Treatment of bladder stones without associated prostate surgery: Results of a prospective study

OBJECTIVES

To assess the effectiveness of noninvasive bladder lithiasis treatment without associated prostate surgery to know whether bladder lithiasis is an absolute indication for prostate surgery.

METHODS

Fifty patients with bladder lithiasis were entered in a prospective trial and were treated with extracorporeal shock wave lithotripsy if lithiasis was smaller than 4 cm2. Independent of the presence or absence of bladder outlet obstruction, in no case was prostate surgery associated. The variables studied were the effectiveness of the treatment, changes in the International Prostate Symptom Score (IPSS), and the subsequent need for desobstructive prostate surgery. The statistical study was performed using Student's t test and the proportional hazards model.

RESULTS

Bladder lithiasis was successfully eliminated in 93% of the cases (in 77% of them with a single extracorporeal shock wave lithotripsy session). The mean IPSS decreased from 17.7 to 9.7 points (P = 0.0001) after lithiasis elimination. After a mean follow-up of 22 months, a mere 8% of the patients needed subsequent prostate surgery because their IPSS had increased to 20 points or more. The sole prognostic factor for the need for ensuing prostate surgery was the pretreatment IPSS score (P = 0.042).

CONCLUSIONS

Noninvasive management of bladder lithiasis with no associated prostate surgery is highly efficient and results in marked symptomatic improvement. Furthermore, the number of patients needing subsequent prostate surgery was very low at mid-term follow-up. Because of all of the above, the existence of bladder lithiasis is not an absolute indication for prostate surgery.

PASSIVE DILATION BY URETERAL STENTING BEFORE URETEROSCOPY: ELIMINATING THE NEED FOR ACTIVE DILATION

PURPOSE

We sought to evaluate the use of passive dilation by stenting of ureteral orifices that were inaccessible at initial cystoscopic evaluation in children before a ureteroscopic procedure.

MATERIALS AND METHODS

We evaluated all patients younger than 18 years undergoing a ureteroscopic procedure in whom the ureteral orifice could not be accessed endoscopically by a ureteroscope.

RESULTS

A total of 26 children (14 boys and 12 girls) 7.3 to 14.1 years old (median age 10.3 years) underwent 28 passive dilations of initially inaccessible ureters. Stents remained indwelling for 2 to 8 weeks (median 3). All patients underwent successful ureteroscopy with a semirigid and/or flexible ureteroscope after preoperative stent placement. No patient required active dilation of the ureteral orifice at ureteroscopy. There were no complications from stent placement before the ureteroscopic procedures. No patient had a urinary tract infection or bladder spasms requiring anticholinergic therapy from stent insertion and/or early stent removal.

CONCLUSIONS

Our study shows that passive dilation of the ureteral orifice in preparation for ureteroscopy is a straightforward, successful and beneficial technique in children, with no associated complications.

Refinements in treatment of large bladder calculi: simultaneous percutaneous suprapubic and transurethral cystolithotripsy

OBJECTIVES

To present a combined endourologic approach to treat bladder calculi consisting of simultaneous percutaneous suprapubic and transurethral cystolithotripsy.

METHODS

We report on a series of 12 consecutive patients with bladder stone burdens of 40 mm or greater. Percutaneous 30F access was obtained under cystoscopic control. Fragmentation and stone removal were performed simultaneously by two urologists using a Swiss lithoclast, holmium laser, and/or ultrasound lithotriptor through both percutaneous and transurethral routes. Suprapubic and transurethral catheters were placed postoperatively.

RESULTS

Twelve patients with a median age of 66 years (range 33 to 80) were treated by simultaneous percutaneous suprapubic and transurethral cystolithotripsy. Six underwent transurethral resection of the prostate at the completion of stone clearance. The median stone size was 60 mm (range 40 to 80), and the median lithotripsy time was 56 minutes (range 45 to 70). The median postoperative hospitalization was 2.7 days (range 2 to 5), and complete stone clearance was achieved in all cases. One patient, who underwent concomitant transurethral resection of the prostate, developed urinary retention 1 week postoperatively and was successfully treated by temporary transurethral catheterization. One patient with a positive urine culture preoperatively developed fever on the first postoperative day and was treated with intravenous antibiotics according to the antibiogram results for 5 days. No other complications had occurred after a median follow-up of 10 months (range 3 to 15).

