GIANT PROSTATIC CALCULI

ATMARAM S. GAWANDE, M.D.

MADHAV H. KAMAT, M.D.
JOSEPH J. SEEBODE, M.D.

From the Department of Surgery, Division of Urology, College

of Medicine and Dentistry of New Jersey and Affiliated
Hospitals, New Jersey Medical School,
Newark, New Jersey

ABSTRACT-An unusual case of giant prostatic calculus associated with urinary incontinence is
presented. The calculus was removed suprapubically and the postoperative courxe was uneventful
exceptfw continuing incontinence. An incontinence procedure was performed with satisfactory results.
___

Microscopic prostatic calculi are not uncommon three months. He returned to a normal voiding
in late adult life. l Under certain circumstances, pattern and remained free of symptoms until
marked enlargement and increase in number three months prior to this admission.
occur. Physical examination on this admission re-
A large prostatic calculus is a rare finding. The vealed a well-developed, malnourished, dehy-
case herein reported represents the thirteenth drated white man. There was no flank tenderness.
case in English literature. Englisch in 1904,2 re- The kidneys and bladder were not palpable or ten-
ported the first and heaviest stone weighing 1,050 der. The genitalia were unremarkable. The
Cm. Barrett in 19573 reviewed 9 cases of giant examination of perineum revealed extensive scar-
prostatic calculi and added 1 of his own. Young in ring and healed fistulous tracts. Rectal examina-
19344 and Horwitch in 19535 each reported 1 tion revealed normal sphincter tone. A large fixed
case, bringing the total reported cases up to 12. stony-hard mass was felt in the area of the pros-
tate, suggestive of carcinoma of the prostate. The
Case Report sulcus and borders could be reasonably defined.
Laboratory work-up was as follows: Urinalysis
A fifty-four-year-old white man was admitted to revealed a specific gravity of 1.020; albumin 1
Martland Hospital, on July 8, 1971, complaining plus; sugar and acetone were negative; white
of frequency, dysuria, and urinary incontinence blood cells 6 to 10 per high-power field; red blood
of three month’s duration. The patient denied any cells 0 to 1 per high-power field. Urine culture
history of urinary tract infection, prostatitis, ure- revealed Proteus vulgaris greater than 100,000
thritis, urethral stricture, venereal disease, or uri- organisms per cubic centimeter, which were
nary calculi. Twenty-eight years prior to this ad- sensitive to most of the antibiotics except tetra-
mission, he was admitted to Fort Monmouth cycline and ampicillin.
Army Hospital with acute urinary retention and The complete blood count revealed a hemoglo-
a high fever. On the same day he had perineal bin of11.8 Gm. per 100 ml., a hematocrit of35.1,
drainage of a prostatic abscess; a urethral catheter and a white blood count of 4,800 per cubic milli-
was left indwelling. The patient was discharged meter with normal differential. Blood chemistries
with partial urinary incontinence which lasted were as follows: urea nitrogen 21 mg. and creati-
FIGURE 1. (A) Roentgenogram revealing large radiopaque density in area of prostate. (B) Intravenous
urogram shows moderate hydronephrosis and hydroureter. There is minimal dye in bladder above stone. (C)
Retrograde urethrogramreveals stricture in area of bulbomembranous urethra and multiple fistulous tracts. Dye is
seen in bladder which appears small and contracted.
nine 1.2 mg. per 100 ml. ; sodium 136, potassium
3.5, and chloride 100 mEq. per liter, blood sugar
100 mg. per 100 ml. ; acid phosphatase 0.54
(Shinowara units) and alkaline phosphatase 5
(Babsen units); serum calcium 9 and phosphorus
4.2 mg. per 100 ml.
FIGURE2. Postoperative cystourethrogram. Cystos-
tomy tube contains dye. Prostatic urethra markedly
dilated where stone had been removed. Stricture can
be seen in bulbomembranous urethra.
320
A ilat plate of the abdomen on admission re-
vealed a large calculus in the area of the prostate
as seen in Figure 1A. The calculus was pear-
shaped and appeared to replace the prostate. The
intravenous urogram revealed 2 plus hydrone-
phrosis and hydroureter with a small contracted
bladder which appeared to be above the stone
(Fig. 1B). No dye was seen around the stone. A
retrograde urethrogram (Fig. 1C) revealed an ex-
tensive stricture of the bulbous urethra with mul-
tiple small fistulas. The dye was seen around the
large calculus and in the bladder.
Attempts were made to dilate the stricture with
filiforms and followers without success. An ure-
throscopy revealed a severe stricture in the bul-
bomembranous urethra. Attempts to pass a fili-
form under direct vision were also unsuccess-
ful. We decided at this point that surgery should
