PREDISPOSING FACTORS IN BLADDER CALCULI Review of 100 Cases ROBERT DOUENIAS, M.D. MARK RICH, M.D. GOPAL BADLANI, M.D. DAVID MAZOR, M.D. ARTHUR SMITH, M.D. From the Department of Urology, Long Island Jewish Medical Center, New Hyde Park, New York
ABSTRACT--One hundred patients, aged twenty to ninety-two years, underwent 111 proc ]or removal of bladder calculi. Most patients (88) had some type o] bladder outlet obstructi,o~ types o] stones were identified: those that had apparently ]ormed in the upper tract an, trapped in the bladder (17 cases) and those that appeared to have ]ormed in the bladde r presence o] various types o] outlet obstruction. Stone analysis revealed uric acid stones in 1 cent, calcium oxalate stones in 19 percent, and stones o] mixed composition in 31 percen patients had metabolic abnormalities predisposing to stone :formation; in 2 cases, these abne ties were discovered during the evaluation ]or stone disease. Treatment depended on stone c teristics, associated pathology, and the general health o] the patient. A review o] the literatu: regard to the morbidity and mortality o] combining treatment o] vesical calculi and bladdel obstruction secondary to prostatic obstruction is included.
Bladder calculi, once epidemic in m a n y places, are now rare in the United States. To determine what clinical conditions are most likely to be associated with this problem, we reviewed the most recent 100 patients treated at our institution. Material and Methods One hundred patients underwent 111 procedures for removal of bladder stones between January 1982 and August 1987. All but 2 patients were men, and 71 percent were between sixty and seventy-nine years of age (Table I). In TABLE I. Age (Yrs.) 20-39 40-59 60-69 70-79 80 +
240
Age distribution of patients with bladder stones No. of Pts. 5 16 42 29 8
88 patients, there was some type of bla& let obstruction, most often benign prosti perplasia, with prostatic carcinoma, u stricture, bladder neck contracture, and sear secondary to previous prostate surg counting for 23 cases (Table II). Urinal
Associated pathology Associated Pathology Bladder outlet obstruction requiring resection Urinary tract infection History of renal colic Bladder neck eontraeture Prostate cancer Neurogenic bladder Urethral stricture Previous prostatic surgery Bladder diverticulum, gout Bladder cancer, foreign body, Paget disease, urethral stones, Crohn disease, false stone (bullet) TABLE II.
*Patients also had some form of outlet
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VOLUME xXXVI
TABLEIII.
Symptoms No. of Pts. 79 62 47 42 34 18 13 5 5 4
m 'y s t r e a m
2
~sent in 28 patients, most eommriehia eoli (11 cases) or Pro~st patients had multiple sympats that had been present for as ¢ or as long as several years months) (Table III). ~f the stones depended on paleral health; the size, number, e stone; and the associated paml indications for open eysto~rostatic size greater than 50 g, m l u m with multiple stones, acid) stones, severe urethral I body, or failed transurethral techniques are summarized in ~f them are described in detail e procedure time ranged from ndred eighty minutes in closed -five to one hundred twenty oases. Results ere multiple in slightly more ttients (55 cases) and in 63 of dder outlet obstruction and )f the 144 stones from 89 paanalyzed, 45 (59%) were of %) of calcium oxalate, and 27 composition. Only 9. of the pamid stones had a history or evihyperuricemia. Oxalate stones ) of the 17 patients with a hisc suggesting stone passage from All 6 patients with neurogenic ixed magnesium a m m o n i u m ite) stones and urinary tract intea-splitting organisms. Stone 0.1 to 10 em, with approxi-
.CH 1991
/
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XXXVII,
NUMBER
TABLEIV. Summary of procedures Procedure Electrohydraulic lithotripsy Open cystolithotomy and prostatectomy Cystoscopy (forceps and Elik) Cystolitholapaxy
No. 39 31 21 20
mately 80 percent being less than 2 cm in greatest diameter.
Symptoms and signs A noteworthy feature was the paucity of irritative symptoms in patients with large stones. For example, patients with stones greater than 5 cm presented with sudden gross hematuria only, presumably because the lesser movement permitted these large concretions in the thickwalled bladder lessened the irritation. A particularly striking disparity between the intensity of symptoms and the size of the stone burden follows.