CONCLUSIONS

Simultaneous percutaneous suprapubic and transurethral cystolithotripsy appears to be a safe approach for the management of large bladder calculi and may shorten the total fragmentation time. It can be combined with transurethral resection of the prostate without prolonging hospitalization. The simultaneous use of two modalities of stone fragmentation represents an effective and minimally invasive way of treating large bladder calculi.

Sulfadiazine-related obstructive urinary tract lithiasis: an unusual cause of acute renal failure after kidney transplantation

We report on the first case of acute renal failure related to obstructive urinary tract lithiasis involving sulfadiazine crystals in a kidney transplant recipient. This patient had disseminated toxoplasmosis which was treated by sulfadiazine (4 g/day) and pyrimethamine (50 mg/day). In the fourth week of anti-toxoplasmosis therapy, he presented with obstructive acute renal failure: the plasma creatinine level increased from 220 micromol/l to 547 micromol/l. Apercutaneous pyelography was conducted showing the presence of a lithiasis located at the junction between the graft ureter and the bladder. Six days later, he underwent surgery to retrieve an orange-colored, friable stone. Its spectrophotometric analysis confirmed that the stone consisted of N-acetyl sulfadiazine crystals.

Endoscopic treatment of bladder calculi in post-renal transplant patients: a 10-year experience

BACKGROUND AND PURPOSE

Urinary calculus formation following renal transplantation is an uncommon phenomenon. As a result of the growing number of renal transplants performed and the greater graft survival, there has been increased awareness of transplant-related complications, one of which is calculus formation. We report our experience in the management of bladder calculi after renal transplantation.

PATIENTS AND METHODS

We retrospectively reviewed the charts of 500 consecutive renal transplant patients from 1992 through 2002 and encountered 7 who had bladder calculi postoperatively. Ureteroneocystostomy had been performed using polyglactic acid suture. Bladder calculi were treated endoscopically by litholapaxy, electrohydraulic lithotripsy (EHL), or holmium:YAG laser lithotripsy.

RESULTS

Three calculi were found incidentally at the time of stent removal, and the others were associated with hematuria (43%), urinary tract infection (14%), or irritative voiding symptoms (14%). Eighty-six percent of the calculi were close to the allograft ureteral orifice.

CONCLUSION

While various forms of lithotripsy were employed in treating bladder calculi, Hol:YAG laser lithotripsy appeared to be both efficacious and safe. Both EHL and litholapaxy were complicated by mucosal bleeding necessitating Bugbee fulguration. Holmium:YAG laser lithotripsy was not associated with mucosal bleeding, and fulguration was not required near the allograft ureteral orifice. In addition, ureteral stenting is not required. Bladder calculi may form over both absorbable and nonabsorbable suture material, and the ideal suture for the ureteroneocystostomy has yet to be found. Until then, the Hol:YAG laser should be the lithotrite of choice for bladder calculi following renal transplantation.

[Bladder stone at an ureterovesical anastomotic site after renal transplantation: a report of three cases]

Three cases of bladder stones at the ureterovesical anastomotic site after renal transplantation (RT) are reported. The three patients were successfully treated with kidney grafts. The method used for the ureter bladder anastomosis in all patients was the extravesical technique with polyglyconate (Maxon) for case 1 and a polydioxanone suture (PDSII) for cases 2 and 3. Calculi formation was found between 3 to 15 months after RT. Endoscopic vesicolithotripsy was performed and the stones adherent to the ureterovesical anastomotic site were removed successfully in all cases. Stone analysis revealed uric acid (case 1), CaOx and CaP (case 2). Stone analysis was not done in case 3. The patients' symptoms improved and no bladder stones could be discerned postoperatively.

Urolithiasis associated with indinavir in a patient with spinal cord injury

OBJECTIVE

To report a case of indinavir-induced urolithiasis, and the greater risk of this occurrence in individuals with spinal cord injury (SCI) who require fluid restriction for an intermittent catheterization program (ICP).

METHODS

Case report.

