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Urinary Bladder Stone: Ways of Management at Prince

Hussein Urology Center
Firas Al-Hammouri MD*, Adnan Abu-Qamar MD*, Mazen Al-Quran MD*, Saed Al-Ajloni MD*,
Abdullah Al-Abadi SN**

ABSTRACT
Objective: To describe our experience in the management of primary and secondary urinary bladder stone,
we use different options of surgical intervention for clearance of the stones.

Methods: Between January 2005 and May 2009, we treated 242 patients with urinary bladder stones in our
center, 208 males and 34 females. Transurethral cystolitholapaxy was the first option for single stone less than
4cm and multiple stones each less than 2cm. Open cystolithotomy was performed in presence of hard stone
more than 4cm and in presence of concomitant huge obstructing prostate > 100gm or bladder surgery.
Percutaneous suprapubic cystolithotripsy was performed among pediatric age group and patients with
permenant cystostomy. Extracorporeal shockwave lithotripsy was a reserved for high risk patients.
Results: Out of 242 patients, 190 patients underwent transurethral cystolitholapaxy; Transurethral Resection
of Prostate and optical urethrotomy were performed among 105 patients (55.3%). Presence of foreign bodies
as in retained ureteral stents, eroded tension free vaginal tape mesh, suture materials were main causes of the
rest of the patients. The duration of urethral catheterization was 24-48 hours, complete clearance was achieved
in 185 patients (97.4%), complications were detected in 24 patients (12.6%), hematurea and transient pyrexia
were the main complications. Cystolithotomy was performed in 35 patients, concomitant open prostatectomy
in 15 cases, bladder diverticulectomy in two cases and 18 cases excluded from cystolitholapaxy criteria. The
mean duration of urethral catheterization was 9 days (average 5-14 days) and wound infection was the
commonest complication. Percutaneous suprapubic cystolithotripsy was done in 11 cases, failure occurred in
one patient (9%), the average duration of catheterization was 3 days and transient pyrexia was detected in two
(18%). Extracorporeal shockwave lithotripsy was a first option in 6 high risk patients with stone clearance rate
83% and significant hematurea occurred in one patient.

Conclusion: Transurethral cystolitholapaxy offers the first choice of management for single urinary bladder
stones less than 4cm, and multiple small bladder stones. Percutaneous suprapubic cystolithotripsy is a safe
procedure and it is an option of management in pediatric age group and in patients with permenant cystostomy.
Extracorporeal shockwave lithotripsy can be used in high risk patients. In concomitant prostate or bladder
surgery and in hard stones or stones that are more than 4cm, Open surgery is the first treatment of choice.
Key words: Cystolitholapaxy, Percutaneous cystolithotripsy, Vesical lithiasis.
JRMS June 2011; 18(2): 61-66

Introduction
th

Until 20 century, bladder stones were one of the

most prevalent disorders among the poor class and
the incidence was especially high in childhood and
adolescent.(1) The decrease in incidence of bladder

From the Departments of:
*Urology, Prince Hussein Bin Abdullah II Center for Urology and Organ Transplants, King Hussein Medical Center, (KHMC), Amman-Jordan
**Nursing, (KHMC)
Correspondence should be addressed to Dr. F. Al-Hammouri, (KHMC), E-mail: firas_hammouri @yahoo.com
Manuscript received January 6, 2010. Accepted April 15, 2010