Case Abstract A ninety-year-old man entered the hospital with a four-day history of intermittent gross hematuria. He gave a few years history of frequency, hesitancy, noeturia, and poor urinary stream. The physical examination was unremarkable. On the intravenous urogram, the scout film and the post voiding films showed a homogenous radiopaque density filling the bladder (Fig. 1A, B). At cystoseopy, trilobar prostatic hyperplasia and multiple small calculi in the prostatic urethra were found. Examination of the bladder was prevented by the presence of fine gravel filling the cavity (Fig. 1C). The bladder was rendered free of calculi by multiple Elik irrigations, and an uncomplicated transurethral prostatic resection was performed. The brown-black calcific granules proved to be magnesium ammonium phosphate. The urine was sterile. The postoperative film showed no calculi (Fig. 1D).
Associated pathology The a m o u n t of prostatic tissue reseeted ranged from 7 to 155 g, with an average of 35 g (Table V). There was no direct relation between the degree of obstruction and the size of the prostate, with 42 percent of patients with obstructive symptoms having prostates weighing less than 20 g. In 1 patient, a foreign body had acted as nidus for stone formation. The patient had
3
241
(A) Scoutfi~ and (B) postvoid film oJ ~ travenous pyelogram.:~(~ Cystoscopic view of blad~ stones. (D) Postoperativ~~ ney-ureter-bladder film :i!N FmURE 1.
introduced an 8-inch crochet needle transurethrally two months before he presented with gross hematuria. The needle was encased in stone material. Another patient who appeared to have a stone on initial radiography in fact had a bullet from a previous gunshot. The object lay adjacent to the left posterolateral wall of his bladder and caused severe terminal dysuria. TABLE V, Weightof prostatic tissue resected Weight Reseeted (g) No. of Pts. 10 14 11-19 13 20-29 22 30-39 12 40-49 6 50-59 2 60-69 4 70-79 3 80-89 1
>90
242
3
Comment Two types of bladder stones v in this series: those that apt formed in the upper urinary I pass d o w n the ureter but n, urethra, and those that appeare( in the bladder. Both types were eiated with bladder outlet obst ten with infection. The former patients, all of whom had pro sia, and were located in th( pouch. This location probabl3 their retention in the bladder af gotiated the ureter. These stone ten (10 cases) of calcium oxa] type was seen in patients w i t h plasia, bladder diverticula, neu: bladder neck contracture, and u ing (stricture, stones). An unusually large number o: had stones of uric acid, althoug] had gout. In contrast, Smith
UROLOGY
/
MARCH 1991
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VOLUME XXXVII, N
f morbidity and mortality Percent Complication 2.6 % 5RP Complication 21.1% ipsy Complication 1.9 % ipsy Mortality
1.5 %
Mortality
3.2 %
RP
[er stones in only 5.4 perr medical center serves a m, and the high incidence l this population may exhigh frequency of such rant of the prostate was er type of stone, which is urodynamic results of associates, 9 who demonof prostatic enlargement a the severity of outflow ,~been reported to be the ,~ral metabolic abnormalia, hyperparathyroidism, ous disorders. We identicpercalcemia: one as a re,ith osteosareoma and one :atic prostate cancer. Two ,~out, and one had Crohn ~lic etiologies such as hy~lcemia, cystinuria, and ~e considered, even if an Kists. ff bladder outlet obstruc:ostatie enlargement and . dealt with in a variety of endoscopic removal of either eystolitholapaxy, tripsy, or Elik evacuation ~e performed at the same 1 resection of the prostate. :omy may be combined :atectomy or transurethral ate. Alternatively, a two',al with the stone may be :urethral resection of the zed in our series, a review Lregard to the morbidity
91