RESULTS

A 38-year-old man with a T4 ASIA A SCI (according to the American Spinal Injury Association classification scale) and human immunodeficiency virus (HIV) infection was using an ICP and taking indinavir (a protease inhibitor) as part of his antiviral regimen. Cystoscopy was performed to rule out recurrent urethral condylomata. He was found to have a bladder stone measuring 0.5 cm x 0.5 cm x 0.3 cm, which, on analysis, was composed of indinavir (100% exterior, 90% interior). The bladder stone was removed under direct visualization. The plain abdominal radiograph did not reveal any stones.

CONCLUSION

Indinavir is a frequently used drug for the treatment of HIV that has the potential to induce urinary lithiasis. This is particularly problematic for individuals with SCI who are on fluid restriction and an ICP. Therefore, cystoscopy and monitoring for indinavir-induced urolithiasis should be undertaken in individuals with SCI who are taking indinavir. Considerations include switching to a different protease inhibitor or choosing an entirely new HIV drug cocktail with less potential for urolithiasis.

Development of vesical calculi following tension-free vaginal tape procedure

We present a case of a bladder stone that had formed around the intravesical portion of tension-free vaginal tape (TVT) material following unnoticed bladder perforation during the procedure. Endoscopic lithotripsy of the bladder calculi was performed and the TVT sling material was removed by an endoscopic approach. High clinical suspicion of bladder complications is necessary when evaluating patients presenting with urinary symptoms after a TVT procedure.

Medical management of pediatric stone disease

Childhood urolithiasis remains endemic in certain parts of the world, namely, Turkey and the Far East. The prevalence of nephrolithiasis in North American children varies widely among geographic regions and accounts for 1 per 1000 to 1 per 7600 pediatric hospital admissions. Stones occur in children of all ages. The clinical manifestations of stone disease are often more subtle in children when compared with the dramatic adult presentation. This article discusses the evaluation and medical management of pediatric stone disease.

TIME TO RECURRENT STONE FORMATION IN PATIENTS WITH BLADDER OR CONTINENT RESERVOIR RECONSTRUCTION: FRAGMENTATION VERSUS INTACT EXTRACTION

PURPOSE

Stone formation following bladder or continent reservoir reconstruction in children is a major source of long-term morbidity. We determine whether the method of stone removal (fragmentation or intact extraction) affected the time to stone recurrence in children after bladder reconstruction.

MATERIALS AND METHODS

Medical records from 1993 to 2003 were examined to identify patients with urinary reconstruction subsequently treated for bladder calculi at our institution. Retrospective review of the medical records was performed to determine the type of urinary reconstruction, time to stone recurrence, method of stone removal and length of followup. Kaplan-Meier analysis was performed with each stone episode considered as an individual event. Time to recurrence was measured in months from stone removal to identification of recurrent stones.

RESULTS

A total of 60 patients with bladder or continent reservoir reconstructions had undergone 103 stone removal procedures (range 1 to 8 procedures per patient). Patients were rendered stone-free after each procedure. Stones recurred following 42.4% of intact and 43.9% of fragmented extractions at a mean of 27.0 (SD 31.3) and 27.6 (SD 21.8) months, respectively. Kaplan-Meier survival analysis curves for intact and fragmented extractions were not statistically different.

CONCLUSIONS

Time to stone recurrence in patients with bladder or continent reservoir reconstruction is not altered by the method of stone removal (fragmented versus intact extraction). Since recurrence remains a frequent problem in children after bladder augmentation and/or reconstruction, use of the least invasive modality should be the initial management recommendation.

Dissolution of infection-induced struvite bladder stones by using a noncalculolytic diet and antibiotic therapy

An 8-year-old, female spayed miniature schnauzer was presented for pollakiuria and gross hematuria. Infection-induced struvite urolithiasis with concurrent bacterial urinary tract infection was diagnosed. The treatment is described, followed by a brief discussion of struvite stones and their medical management.