JOURNAL OF THE ROYAL MEDICAL SERVICES
Vol. 18
No. 2 June
2011

61

Methods Between January 2005 and May 2009. The size and the number of the stones were determined in addition to the etiology of the secondary stones. although multiple stones are found in 25% of cases. advanced 1cm beyond the lens and 1cm away from the urinary bladder mucosa with partially filled bladder to prevent injury. Percutaneous suprapubic cystolithotripsy was planned pre-operatively for pediatric age group and patients with permenant cystostomy. 18 No. small capacity urinary bladder. associated open urinary bladder or prostate surgery. small capacity urinary bladder. we use different options of surgical intervention for clearance of the stones. fragmentation was initiated under direct vision into small fragments followed by stone crushing forceps in some cases. history of previous lower urinary tract surgery. The first option was to disintegrate the urinary bladder stone through transurethral route using lithoclast and stone crushing forceps (Cystolitholapaxy). The choice of intervention depend on size and the number of stones. The procedure was done under regional or general anesthesia in the traditional way of surgery. Presence of urinary tract infection was treated first according to culture sensitivity and the patients were listed on elective bases. Cystolithotomy was performed in cases with associated open prostatectomy or urinary bladder surgery. open cystolithotomy and ESWL were the options of management. it is classified as migrated from upper urinary tract. Exclusion criteria for transurethral lithotripsy were: stones more than 4cm 62 or multiple stones more than 2cm each. endourology procedures. percutaneous routes. stone disintegration was done through the Amplatz sheath by a 26F nephroscope using pneumatic electrohydrolic lithoclast. urine analysis and culture. ESWL of urinary bladder stone was the first choice in case of single stone less than 2 cm without evidence of distal outflow obstruction. patients with lower limb deformities that affect lithotomy position. Urinary Tract Ultrasound. 242 patients with urinary bladder stones attended our Prince Hussein Urology Center. The procedure was done under general anesthesia in supine position. The probe was inserted through the working channel. Options of management were explained to the patient and the possibility of intra-operative conversion to other modality of management from endourology procedure to open surgery was also explained. physical examination. pediatric age group and patients with small caliber urethra. All the patients were kept on oral antibiotics (quinolones) for five days. Suprapubic catheter was left for 24 hours and urethral catheter was kept for 72 hours. 2 June 2011 . KUB. and at our study it was the first option of management in high risk patient whose medical illnesses did not permit surgery. In our study we describe our experience in the management of primary and secondary urinary bladder stone. or secondary calculi. Urological assessment was performed including proper medical and urological history. the urethral catheter was lifted for (5-14) days. 208 males (86%) and 34 females (14%) with an average age 42 years (range 7-82). manual Ellik evacuator was used to retrieve the fragments and a Foley catheter was left for 24-48 hours. Endourological treatment via transurethral. primary idiopathic. age of the patient.(3) Bladder calculi account for 5% of urinary calculi. then the JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. a 25F cystoscope or 26F nephroscope were used and stone disintegration using pneumatic electrohydrolic (EMS) lithoclast. associated other planned urological procedure and the caliber of the urethra.(2) A solitary bladder calculus is usual. nonenhanced contrast CT scan and specific investigations in a case of secondary urinary bladder stone.(4) Bladder stones are managed by Extracorporeal Shockwave Lithotripsy (ESWL).calculi is attributed mainly to dietary and nutritional progress especially in children. after filling of the urinary bladder by normal saline suprapubic puncture was performed and dilatation of the tract was done using fascial and Amplatz dilators over a guidewire with the help of fluoroscopy the same way that is used for percutaneous nephrolithotomy. Indwelling urethral catheter inserted and 200ml normal saline installed inside the bladder to help localization of the stone in prone position. The procedure was performed in dorsal lithotomy position using regional or general anesthesia. renal function test. in addition to the experience in our unit had already determined that open surgery was the choice for stone size more than 4cm or multiple stones each more than 2cm . or open surgery. ESWL was done as a day case procedure.