and mortality of the various combinations was performed (Table VI). With eystolitholapaxy alone, Nseyo et al. 10 noted a 2.6 percent complication rate (1/38 patients) involving an extraperitoneal bladder perforation. Combined eystolitholapaxy with TURP had a complication rate of 21.1 percent (8/38 patients), these ineluded an instrument malfunction, stone fragment in the urethra, urethral tear, and five incomplete initial treatments requiring a second or staged procedures. Bulow and Frohmuller u used eleetrohydraulie lithotripsy in 304 patients with a complication rate of 1.9 percent consisting of one intraperitoneal and 5 extraperitoneal bladder perforations. Mechanical difficulties were categorized as technical problems and were not included in the complication rate. Great strides have been made to improve the precision and safety of transurethral resection; t h e m o r t a l i t y r a t e r e p o r t e d by Barnes, Bergman, and Worton in 196312 in conjunction with eystolithotomy is unacceptably high. Recently we have begun performing antegrade extraction of vesieal calculi utilizing the ultrasonic lithotriptor. Large or dense stones that normally require eystolithotomy have been treated successfully with this method. The utility of this procedure combined with TURP remains to be determined. New Hyde Park, New York 11042
(DR. SMITH) References 1. Smith JM, and O'Flynn JD: Transurethral removal of bladder stones: the place of litholapaxy, Br J Urol 49:401 (1977). 2. Yutkin LA: Electrohydraulic effect. Translation: United States Department of Commerce of Technical Service Document 62-15184 MCL 1207/1-2, 1962. 3. Bapat SS: Endoscopic removal of bladder stones in adults, Br J Urol 49:527 (1977). 4. Raney AM: Electrohydraulic cystolithotripsy, Urology 7:
379 (1976). 5. Mitchell ME, and Kerr WS Jr: Experience with electrohydraulic disintegrator, J Urol 117:159 (1976). 6. Gottesman JE, and Flanagan MJ: Removal of bladder stones in female, Urology l h 636 (1978). 7. Atsman A, DeVries A, and Frank M: Uric Acid Lithiasis, Amsterdam, Elsevier, 1963. 8. Gutman AB, and Yu TF: Uric acid nephrolithiasis, Am J Med 45:756 (1968). 9. Turner-Warwick R, et ah A urodynamic view of prostatic obstruction and results of prostatectomy, Br J Uro145:631 (1973). 10. Nseyo VV, Rivard DJ, Garlick WB, and Bennett AH: Management of bladder stones: should transurethral prostatic resection be performed in combination with cystolithotomy, Urology 39:265 (1987). 11. Bulow H, and Frohmuller HGW: Electrohydraulic lithotripsy with aspiration of the fragments under vision--304 consecutive cases, J Urol 126:454 (1981). 12. Barnes BW, Bergman RT, and Worton E: Litholapaxy vs. eystolithotomy, J Urol 89:680 (1963).
/ VOLUME XXXVII, NUMBER 3
243
ABSTRACT--One hundred patients, aged twenty to ninety-two years, underwent 111 proc ]or removal of bladder calculi. Most patients (88) had some type o] bladder outlet obstructi,o~ types o] stones were identified: those that had apparently ]ormed in the upper tract an, trapped in the bladder (17 cases) and those that appeared to have ]ormed in the bladde r presence o] various types o] outlet obstruction. Stone analysis revealed uric acid stones in 1 cent, calcium oxalate stones in 19 percent, and stones o] mixed composition in 31 percen patients had metabolic abnormalities predisposing to stone :formation; in 2 cases, these abne ties were discovered during the evaluation ]or stone disease. Treatment depended on stone c teristics, associated pathology, and the general health o] the patient. A review o] the literatu: regard to the morbidity and mortality o] combining treatment o] vesical calculi and bladdel obstruction secondary to prostatic obstruction is included.
Bladder calculi, once epidemic in m a n y places, are now rare in the United States. To determine what clinical conditions are most likely to be associated with this problem, we reviewed the most recent 100 patients treated at our institution. Material and Methods One hundred patients underwent 111 procedures for removal of bladder stones between January 1982 and August 1987. All but 2 patients were men, and 71 percent were between sixty and seventy-nine years of age (Table I). In TABLE I. Age (Yrs.) 20-39 40-59 60-69 70-79 80 +
240
Age distribution of patients with bladder stones No. of Pts. 5 16 42 29 8
88 patients, there was some type of bla& let obstruction, most often benign prosti perplasia, with prostatic carcinoma, u stricture, bladder neck contracture, and sear secondary to previous prostate surg counting for 23 cases (Table II). Urinal
Associated pathology Associated Pathology Bladder outlet obstruction requiring resection Urinary tract infection History of renal colic Bladder neck eontraeture Prostate cancer Neurogenic bladder Urethral stricture Previous prostatic surgery Bladder diverticulum, gout Bladder cancer, foreign body, Paget disease, urethral stones, Crohn disease, false stone (bullet) TABLE II.