[Cysteine lithiasis]

Cystinuria is a common inherited amino-aciduria resulting in abnormal urinary excretion of cystine and the dibasic aminoacids, lysine, arginine and ornithine. Formation of cystine kidney stones, recurrent infections and subsequent renal failure are the main complications of the disease. Recently, the gene SLC3A1 and SLC7A9, encoding the two subunits rBAT et b0,+AT of the proximal renal transporter complex, have been identified. In this article, we report the medical history of a 30-year-old patient and discuss the recent molecular progress, the clinical evolution, and the medical treatment of the cystinuria.

Pneumatic lithotripter application for giant bladder stone in a patient with augmentation cystoplasty

An 18-year-old patient with repaired bladder exstrophy developed a 550-g stone burden in his augmented bladder. The stones were removed percutaneously with the aid of a pneumatic lithotripter. This should be considered the method of choice in these difficult cases.

Urodynamic findings before and after noninvasive management of bladder calculi

OBJECTIVES

To determine the most frequent urodynamic observations associated with bladder calculi, and to assess whether the presence of calculi alters these observations.

PATIENTS AND METHODS

Fifty patients with bladder stones were included in a prospective study in which two urodynamic tests were used, one at inclusion and another once the patient was stone- free after treatment by noninvasive methods (mainly extracorporeal shockwave lithotripsy).

RESULTS

The results from the urodynamic evaluation with the stone in the bladder were: bladder outlet obstruction in 51%, detrusor overactivity in 68%, detrusor under-activity in 10%, and a normal study in 18%. There were no significant differences between the urodynamic study before or after treatment in maximum flow rate and postvoid residual volume, detrusor overactivity and detrusor pressure at maximum flow.

CONCLUSIONS

Conversely to what has been accepted for years, bladder calculi are not always associated with bladder outlet obstruction and the urodynamic results are not influenced by the presence of bladder stones during the urodynamic testing.

[Two cases of encrusted cystitis]

Encrusted cystitis is a type of severe cystitis, which progresses chronically and is characterized by excessively alkaline urine and calcifications within the bladder wall. We report two cases of encrusted cystitis. Both cases were high aged and had severe anemia with chronic cystitis. They complained of gross hematuria, voiding frequency and pain upon urination. Urine pH was 8-9, and urine cytology was negative. Urine culture contained Corynebacterium Group D2. Abdominal computed tomography and transurethral resection revealed wall bladder wall calcification and inflammatory change. We diagnosed it as encrusted cystitis. The patients underwent excision of plaques of calcified encrustation, adapted antibiotic therapy and acidification of urine. It is essential to diagnose encrusted cystitis early and to provide adequate treatment promptly.

[Bladder calculi. Is extracorporeal shock wave lithotripsy the first choice treatment?]

OBJECTIVES

To evaluate the effectiveness of extracorporeal shock wave lithotripsy (ESWL) treatment of bladder stones using a retrospective study.

METHODS

Between February 1991 and June 2002, 45 patients with bladder stones were treated (41 males and 4 females). Age ranged from 23 to 87 years. 63% had previous renal-ureteral lithiasis and 29% had undergone upper urinary tract ESWL. We used the Storz Modulith SL 10/SL 20. Treatments were performed using intravenous analgesia on an outpatient basis.

RESULTS

83 sessions of ESWL were performed on 53 stones. Complete fragmentation and elimination was achieved in 55% of the patients after a single session, 26.7% of the patients after 2 sessions, 6.7% after 3 sessions, 8.8% four, and 2.2% five. Mean number of shock waves was 3196.3 with an average 7-8 Kv. 8.5% had stone recurrence due to residual lithiasis, whereas 79% achieved total elimination. 13% required endoscopic procedures to evacuate stone fragments impacted in urethra. 6.6% required transurethral prostatic resection after ESWL.

CONCLUSIONS

ESWL therapy is an effective option for the treatment of patients with bladder stones, non invasive, with low morbidity, without need for anesthesia, and outpatient. The effectiveness is high (79% of the patients stone free) and even higher when treating smaller stones.

Vesical Calculi With Unrepaired Vesicovaginal Fistula: A Clinical Appraisal of an Uncommon Association

PURPOSE

Primary vesical calculi are uncommon in patients with vesicovaginal fistula (VVF). We retrospectively analyzed 19 such cases and present our experience with the management of this condition.

