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Volume 67, Number 11

OBSTETRICAL AND GYNECOLOGICAL SURVEY


Copyright * 2012
by Lippincott Williams & Wilkins

CME REVIEW ARTICLE

CHIEF EDITORS NOTE: This article is part of a series of continuing education activities in this Journal through
which a total of 36 AMA/PRA Category 1 Creditsi can be earned in 2012. Instructions for how CME credits
can be earned appear on the last page of the Table of Contents.

31

Urinary Bladder Stones in Women


Kobi Stav, MD* and Peter L. Dwyer, MB, BS, FRANZCOG
*Physician, Neurourology Unit, Department of Urology, Assaf Harofeh Medical Center, Zerifn, Israel Afliated
With Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; and Professor, Department of Urogynaecology,
Mercy Hospital for Women, Melbourne, Australia, Afliated With Melbourne University, Melbourne, Australia.

Purpose: The objective of this study was to review the history, epidemiology, diagnosis, and current
management techniques for bladder stones (BS) in women.
Methods: A MEDLINE search for articles published from 1950 to 2011 was done using a list of terms
related to BS including calculi, cystolithiasis, stones, urinary bladder, and women.
Results: Approximately 5% of all BS occur in women and are usually associated with foreign bodies
(sutures, synthetic tapes, or meshes) or urinary stasis. Bladder stones can be asymptomatic but may
result in hematuria, recurrent infections, and irritable symptoms. Stones can be detected by x-ray,
ultrasound, or computed tomography scan and frequently at the time of routine cystourethroscopy
performed during pelvic surgery. Because BS is a sign of an underlying problem, definite treatment of
the underlying abnormality is nearly always indicated. The preferred treatment for BS is endoscopic
transurethral fragmentation of the stone (cystolithotripsy). Any associated suture or synthetic mesh
can be removed or cut flush with the bladder mucosa. Partial resection of the mesh with cystotomy
should be considered whenever transurethral treatment failed. When stone burden is large, percutaneous endoscopic disintegration or open suprapubic cystolithotomy is preferable. Extracorporeal
shockwave lithotripsy has been demonstrated to be simple, effective, and well tolerated. However,
ancillary procedures are required in a significant number of patients.
Conclusions: The increased usage of synthetic material in reconstructive pelvic floor surgery in women
will probably increase the incidence of BS on intravesical foreign bodies. Bladder stones should be ruled
out in women investigated for irritable bladder symptoms or recurrent urinary infection.
Target Audience: Obstetricians and gynecologists, family physicians
Learning Objectives: After completing this CME activity, physicians should be better able to identify
risk factors for bladder stones, diagnose bladder stones, and compare the optional treatments for bladder
stones in women.

Bladder stones (BS) (cystolithiasis/bladder calculi)


refer to the presence of stones or calcified materials
in the urinary bladder. These stones are usually associated with urinary stasis or a foreign body, but they
can form in healthy individuals without evidence of

All authors and staff in a position to control the content of this CME
activity and their spouses/life partners (if any) have disclosed that
they have no financial relationships with, or financial interests in, any
commerical organizations pertaining to this educational activity.
Correspondence requests to: Kobi Stav, MD, Urology Department, Assaf Harofeh Medical Center, Zerifin 70300, Israel. E-mail:
stavkobi@yahoo.com.au.

anatomic defects or dysfunctional voiding. Bladder


stones in women can result in significant symptoms
and are a significant source of discomfort. In a busy
urogynecological or female urology practice, the finding of BS on sutures or synthetic mesh inside the
bladder after urogynecology procedures is a relatively
common occurrence in women investigated for irritable
bladder symptoms or recurrent urinary infection. Also,
gynecologists increasingly perform cystourethroscopy
at the time of pelvic surgery such as hysterectomy to
exclude urinary tract injury. Bladder pathology including cancer and stones may be an incidental finding but
will need to be diagnosed and treated appropriately.

www.obgynsurvey.com | 715

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Obstetrical and Gynecological Survey

A few contemporary series regarding BS exist in


the worldwide literature. In this article, we will review
the history, epidemiology, diagnosis, and current management techniques for BS in women.

the 1970s.6 Over the next decades, several other


modalities had been developed and allow safe transurethral stone fragmentation.7
EPIDEMIOLOGY

