Urolithiasis DOI 10.1007/s00240-014-0732-6
LETTER TO THE EDITOR
A huge bladder calcium oxalate stone Xia Peng · Zhang Jifu · Chen Wenwei
Received: 28 July 2014 / Accepted: 15 September 2014 © Springer-Verlag Berlin Heidelberg 2014
Giant bladder stones are occasionally reported in modern urologic practice. We report a giant bladder stone consisting mainly of calcium oxalate in a male patient. A 67-year-old male patient has admitted to the hospital with lower abdominal pain, dysuria and pollakiuria. The patient came from mountainous rural area where the typical foods eaten by inhabitants contain high levels of oxalate, such as sweet potatoes, bamboo shoots, tampala and mushrooms. The patient had no history of inflammatory bowel disease or surgery. He had a serious urinary tract infection history for 2 months at the age of 11. He was found to have a 1.5-cm bladder stone at the age of 36, but he refused surgical treatment and reduced intake of fluids. Family history of urinary stone disease was positive. Physical examination revealed mild tenderness in the lower abdomen. Digital rectal examination revealed prostate not enlarged. Routine hemogram was normal. Blood urea nitrogen and serum creatinine levels were 5.72 mmol/l and 134 umol/l, respectively. Serum calcium, phosphate ions, uric acid and parathyroid hormone levels were normal. Urinalysis revealed leukocyturia and a pH of 5.5. Analysis of 24-h urine specimen showed that calcium was 6.50 mmol/day and oxalate was 0.58 mmol/ day. Plain radiography showed a large, regular bladder
stone measuring 9.8 × 7.2 cm (Fig. 1). Type B ultrasound revealed severe bilateral hydronephrosis, hydroureter and a large bladder stone. Open cystolithotomy was performed and a blackish brown hard stone was removed with no adhesion to the bladder. The stone weighed 510 g and measured 9.2 × 8.8 × 6.0 cm (Fig. 1). The stone was analysed and composed of calcium oxalate monohydrate (90 %) and uric acid (10 %). After the operation, the patient decreased the consumption of oxalate-rich foods and the
X. Peng · C. Wenwei (*) Department of Transplantation, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, China e-mail: [email protected] X. Peng e-mail: [email protected] Z. Jifu Department of Surgery, Qingyuan County People’s Hospital, Lishui, Zhejiang, China
Fig. 1 Plain abdominal film showing a large, regular bladder stone
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Urolithiasis
urinary oxalate levels dropped significantly. At 12 months of follow-up, the patient’s renal function was normal, and improvement of hydronephrosis was observed on ultrasonic images.
Discussion Giant bladder calcium oxalate stone is very rare in modern urologic practice. Calcium oxalate stone development is relatively slow and may cause clinical symptoms and be removed before growing to a large size. In our case, the stone grew in the bladder for more than 31 years. Bladder stones usually occur due to bladder outlet obstruction, neurogenic voiding dysfunction, urinary tract infection, or foreign bodies. And patients usually have other lithogenous factors such as low urinary pH, low urinary magnesium and increased urinary uric acid supersaturation [1]. Hyperoxaluria, hypercalciuria and a low urine calcium–oxalate ratio are involved in calcium oxalate monohydrate urinary stone formation [2]. In our case, hyperoxaluria, and low urinary pH may promote the stone formation, with superimposed infection as
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bacteria can also promote calcium oxalate crystal growth and aggregation [3]. But a low urine calcium–oxalate ratio was not detected in this patient during the period of hospitalization. The dietary habits of the patient were responsible to the hyperoxaluria, as he tend to eat oxalate-rich foods. In addition, decreased urine flow can also promote the stone growth by increasing the precipitation of calcium and oxalate. To the best of our knowledge, this is one of the largest bladder calcium oxalate stones in the literature. Conflict of interest All authors declare that they have no conflicts of interest.
