obstruction, or infection. Males with prostate disease or previous prostate surgery and women who undergo anti-incontinence surgery are at higher risk for developing bladder calculi. Patients with SCI with indwelling Foley catheters are at high risk for developing stones. There appears to be a significant association between bladder calculi and the formation of malignant bladder tumors in these patients. Transplant recipients are not at increased risk for developing vesical calculi in the absence of intravesical suture fragments and other foreign bodies. Patients who undergo bladder-augmentation procedures using a vascularized gastric patch appear to be protected from vesicolithiasis, perhaps by the acidic environment. Ileum and colon tissues, however, are colonized by urease-producing organisms, producing an alkaline pH that promotes stone formation. Children remain at high risk for bladder-stone development in endemic areas. Diet, voiding dysfunction, and uncorrected anatomic abnormalities, such as posterior urethral valves and vesicoureteral reflux, predispose them to bladder-calculus formation. Finally, there are a number of techniques and modalities available to remove bladder stones. Relieving obstruction, eliminating infection, meticulous surgical technique, and accurate diagnosis are essential in their treatment.     

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.     

Prolapsed benign polyp of ureter associated with giant ureteral calculus

We report a case of a benign fibroepithelial polyp of the lowermost ureter, which prolapsed into the bladder and was associated with a huge, impacted ureteral stone. The polyp was considered to have resulted from chronic irritation of the ureteral mucosa caused by the stone. Review of the literature showed that six out of 74 reported cases had concomitant stones but the polyp was apparently caused by the calculi in only one case.     

经尿道前列腺电切联合小切口膀胱取石术治疗BPH并膀胱结石

目的：探讨BPH合并膀胱结石进行同期治疗更为有效的方法。方法：采用TURP联合经皮小切口卵圆钳膀胱取石术治疗BPH合并膀胱结石患者25例。即在电切镜监视引导下,将卵圆钳经耻骨上小切口插入膀胱腔内取石,再行TURP。结果：25例均一次手术成功,取石率100％,手术时间35～90min,平均65min,其中取石时间3～15min,平均7min;术后留置膀胱造瘘管1～3天,留置尿管3～5天;术后住院时间5～8天,平均6．2天。术后随访3～26个月,无结石复发,Qmax〉15ml／s。结论：TURP联合小切口卵圆钳膀胱取石术治疗BPH合并膀胱结石,具有取石时间短、创伤小、操作简单及安全有效等优点,尤其适合膀胱较大结石或多发结石患者。