BACKGROUND AND HISTORY


Urinary BS have played a role in medicine
through the ages. The oldest BS discovered dates
back to 4800 BC and was found by archeologists in
Egypt around the turn of the 20th century.1 The first
literary references to BS date back to the time of
Hippocrates. Specialists for urinary stones must have
been in existence, as the Hippocratic Oath mentions
the treatment of stones. He warned that to cut
through the bladder is lethal, and his warning to
young physicians was to leave this highly risky and
complicated procedure to the lithotomists.2
Famous historical figures who had BS include
King Leopold I of Belgium, Napoleon Bonaparte,
Emperor Napoleon III, Peter the Great, Louis XIV,
George IV, Oliver Cromwell, Benjamin Franklin, the
philosopher Bacon, the scientist Newton, the physicians Harvey and Boerhaave, and the anatomist
Scarpa.2 Note that none of these people are women,
which may indicate the higher prevalence in men, but
also that stones in women were not considered worthy of documentation.
In Europe, during the 19th century, BS were usually diagnosed in children. Since the industrial revolution, improved nutrition and antimicrobial treatment
have eliminated pediatric BS in the Western world.3
However, in underdeveloped countries, children still
suffer from endemic primary BS.
Ammonius (200 BC), Celsus (first century), and the
Hindu surgeon Sushruta were among the first to write
about perineal lithotomy to treat BS.2,3 Pierre
Franco introduced suprapubic lithotomy in the 16th
century.4 An itinerant lithotomist Beaulieu performed the often-lethal procedure in France through
the early 1700s.5 Transurethral lithotripsy became
more common in the early 1800s. The Egyptian
physicians passed large wooden cannulas through the
urethra, followed by manual aspiration of the stones
from the bladder. A popular technique of the 1700s
involved passage of a long nail via the urethra; the
nail was then struck with a blacksmiths hammer,
fracturing the stone. Sir Philip Crampton was the first
to introduce the manual crushing concept in Dublin
(circa 1834). However, litholapaxy was not firmly
established until Henry J. Bigelow performed (1876)
and popularized (1878) the procedure.2 The mechanical crushing of stones remained popular until

The incidence of primary BS in the Western world


has been progressively declining since the 19th century because of improved nutrition and infection
control. Nowadays, BS represent 5% of all urinary
stones in the Western world.8
Bladder stones primarily affect men who are usually older than 50 years and have associated bladder
outlet obstruction due to benign prostatic hyperplasia
or carcinoma of prostate. Approximately 5% of all
BS occur in women.9 However, BS remain common
in less-developed countries and areas such as Thailand, Burma, Indonesia, the Middle East, and North
Africa. The prevalence of BS is declining in these
areas as well.7 No conclusive worldwide figures accurately reflect the frequency of BS. This is
mostly because of poor hospital records in developing countries.
ETIOLOGY
Predisposing factors for urinary BS formation are
summarized in Table 1. Bladder stones can be
formed de novo inside the urinary bladder or in the
kidneys. It is not uncommon for small crystals to
form in the urine of healthy people, as many of the
substances eliminated by the kidneys are barley soluble in water. A change in the acidity of urine can
change the chemical environment of the urine causing
crystals to form.3 If the crystals remain small enough,
they are flushed out without causing any symptoms.
Nutritional deficiencies in vitamin A, magnesium,
phosphate, and vitamin B6, combined with a lowprotein, high-carbohydrate diet and dehydration, are
implicated in the pathogenesis of pediatric BS, in
Africa and Middle East.10
An anatomical abnormality of the urinary tract is a
risk factor for BS by producing a stagnant area
that does not drain properly. Inappropriate drainage
of the bladder can be caused by outlet obstruction
(eg, pelvic organ prolapse, urethral stricture) or by
failure of the detrusor muscle to contract properly,
resulting in a significant postvoid residual volume of
urine.11 Detrusor dysfunction can be caused by
scarring (eg, previous pelvic radiation, aging) or a
result of neurological diseases. A unique functional
entity is detrusor sphincteric dyssynergia, which
causes bladder outlet obstruction. An injury to the

Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Urinary Bladder Stones in Women