References 1. Childs MA, Mynderse LA, Rangel LJ, Wilson TM, Lingeman JE, Krambeck AE (2013) Pathogenesis of bladder calculi in the presence of urinary stasis. J Urol 189(4):1347–1351 2. Bibilash BS, Vijay A, Marickar YF (2010) Stone composition and metabolic status. Urol Res 38(3):211–213 3. Chutipongtanate S, Sutthimethakorn S, Chiangjong W, Thongboonkerd V (2013) Bacteria can promote calcium oxalate crystal growth and aggregation. J Biol Inorg Chem 18(3):299–308
LETTER TO THE EDITOR
A huge bladder calcium oxalate stone Xia Peng · Zhang Jifu · Chen Wenwei
Received: 28 July 2014 / Accepted: 15 September 2014 © Springer-Verlag Berlin Heidelberg 2014
Giant bladder stones are occasionally reported in modern urologic practice. We report a giant bladder stone consisting mainly of calcium oxalate in a male patient. A 67-year-old male patient has admitted to the hospital with lower abdominal pain, dysuria and pollakiuria. The patient came from mountainous rural area where the typical foods eaten by inhabitants contain high levels of oxalate, such as sweet potatoes, bamboo shoots, tampala and mushrooms. The patient had no history of inflammatory bowel disease or surgery. He had a serious urinary tract infection history for 2 months at the age of 11. He was found to have a 1.5-cm bladder stone at the age of 36, but he refused surgical treatment and reduced intake of fluids. Family history of urinary stone disease was positive. Physical examination revealed mild tenderness in the lower abdomen. Digital rectal examination revealed prostate not enlarged. Routine hemogram was normal. Blood urea nitrogen and serum creatinine levels were 5.72 mmol/l and 134 umol/l, respectively. Serum calcium, phosphate ions, uric acid and parathyroid hormone levels were normal. Urinalysis revealed leukocyturia and a pH of 5.5. Analysis of 24-h urine specimen showed that calcium was 6.50 mmol/day and oxalate was 0.58 mmol/ day. Plain radiography showed a large, regular bladder
stone measuring 9.8 × 7.2 cm (Fig. 1). Type B ultrasound revealed severe bilateral hydronephrosis, hydroureter and a large bladder stone. Open cystolithotomy was performed and a blackish brown hard stone was removed with no adhesion to the bladder. The stone weighed 510 g and measured 9.2 × 8.8 × 6.0 cm (Fig. 1). The stone was analysed and composed of calcium oxalate monohydrate (90 %) and uric acid (10 %). After the operation, the patient decreased the consumption of oxalate-rich foods and the
X. Peng · C. Wenwei (*) Department of Transplantation, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, China e-mail: [email protected] X. Peng e-mail: [email protected] Z. Jifu Department of Surgery, Qingyuan County People’s Hospital, Lishui, Zhejiang, China
Fig. 1 Plain abdominal film showing a large, regular bladder stone
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Urolithiasis
urinary oxalate levels dropped significantly. At 12 months of follow-up, the patient’s renal function was normal, and improvement of hydronephrosis was observed on ultrasonic images.
Discussion Giant bladder calcium oxalate stone is very rare in modern urologic practice. Calcium oxalate stone development is relatively slow and may cause clinical symptoms and be removed before growing to a large size. In our case, the stone grew in the bladder for more than 31 years. Bladder stones usually occur due to bladder outlet obstruction, neurogenic voiding dysfunction, urinary tract infection, or foreign bodies. And patients usually have other lithogenous factors such as low urinary pH, low urinary magnesium and increased urinary uric acid supersaturation [1]. Hyperoxaluria, hypercalciuria and a low urine calcium–oxalate ratio are involved in calcium oxalate monohydrate urinary stone formation [2]. In our case, hyperoxaluria, and low urinary pH may promote the stone formation, with superimposed infection as
13
bacteria can also promote calcium oxalate crystal growth and aggregation [3]. But a low urine calcium–oxalate ratio was not detected in this patient during the period of hospitalization. The dietary habits of the patient were responsible to the hyperoxaluria, as he tend to eat oxalate-rich foods. In addition, decreased urine flow can also promote the stone growth by increasing the precipitation of calcium and oxalate. To the best of our knowledge, this is one of the largest bladder calcium oxalate stones in the literature. Conflict of interest All authors declare that they have no conflicts of interest.
References 1. Childs MA, Mynderse LA, Rangel LJ, Wilson TM, Lingeman JE, Krambeck AE (2013) Pathogenesis of bladder calculi in the presence of urinary stasis. J Urol 189(4):1347–1351 2. Bibilash BS, Vijay A, Marickar YF (2010) Stone composition and metabolic status. Urol Res 38(3):211–213 3. Chutipongtanate S, Sutthimethakorn S, Chiangjong W, Thongboonkerd V (2013) Bacteria can promote calcium oxalate crystal growth and aggregation. J Biol Inorg Chem 18(3):299–308