*Patients also had some form of outlet
UROLOGY
/
MARCH 1991
/
VOLUME xXXVI
TABLEIII.
Symptoms No. of Pts. 79 62 47 42 34 18 13 5 5 4
m 'y s t r e a m
2
~sent in 28 patients, most eommriehia eoli (11 cases) or Pro~st patients had multiple sympats that had been present for as ¢ or as long as several years months) (Table III). ~f the stones depended on paleral health; the size, number, e stone; and the associated paml indications for open eysto~rostatic size greater than 50 g, m l u m with multiple stones, acid) stones, severe urethral I body, or failed transurethral techniques are summarized in ~f them are described in detail e procedure time ranged from ndred eighty minutes in closed -five to one hundred twenty oases. Results ere multiple in slightly more ttients (55 cases) and in 63 of dder outlet obstruction and )f the 144 stones from 89 paanalyzed, 45 (59%) were of %) of calcium oxalate, and 27 composition. Only 9. of the pamid stones had a history or evihyperuricemia. Oxalate stones ) of the 17 patients with a hisc suggesting stone passage from All 6 patients with neurogenic ixed magnesium a m m o n i u m ite) stones and urinary tract intea-splitting organisms. Stone 0.1 to 10 em, with approxi-
.CH 1991
/
VOLUME
XXXVII,
NUMBER
TABLEIV. Summary of procedures Procedure Electrohydraulic lithotripsy Open cystolithotomy and prostatectomy Cystoscopy (forceps and Elik) Cystolitholapaxy
No. 39 31 21 20
mately 80 percent being less than 2 cm in greatest diameter.
Symptoms and signs A noteworthy feature was the paucity of irritative symptoms in patients with large stones. For example, patients with stones greater than 5 cm presented with sudden gross hematuria only, presumably because the lesser movement permitted these large concretions in the thickwalled bladder lessened the irritation. A particularly striking disparity between the intensity of symptoms and the size of the stone burden follows.
Case Abstract A ninety-year-old man entered the hospital with a four-day history of intermittent gross hematuria. He gave a few years history of frequency, hesitancy, noeturia, and poor urinary stream. The physical examination was unremarkable. On the intravenous urogram, the scout film and the post voiding films showed a homogenous radiopaque density filling the bladder (Fig. 1A, B). At cystoseopy, trilobar prostatic hyperplasia and multiple small calculi in the prostatic urethra were found. Examination of the bladder was prevented by the presence of fine gravel filling the cavity (Fig. 1C). The bladder was rendered free of calculi by multiple Elik irrigations, and an uncomplicated transurethral prostatic resection was performed. The brown-black calcific granules proved to be magnesium ammonium phosphate. The urine was sterile. The postoperative film showed no calculi (Fig. 1D).
Associated pathology The a m o u n t of prostatic tissue reseeted ranged from 7 to 155 g, with an average of 35 g (Table V). There was no direct relation between the degree of obstruction and the size of the prostate, with 42 percent of patients with obstructive symptoms having prostates weighing less than 20 g. In 1 patient, a foreign body had acted as nidus for stone formation. The patient had
3
241
(A) Scoutfi~ and (B) postvoid film oJ ~ travenous pyelogram.:~(~ Cystoscopic view of blad~ stones. (D) Postoperativ~~ ney-ureter-bladder film :i!N FmURE 1.