MATERIALS AND METHODS

Between January 1989 and December 2002, 19 patients were treated for this association. All patients provided a history and underwent physical examination, metabolic evaluation for stone disease, urine culture test and cystovaginoscopic examination. They were treated with a staged procedure with the fistula repaired 2 to 3 months after stone removal.

RESULTS

VVF was a result of obstructed labor in all cases. The patients presented a mean of 28.8 months after fistula formation. No metabolic abnormality was detected in any patient. Urine culture was positive for Proteus mirabilis in 6 and Escherichia coli in 5, and it yielded mixed growth in 8. All women had some residual urine in the bladder (mean 11 ml). The fistula was located supratrigonally in 13 cases, while it was high trigonal in the remainder. A total of 17 patients were treated endoscopically by cystolitholapexy or fragmentation of the stone by transurethral cystolithotripsy using a Lithoclast (Microvasive Urology, Natick, Massachusetts). Two patients required open suprapubic cystolithotomy. All patients underwent fistula repair 3 months after stone removal with successful results in 16.

CONCLUSIONS

Primary vesical calculi in patients with VVF are associated with urinary contamination, a high or supratrigonal fistula location, residual urine in the bladder and a long history of disease. Staged management of the problem showed good results.

[Contact ureterolithotripsy by the Ho laser "Medialis H" by the firm "Dornier"]

The authors describe results of application of Ho laser "Medilas H" (Dornier) in patients with uroliths located in different parts of upper urinary tracts. The results of new approaches to uroliths fragmentation in different parts of the ureter are outlined.

[The frequency-doubled double-pulse Neodym:YAG laser lithotripter (FREDDY) in lithotripsy of urinary stones. First clinical experience]

Laser lithotripsy does not play an important role in urinary stone treatment, mostly due to ineffective fragmentation efficiency, and high purchase and maintenance costs. The aim of the following retrospective study was to show the clinical significance and efficiency of an innovative laser lithotripsy system for urinary stone treatment. Between November 1998 and October 1999, 48 patients were treated with the innovative frequency- doubled double-pulse Neodym: YAG laser lithotripter FREDDY. A total of 50 renal units were treated, 43 ureteroscopically, four ureterorenoscopically, three percutaneous-nephroscopically, and one bladder stone cystoscopically. With a median laser operation time of 5 min (range: 1-30 min) and a total procedure duration of 60 min (range: 15-180 min), a stone-free rate of upper ureteral stones of 62%, middle ureteral stones of 91% and distal ureteral stones of 100% were documented on the first day after treatment. In an observation period of 6 months, no complications were seen. In our experience Laser lithotripsy with FREDDY is an effective, simple and reliable method for the treatment of ureteral stones, with low purchase and maintenance costs. The extremely thin and highly flexible quartz fibre may extend the endoscopic spectrum to otherwise poorly accessible upper ureteral stones, the renal pelvis and renal calix stones. Therefore, a prospective validation study for comparison with ballistic lithotriptors is of great interest.

Franz von Paula Gruithuisen (1774-1852): lithotrity pioneer and astronomer. On the 150th anniversary of his death

On the occasion of the 150th anniversary of the death of Franz von Paula Gruithuisen, the authors present his life and work. His most significant work in the fields of urology and lithotrity is examined, with special emphasis on the development of the latter field. He published his epoch-making historic study in 1813 in the Journal of Medicine and Surgery (Medicinisch-Chirurgische Zeitung). Franz von Paula Gruithuisen, the Bavarian physician and astronomer, led the way in the field of lithotrity. He developed crucial ideas on how to remove bladder stones transurethrally in a way that was safer and less likely to cause death. His instruments can be regarded as the model on which subsequent devices are based. Gruithuisen's influence on European medical scientists and, in particular, his rivalry with Jean Civiale are discussed.

Spontaneous feeding tube knotting over a vesical calculus

A case of spontaneous feeding tube knotting over a vesical calculus, in a 3 years child, is presented which had evaded clinical diagnosis and was discovered at open cystolithotomy. A vesical calculus with a firm simple knot of feeding tube over it and stuck at internal urethral meatus was found. Feeding tube was cut and cystolithotomy performed. Postoperative follow-up was without complication.