TABLE 1
Predisposing Risk Factors for Cystolithiasis in Women
Anatomical abnormality
Bladder diverticulum
Urethral diverticulum
Vesicoureteral reflux
Bladder outlet obstruction
Pelvic organ prolapse
Urethral stricture
Bladder neck contracture
Urethral tumor
Detrusor dysfunction
Scarred detrusor
Post pelvic radiation
Postmultiple resections of bladder tumors
Aging
Recurrent infections
Neurologic causes
Multiple sclerosis
Cauda equine syndrome
Postpelvic surgery
Diabetes mellitus
B12 deficiency/tabes dorsalis
PostYcerebrovascular accidents
Spinal cord injury
Functional obstruction
Dysfunctional voiding
Detrusor sphincteric dyssynergia
Metabolic conditions
Hypercalcemia/hypercalciuria
Hyperuricemia/hyperuricosuria
Hyperphosphatemia/hyperphosphaturia
Hyperoxaluria
Cystinuria
Xanthinuria
High magnesium excretion (high magnesium/
plant-based diets)
Alkalic urineVusually due to infection with
ammonia-producing organisms
Acidic urineVdehydration, acidic diet, renal tubular acidosis
Foreign bodies
Synthetic sling/mesh
Nonabsorbable suture from previous surgery
Erosion of artificial sphincter
Tumors
Shattered Foley catheter balloon
Long-term bladder catheterization
Staples
Ureteral stents
Migrating contraceptive devices

spinal cord between the lower (S2-S4) and the upper


(pons) urinary centers can cause dissynchronization
between the external sphincter and the detrusor
muscle, resulting in increased bladder pressures and
large postvoid residual volume of urine.
Infection may cause supernaturation and heterogeneous nucleation around a nidus. In addition, aggregation results in crystal growth and stone formation.
Urinary tract infection with urea-splitting organisms

& CME Review Article

717

such as Proteus, Klebsiella, Serratia, and Enterobacter species produces alkaline urine, which promotes formation of struvite stones (ammonium
magnesium phosphate).12 The formation of calcium
phosphate stones is associated with acidic urine.3
Another etiologic factor for BS formation includes
foreign bodies in the bladder that act as a nidus for
stone formation. Foreign body stones of the urinary
bladder are mostly composed of a mixture of struvite
and carbonate apatite, which are components of infection stones.13 The most common foreign bodies in
the urinary bladder are iatrogenic mainly from
retained nonabsorbable sutures and more recently
synthetic slings (Fig. 1D) or mesh used for the
treatment of stress incontinence or pelvic organ
prolapse.14Y16 Any foreign body within the urinary
tract has lithogenic potential. There are numerous
reports concerning bladder migration of intrauterine
devices and intravaginal accessories, including pessaries, diaphragms, and cerclages.17 Stone formation
around the intravesical portion of midurethral sling or
suture of colposuspension for stress urinary incontinence is well documented.18 Intravesical sutures
occurring as a result of a Burch colposuspension or
Marshall-Marchetti-Krantz procedure are usually
found above the bladder neck at 1 and 11 oclock
with a 70-degree cystoscope (Fig. 1A).19 It is also in
this area that perforation of a tension-free vaginal
tape (TVT) and other minimally invasive retropubic
slings occur (Figs. 1C, D). Transobturator tapes can
also unintentionally penetrate the lower urinary tract
and are usually found in the urethra or bladder neck
area and can be missed especially if careful visualization with cystourethroscopy of both bladder and
urethra has not been performed postoperatively. The
presence of synthetic tape in the bladder can be due
to misdiagnosis of bladder perforation during the
procedure or due to erosion or protrusion over time.
In general, if there is no clear etiology for BS such
as a foreign body, a urological evaluation must be
undertaken to find a cause for urinary stasis.
SYMPTOMS AND CLINICAL
PRESENTATION
Although a stone of only a few millimeters can
cause severe pain if it gets held up during its travel
through the ureter (renal colic), a BS can be of several centimeters and not cause symptoms. Many BS
are asymptomatic and are found incidentally. When
the stones are small, they may pass out in the urine
and cause no symptoms at all. Patients with significant bladder outlet obstruction may initially present

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718

Obstetrical and Gynecological Survey

FIG. 1. Bladder stones due to synthetic foreign bodies. A, Stone attached to nonabsorbable Burch colposuspension suture. B, Ethibond
suture with encrustation and stone formation. C, Bladder perforation of TVT diagnosed during the procedure. D, A close view of early
encrustation on a TVT sling.