7%) - was noticed in 56 patients. and the demographic data of the patients are presented in Table II.0-4. 18 No.2cm (1.8cm) 1. Demographic data of the study group Transurethral Cystolithotomy Cystolitholapaxy No. 190 patients underwent transurethral cystolitholapaxy.9%) Percutaneous suprapubic cystolithotripsy 2 patients (18%) - ESWL 6 58-80 years 3 3 ESWL 1 patient (16.4%) confirmed intra-operatively using the cystoscope and follow up KUB with Ultrasound 4-6 weeks later. Two patients converted to open surgery one of them due to hard big stone and the other due to intra-peritoneal bladder perforation.7-2.1cm (1. Results The number and the size of stones in the four procedures are shown in Table I.9cm (1. 3 patients had residual stones after poor vision due to bleeding from prostate and all of them had completion cystolitholapaxy one week later with complete clearance.6-2.8-3. one patient had a multiple small stones on eroded tension free vaginal tape (TVT) mesh through the wall of urinary bladder. a urethral catheter was removed after finishing the procedure. Stone migrated from the upper urinary tract JOURNAL OF THE ROYAL MEDICAL SERVICES Vol.3%) 2 patients (1%) 2 patients (1%) - catheter was opened for free drainage during the procedure.4cm) 2.3%). the mean operative time for cystolitholapaxy after exclusion of the time of associated endourology intervention was 28 minutes (range 12-70 minutes).9cm (0. Complete clearance was achieved in 185 patients (97.9%) 1 patient (2.7cm (2. 2 June 2011 Size of stones average (range) 2. two patients had multiple small stones on nonabsorbable thread that were cut through the urinary bladder after two years of previous laparatomy. another 20 patients had retained ureteral stent (DJC) more than 6 months duration with multiple stones on the vesical end of the stent.6%) 1 patient (2.8cm) 2. 5 patients had stones at site of ureterovesical anastomosis over a suture material in patients with kidney transplant. Complications of the procedures performed Transurethral Cystolitholapaxy Transient pyrexia Hematuria Urine retention Urinary bladder perforation Wound infection Vesicocutaneous fistula Cerebrovascular accident 8 patients (4.2%) 12 patients (6.8-2. of stones Single Multiple (2-12) Single Multiple (2-8) Single Multiple (2-4) Single Table II.0cm) 3. Number and size of stones in each procedure Procedure Transurethral Cystolitholapaxy Cystolithotomy Percutaneous suprapubic cystolithotripsy ESWL No.2cm) 3.9cm (1.7cm (0. 3000 shock wave were given and stonefragmentation was detected fluoroscopically. of patients 190 35 Age 16-82 years 30-80 years Male 164 34 Female 26 1 Table III. From these patients 105 patients had distal outflow obstruction (55. 62 patients underwent simultaneous Transurethral Resection of Prostate (TURP) and optical urethrotomy was done for 43 patients. and one patient had a stone at the site of urethrovesical anastomosis noticed 8 months after retropubic radical prostatectomy. A follow up Kidney-Ureter-Bladder plain film (KUB) and urinary bladder Ultrasound were performed in all patients 4-6 weeks later to look for any residual stones.Table I.1cm) Percutaneous suprapubic cystolithotripsy 11 7-42 years 7 4 Cystolithotomy 3 patients (8. From the 242 patients. The duration of catheterization was 24-48 hours 63 .3cm) 1.7-2.5-5.

0%) that were managed conservatively.(6) Transurethral cystolitholapaxy is JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. Two patients developed pyrexia in the first post-operative day. the duration of urethral catheterization in the pediatric cases was 3 days. The mean (range) follow up was 19. and complete fragmentation of the stones was detected in four patients. suprapubic endoscopic route.5) Infravesical obstruction and prostate enlargement is responsible in two thirds of patients.0%) had urinary bladder perforation noticed during the procedure. In our center we do not use medical management because it is ineffective in most of the case. Encrusted ureteral stents are associated with stones on the intravesical part of the stent. and two patients (1.(9) we report a single case two years after TVT surgery that was done in our hospital.6) and most of our cases due to outflow obstruction or presence of foreign bodies. and one patient developed ischemic cerebro-vascular accident on the 4th post-operative day treated by anticoagulant and developed significant neurological insult are demonstrated in (Table III) Percutaneous suprapubic cystolithotripsy was performed in 11 patients. Table (III).2%) that was treated by hydration and intravenous antibiotics.(7) Five patients of our study stones were due to suture materials. ESWL was done for 6 patients with single stone. including the material of the stent. 2 June 2011 . average operative time was 44 minutes (range 30-60 minutes). The mean operative time was 65minutes (range 40-125 minutes) including the time of associated intervention. and two patients with neurogenic urinary bladder and permenant cystostomy.9%) except one case that open cystolithotomy was performed to clear the stones. 8 patients developed post-operative pyrexia (4. another session of ESWL was done for the two patients. the risk of incrustation is increased in history of urolithiasis and longer indwelling time. Bladder stones are managed by transurethral route. open surgery or ESWL.6%) that were treated by local care.(4. stone recurrence was detected in two patients with bilateral renal stones (stone migration). Complications happened in 5 patients (14. the catheter was removed after one week. two patients developed urine retention (1. number and the size of the stones.(4.5 (3-46) months in all patients. One patient developed significant hematurea that required urethral catheterization and hospitalization. one patient developed vesicocutaneous fistula that was treated by prolonged catheterization. infection or foreign body.except in the three patients with completion cystolitholapaxy. 18 cases with stones excluded from cystolitholapaxy criteria.(8) The vesical stone formation due to intravesical mesh erosion of tension free vaginal tape (TVT) is rare. complete clearance was achieved in 10 cases (90. urine composition and duration of use. and 2 cases with excision of bladder diverticula.3%). Cystolithotomy was performed in 35 cases. 12 patients (6. 15 cases associated with open prostatectomy.3%) developed hematuria that warrant irrigation and prolonged catheterization. one of them was intraperitoneal that was treated by laparatomy and the other was extra-peritoneal that was treated conservatively. Transplanted recipients are not at increase risk for developing vesical calculi in the absence of intravesical suture fragments and other foreign bodies. so stone free rate 64 was achieved in (83. a variety of factors contribute to the rate at which encrustation occur. Discussion Bladder calculi are usually occurring because of bladder outlet obstruction.6%). Complications were seen in 24 patients (12. with eroded part of the mesh through the bladder wall and stone formed over it. The only potentially effective medical treatment is alkalization of urine for dissolution of uric acid stones that may lead to calcium phosphate deposits on the surface of the stone making the treatment ineffective. The duration of the procedure was 40 minutes. in three patients from the retained ureteral stent group. 5 of them of pediatric age group with an average age of 11 years (range 7-13 years) and 6 patient with permenant cystostomy for neurogenic urinary bladder due to paraplegia with average age of 34 years (range 19-42 years). Mustafa et al reported a single case with stone over an eroded TVT mesh .2%). The average duration of catheterization was 9 days (range 5-14 days) depend on the type of associated surgical intervention. neurogenic voiding dysfunction. 18 No. Male with prostate disease and women who underwent antiincontinence surgery are at higher risk for developing vesical lithiasis. The choice of treatment depends on the available system. 3 patients had wound infection (8. surgical expertise. one of them showed good response but the other patient had a hard stone that was resistant to this procedure.