introduced an 8-inch crochet needle transurethrally two months before he presented with gross hematuria. The needle was encased in stone material. Another patient who appeared to have a stone on initial radiography in fact had a bullet from a previous gunshot. The object lay adjacent to the left posterolateral wall of his bladder and caused severe terminal dysuria. TABLE V, Weightof prostatic tissue resected Weight Reseeted (g) No. of Pts. 10 14 11-19 13 20-29 22 30-39 12 40-49 6 50-59 2 60-69 4 70-79 3 80-89 1
>90
242
3
Comment Two types of bladder stones v in this series: those that apt formed in the upper urinary I pass d o w n the ureter but n, urethra, and those that appeare( in the bladder. Both types were eiated with bladder outlet obst ten with infection. The former patients, all of whom had pro sia, and were located in th( pouch. This location probabl3 their retention in the bladder af gotiated the ureter. These stone ten (10 cases) of calcium oxa] type was seen in patients w i t h plasia, bladder diverticula, neu: bladder neck contracture, and u ing (stricture, stones). An unusually large number o: had stones of uric acid, althoug] had gout. In contrast, Smith
UROLOGY
/
MARCH 1991
/
VOLUME XXXVII, N
f morbidity and mortality Percent Complication 2.6 % 5RP Complication 21.1% ipsy Complication 1.9 % ipsy Mortality
1.5 %
Mortality
3.2 %
RP
[er stones in only 5.4 perr medical center serves a m, and the high incidence l this population may exhigh frequency of such rant of the prostate was er type of stone, which is urodynamic results of associates, 9 who demonof prostatic enlargement a the severity of outflow ,~been reported to be the ,~ral metabolic abnormalia, hyperparathyroidism, ous disorders. We identicpercalcemia: one as a re,ith osteosareoma and one :atic prostate cancer. Two ,~out, and one had Crohn ~lic etiologies such as hy~lcemia, cystinuria, and ~e considered, even if an Kists. ff bladder outlet obstruc:ostatie enlargement and . dealt with in a variety of endoscopic removal of either eystolitholapaxy, tripsy, or Elik evacuation ~e performed at the same 1 resection of the prostate. :omy may be combined :atectomy or transurethral ate. Alternatively, a two',al with the stone may be :urethral resection of the zed in our series, a review Lregard to the morbidity
91
and mortality of the various combinations was performed (Table VI). With eystolitholapaxy alone, Nseyo et al. 10 noted a 2.6 percent complication rate (1/38 patients) involving an extraperitoneal bladder perforation. Combined eystolitholapaxy with TURP had a complication rate of 21.1 percent (8/38 patients), these ineluded an instrument malfunction, stone fragment in the urethra, urethral tear, and five incomplete initial treatments requiring a second or staged procedures. Bulow and Frohmuller u used eleetrohydraulie lithotripsy in 304 patients with a complication rate of 1.9 percent consisting of one intraperitoneal and 5 extraperitoneal bladder perforations. Mechanical difficulties were categorized as technical problems and were not included in the complication rate. Great strides have been made to improve the precision and safety of transurethral resection; t h e m o r t a l i t y r a t e r e p o r t e d by Barnes, Bergman, and Worton in 196312 in conjunction with eystolithotomy is unacceptably high. Recently we have begun performing antegrade extraction of vesieal calculi utilizing the ultrasonic lithotriptor. Large or dense stones that normally require eystolithotomy have been treated successfully with this method. The utility of this procedure combined with TURP remains to be determined. New Hyde Park, New York 11042
(DR. SMITH) References 1. Smith JM, and O'Flynn JD: Transurethral removal of bladder stones: the place of litholapaxy, Br J Urol 49:401 (1977). 2. Yutkin LA: Electrohydraulic effect. Translation: United States Department of Commerce of Technical Service Document 62-15184 MCL 1207/1-2, 1962. 3. Bapat SS: Endoscopic removal of bladder stones in adults, Br J Urol 49:527 (1977). 4. Raney AM: Electrohydraulic cystolithotripsy, Urology 7:
379 (1976). 5. Mitchell ME, and Kerr WS Jr: Experience with electrohydraulic disintegrator, J Urol 117:159 (1976). 6. Gottesman JE, and Flanagan MJ: Removal of bladder stones in female, Urology l h 636 (1978). 7. Atsman A, DeVries A, and Frank M: Uric Acid Lithiasis, Amsterdam, Elsevier, 1963. 8. Gutman AB, and Yu TF: Uric acid nephrolithiasis, Am J Med 45:756 (1968). 9. Turner-Warwick R, et ah A urodynamic view of prostatic obstruction and results of prostatectomy, Br J Uro145:631 (1973). 10. Nseyo VV, Rivard DJ, Garlick WB, and Bennett AH: Management of bladder stones: should transurethral prostatic resection be performed in combination with cystolithotomy, Urology 39:265 (1987). 11. Bulow H, and Frohmuller HGW: Electrohydraulic lithotripsy with aspiration of the fragments under vision--304 consecutive cases, J Urol 126:454 (1981). 12. Barnes BW, Bergman RT, and Worton E: Litholapaxy vs. eystolithotomy, J Urol 89:680 (1963).
/ VOLUME XXXVII, NUMBER 3
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