be performed after the patient was adequately
covered with antibiotics.
On July 28, 1971, the bladder was opened
through a midline suprapubic incision. The stone
was seen projecting from the prostatic urethra.
The bladder revealed three plus trabeculation
and thickening of the bladder wall. The stone was
extracted by finger manipulation in a manner
similar to the removal of an adenoma. The entire
stone was removed with great difficulty but
with minimal bleeding. No instrument could be
passed per urethra into the bladder or from the
bladder to the meatus. It was decided that fur-
ther manipulation ofthe urethra would be hazard-
ous. The bladder was closed and a suprapubic
catheter was left in-dwelling.
UROLOGY / SEPTEMBER 1974 / VOLUME IV, NUMBER 3
 The postoperative course was satisfactory. The
urethra was dilated gradually by using filiforms
and followers to a 24 F. A cystourethrogram after
the dilation revealed a dilated prostatic urethra
where the stone had been removed (Fig. 2).
The stone was pear-shaped, the apex of the
pyramid being at the external sphincter and
base at the bladder neck (Fig. 3). It measured 6
cm. vertically, 4 cm. transversally, and weighed
320 Gm. The surface of the stone was smooth
except for the groove which was probably pro-
duced by passage of urine. This unusual feature
was noted in Young’s and Barrett’s cases. Stone
analysis revealed magnesium ammonium phos-
phate.
The suprapubic tube was removed and the pa-
tient was discharged with partial urinary inconti- FIGURE 3. Specimen, pear-shaped stone with granu-
lar surface.
nence to the outpatient clinic. He was lost to
follow-up until January, 1973, when he was ad-
mitted to East Orange Veterans Administration
Hospital with total urinary incontinence. The in- and dysuria. Hematuria was noted in only 2 cases.
travenous urogram on this admission revealed Incontinence, which is an unusual symptom, was
normal upper tracts. Cystourethroscopy was present in 2 previous cases and in our case. The
done after gradual dilatation of the urethra to a 24 largest stone was the size of a golf ball being
F. The urethra revealed an irregular and poor reported by Joly in 1929. The heaviest stone
contraction of the external sphincter. The patient weighed 1,050 G m. Our stone weighed 320 Gm.
underwent a Kauffman II incontinence procedure The lightest stone reported was 42 Cm. Most of
with satisfactory results. the stones were rounded, but our stone was un-
usual in that it was pear-shaped.
Comment Joly states that very large and fixed stones espe-
Young has classified prostatic calculi into two cially of the vesicourethral type should be re-
moved by suprapubic cystotomy. Dilatation or
types: (1) en do genous, those arising in the sub-
wedge resection of the bladder neck should be
stance of the gland, and (2) exogenous, those that
done when necessary. Most cases in the literature
develop in the prostatic diverticula, or abscess
were treated by suprapubic route with various
cavities, or migrate there from the kidney, ureter,
revisions of the bladder neck. This often required
or bladder.
finger extraction similar to enucleation of an
In the present case the stone was the exogenous
adenoma, or instrument crushing and extraction.
type having its origin in the abscess cavity which
the patient had twenty-eight years previously.
New Jersey Medical School
The abcess cavity, although drained transperine- 65 Bergen Street
ally did not heal adequately because of the ureth- Newark, New Jersey 07107
ral stricture. In this uncollapsed prostatic abscess (DR. SEEBODE)
cavity a nidus for calculus resulted from sloughed
tissue or calcareous material on which further
References
concretions occurred and filled the prostatic
cavity.
1. JOLY, J. S.:Stone and Calculous Disease ofthe Urinary
A review of the literature revealed that micro-
Organ, London, Wm. Heinemann, 1994, p. 535.
scopic calculi are frequently seen in elderly pa- 2. ENGLISCH, J.: iiber eingel agerte und eingesackte
tients, whereas giant prostatic calculi tend to be Steine der Hamrohre, Arch. klin. Chir. 72: 487 (1994).
seen in younger men. 6 *The youngest patient was 3. BARRETT, J. D. : The giant prostatic calculi, Br. J. Surg.
twenty-one and the oldest was fifty-six years of 45: 267 (1957).
4. YOUNG, H.H.: Prostatic calculi, J. Urol. 32: 666 (1934).
age. Our patient is fifty-four years of age. In most
5. HORWICH, M.: Giant prostatic calculi, Br. J. Surg. 50:
of the cases the symptoms produced were very 547 (1953).
late in the disease and were minimal, as in our 6. RITCH,C. 0.: Giant prostatic calculi; report of case, J.
case. Most common symptoms were frequency Ural. 36: 157 (1936).

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