with lower urinary tract symptoms or persistent urinary tract infections, especially with a urea-splitting
organism.
The most common clinical presentation is irritating
symptoms such as dysuria, pain, incontinence, urinary urgency, and frequency. Pain usually occurs
near the end of micturition as the bladder mucosa
closes down and as the stone impacts on the bladder
neck. Urinary urgency is present in 40% to 50% of
patients.17
Bladder stones can cause gross hematuria; typically, the blood will appear toward the end of urination. Bladder stones can block the bladder outlet or
urethral lumen, resulting in voiding difficulties and
intermittent urinary flow, inability to urinate except
in certain positions, and rarely acute urinary retention. Interruption of the stream is present in 30% to
40% of patients.17
Rarely, BS may obstruct the ureteral orifices,
resulting in hydronephrosis and renal failure. In most
cases, the hydronephrosis is a direct sequela of the
underlying pathology (eg, bladder outlet obstruction)
and not by the stone itself.
Long-standing and untreated BS may result in
dysplasia and squamous cell carcinoma of the bladder. Continuous mucosal injury, disruption of the

protective glycosaminoglycan layer, and subsequent


inflammation secondary to stones substantiate the
correlation between bladder carcinogenesis and BS.3
DIAGNOSIS AND WORKUP
Table 2 lists the optional diagnostic modalities for
BS. Bladder stones can be associated with urinalysis
results that are positive for nitrite, leukocyte esterase,
and blood. Because BS usually cause dysuria, many
patients reduce their daily fluid intake and raise their
urine-specific gravity. Adults with uric acid bladder
calculi are expected to have an acidic pH. Microscopy usually demonstrates red blood cells and pyuria.
Microscopic crystals are usually consistent with the
composition of the stone. Urine cultures help to
document and direct treatment of associated infections. In these patients, the white blood cell count
may be elevated in a full blood examination. The
serum creatinine level may be elevated in patients
with urinary retention.
A BS can be detected by x-ray, ultrasound, computed tomography (CT) scan, or by direct vision
through a cystoscope. Magnetic resonance imaging has virtually no role in the current evaluation of
BS. Detection of most stones is not possible with

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Elevated

Calcification

& Many calcifications are not stones (eg, phleboliths,


calcified lymph nodes, granulomas)
& Some calcium stones may not be seen in x-ray
because of small size, overlying gas, stool, or bone
& Radiolucent stones are not visualized (uric acid
and cystine)
Hyperechoic object with posterior shadowing

Serum creatinine

Plain abdominal x-ray

Bladder ultrasound

Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Any type of stone

Calcium stones

& Advantages: high sensitivity and specificity, fast,


no need for intravenous contrast material,
and can reveal other pathology
& Disadvantages: relatively high radiation dose
exposure, cannot assess renal function, and
relatively expensive
HU density 91000

Direct visualization of the stone

Uric acid stones

HU density G600

CT scanning

Cystoscopy

Calcification within the urinary collecting system


Radiopaque stones
& Disadvantages: the need for intravenous contrast
material, which may provoke an allergic reaction or
renal failure, and the need for multiple delayed films
Filling defect
Radiolucent stones

Effective in identifying all types of stones

May appear in any type of stones


Uric acid stones
May appear in any type of stones
Consistent with the type of the crystal
May be positive in any type of stones
whenever the urine is infected
May be elevated in any type of stones
whenever obstructive uropathy occurs
Calcium-containing stones

Stone Type

Intravenous pyelography

Urine culture

Urine microscopy

Findings

Nitrite, leukocyte and erythrocyte


Acidic urine
Erythrocyte and leukocyte
Crystals
Positive

Urinalysis

Diagnostic Modality

TABLE 2
Optional Diagnostic Modalities for Bladder Stones

Disadvantages of CT scanning: it exposes the


patient to a relatively high radiation dose (and
thus should not be performed
on pregnant women); it cannot be used
to assess individual renal function; it is
relatively expensive
Advantages: assess stones number, size, and
location; evaluation of the anatomy of the
urethra and bladder; identify concomitant
pathologies (eg, strictures, diverticula, tumors,
and foreign bodies)

Filling defect can be other pathology within the


collecting system (eg, tumor, blood clot,
papillary necrosis, or fungus ball)
& Currently the modality of choice for detecting
any stones within the urinary system