27(2): 333-46. Prevalence and type of renal stone in Multan region. 2003. Vandebrink BA. ultrasonic. but we achieved an 83% stone free rate. 10. Urinary lithiasis. Oakley N. 2008. References 1. Percutaneous suprapubic cystolithotripsy is a safe procedure and it is an option of management in pediatric age group or patients with permenant cystostomy. Extracorporeal shock wave lithotripsy in combination with transurethral surgery for management of large calculi and moderate outlet obstruction. Intravesical foreign body-induced bladder calculiresulting in obstructive renal failure. as it appears to be favorable for both the surgeon and the patient. 39(2): 453-5. Hastie K. 22(5): 905-12. Open surgery is used for concomitant prostate or bladder surgery and in hard stones more than 4cm.3229-35. et al. concomitant open prostatectomy or diverticulectomy. 2006 Jun. Hemendra N.probably the most common way to manage cystolithiasis in adult. Urol Clin North Am 2000 May.(12. 65 . this approach permits the use of diverse tools for stone fragmentation including a mechanical stone crusher and instruments providing electrohydraulic. however. failed endoscopic surgery and remains the main treatment of bladder stones in children. Vaughen ED. 18 No.(19) ESWL are the first line of management for the majority of urinary calculi.(6) The complication rate for cystolitholapaxy alone was 13%. Ost MC. Can Urol Assoc J. Transurethral cystolitholapaxy offers the first choice of management for single urinary bladder stones less than 4cm. Fadi K. 2002. 93% of these patients were completely stone-free.(10.11) Transurethral cystolitholapaxy combined with TURP for treating BPH and bladder stones are common for many urologists. transurethral treatment can be time consuming and excessive manipulation has the potential to cause urethral injury. requiring only one anesthesia and short hospital stay. 34(3): 163-7. Aaron TD.(20) Millan-Rodriguez et al in their study they prospectively treated 50 patients with urinary bladder stones of whom 45 patients with stones less than 4cm were treated by ESWL. Luke TL. ESWL is preferably performed in children and in patient with small contracted urinary bladder in whom endourological procedures may be difficult and hazardous. Wadie BS. Open surgery is undoubtedly still the most appropriate treatment for large. Shah. Schwartz BF. J Endourol 2008.6%. Wein AJ’(ed) Campbell’s Urology 8th edition Saunders London. Qureshi K.(4. Menon M. Zafar MH. at our study the complication rate was 12.8 days in open surgery. 7. Bladder lithiasis: from open surgery to lithotripsy. Surgery International. 2(5): 546-548. management and review of literature. etiology. 145: 34-6. Conclusion Urinary bladder stones can be treated using many options of intervention.(6.13) For large and multiple urinary bladder stones. Pak J Med Res 1992. Bosco PJ. that’s why in some centers it is replaced by percutaneous cystolithotripsy. open cystolithotomy seems to be safer.(15) the complication rate is increased in presence of associated TURP. Varkarakis I. with a low incidence of complications but endourological management offers a shorter hospital stay 2. Stoller ML. Management of urinary tract calculi. Int Urol Nephrol 2007. Dellis A.(21) At our study JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 2. Papatsoris AG. Bhatia and Byani reported a 25% complication rate with cystolitholapaxy in addition to TURP. 9. The vesical calculus. Sunil S. Khan MI.10. and multiple small bladder stones.(14) Song and Denstedt reported complication rate of 18% including bladder injury. 8. diagnosis and medical management.6 days compared to 4.18) In children Al-Marhoon et al conclude that open and endourological management of vesical stones is efficient. J Urol 1991.16. 3. In: Relik AB. 60:285-90. hard bladder stone. Rastinehad AR. Bladder erosion of tension free vaginal tape presented as vesical stone. et al. 31(1):13-7. Mustafa M.17) long hospital stay and long duration of urethral catheterization are the main disadvantages of this procedure. 5. pneumatic and laser energy. 2 June 2011 the number of patients treated by ESWL is small due to low number of children with bladder stones that attend our adult urology clinic and it was an option of management in high risk patients. 6. 99(3): 595-600. Simultaneous Transurethral Cystolithotripsy with holmium laser enucleation of the prostate: a prospective feasibility study and review of literature. BJUI 2007. broken lithotrite. Resnick MI. Urol Res. Aron et al and Kamat et al found that the percutaneous route in TURP patients with large and multiple bladder stone more advantage than transurethral route in term of operating time and easier retrieval of stone fragments. Nieh PT. 4. hematuria and urine retention. ESWL can be used in high risk patients.

Campell’s Urology 9th edn. Urol Clin North Am 1997. (Abstract) Sami U. 17.11. Errando SC. comparison of percutaneous with transurethral cystolithotripsy in patients with large prostates and large vesical calculi undergoing simultaneous transurethral prostatectomy. J Endourol 2003. The management of vesical calculi with combined optical mechanical cystolithotripsy and transurethral prostatectomy: is it safe and effective? BJUI 1999. Khai LV. 181(6): 2687-2688. 2 June 2011 . In Walsh PC. Ishtiaq C. Pak JO Medical Sciences 2007. Goel A. 12. A comparison 66 of open vesicolithotomy and cystolitholapaxy. 2007. Shabsigh A. Urodynamic findings before and after noninvasive management of bladder calculi. 19. electrohydraulic and mechanical lithotripsy for vesical lithiasis. Milaan RF. Aybek. 84(1): 32-36. Byani CS. Rousaud BF. 23(1): 47-50. BJUI Int 2004. 17: 505-509. Aron M. 20. et al. Rehan M. (4): 595. 15. 151: 660-2. 13. Saikaya. Denstedt JD. Transurethral resection of prostate and suprapubic ballistic vesicolithotrity for benign prostatic hyperplasia with vesical calculi. Vesical lithoasis: open surgery versus cystolithotripsy versus extracorporeal shock wave therapy. Retic AB. Sarhan OM. Awad BA. et al. 18. Comparison of ultrasonic. 18 No. BJUI 2003. Okeke Z. J Urol 1994. Comparison of endourological and open cystolithotomy in the management of bladder stones in children. Agarwal MS. Chapter 84. Gupta M. JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. Bhatia W. eds. 64(5): 10261027. Vaughan Ed. Intracorporeal lithotripsy. Grocela JA. 1997: 13-23. Al-Marhoon MS. Segura JW. Urology 2004. Lower urinary tract calculi. 93: 1267-1270. 91(3): 293-295. Kamat N. 14. 16. Dretler SP. J Endourol 1990. Stamy TA. Asci. J Urol 2009. Use of Amplatz shesth in male urethra during cystolitholapaxy for large bladder calculi. Song TY.