Renal ultrasound is advised to rule out renal


stones and hydronephrosis
& Helpful in demonstrating renal function

Renal failure can evolve even in unilateral


obstruction
& Useful for assessing total stone burden, size,
and shape

White blood cell count may be elevated

Comments

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Obstetrical and Gynecological Survey

magnetic resonance imaging, and it should not be


used for that purpose in most instances.20 Magnetic
resonance imaging is generally more expensive than
other studies, such as CT scans, which reveal stones
much better.
Plain abdominal x-ray is useful for assessing
total stone burden, as well as the size, shape, and
composition BS in most patients. The study of
choice is plain radiography of the kidneys, ureters,
and bladder. Not all BS may be visible on the x-ray,
whether because of their small size, stone radiolucency, or overlying gas, stool, or bone. Calciumcontaining stones are radiopaque, but pure uric acid,
indinavir-induced (antiretroviral/HIV drug, a protease
inhibitor), and cystine calculi are relatively radiolucent on plain radiography. Many calcifications observed on x-ray radiograph are phleboliths, vascular
calcifications, calcified lymph nodes, appendicoliths,
granulomas, various calcified masses, or even bowel
contents. All can be confused with BS.
Bladder ultrasound is frequently used to determine the presence of a BS. Renal ultrasound is advised to rule out renal stones and hydronephrosis.
The study is mainly used alone in pregnancy or in
combination with plain abdominal radiography.21 The
sonogram, showing a classic hyperechoic object with
posterior shadowing, is effective in identifying both
radiolucent and radiopaque stones.22 A stone easily
identified with ultrasonography but not visible on the
plain radiograph may be a uric acid or cystine stone.
Before the advent of helical CT, intravenous
pyelography (IVP) was the test of choice in diagnosing urinary tract stones. The main advantage of IVP
is the clear outline of the entire urinary system that it
provides. Intravenous pyelography is helpful in identifying the specific problematic stone among numerous pelvic calcifications, as well as in demonstrating
renal function. Intravenous pyelography can also show
nonopaque stones as filling defects. Disadvantages
include the need for intravenous (IV) contrast material,
which may provoke an allergic reaction or renal failure, and the need for multiple delayed films, which
can take several hours. In addition, IVP may fail to
reveal alternative pathology if a stone is not discovered, delaying the final diagnosis.
During the last 2 decades, CT scanning has replaced IVP for the assessment of urinary tract stone
disease, especially for acute renal colic. Computed
tomography scans are readily available in most hospitals and can be performed in a few minutes. Numerous
studies have demonstrated that CT has a sensitivity of
95% to 100% and superior specificity when compared
with IVP.23

A noncontrast CT scan with thin collimation of


2- to 3-mm slices of the abdomen and pelvis, taken
through the kidneys and bladder areas, is considered the test of choice. No oral or IV contrast is
used, because contrast material obscures any calciumcontaining stones; both the stone and the contrast
material would appear bright on the scans. Advantages of CT scanning include the following: it can
be performed quickly (G5-min acquisition time); it
avoids the use of IV contrast materials; and it can
reveal other pathology, and the density of the stone
can assist in predicting stone composition. A radiolucent stone that is not visible on the x-ray that is
visible on the CT scan may indicate a uric acid calculus. This suggests a different diagnosis and therapy
(urinary alkalinization) than for a calcium stone. The
Hounsfield unit (HU) density of the calculus on CT
scanning can also be useful in predicting whether
the stone is composed of uric acid. The mean peak
Hounsfield reading of uric acid stones is 477 T 108 HU,
whereas the mean for calcium stones is 1139 T
40 HU.24 However, because many stones have mixed
mineral composition, there might be densities overlapping. Disadvantages of CT scanning include the
following: it exposes the patient to a relatively high
radiation dose (and thus should not be performed on
pregnant women); it cannot be used to assess individual renal function; and it is relatively expensive.
Cystoscopy allows for the visualization of
stones and assessment of their number, size, and location. Single stones are usually encountered in the
bladder, but multiple stones are seen in 25% to 30%
of cases (Fig. 2).9 In addition, examination of the
urethra, bladder wall, and ureteral orifices allows identification of concomitant pathologies such as strictures,
bladder diverticula, and tumors.25
A biochemical stone profile analysis and metabolic evaluation are indicated in patients with uric
acid stones, concurrent upper tract stones, family history of stone disease, BS without obstruction, and
recurrent stones. Specific metabolic evaluation generally requires the collection of 2 consecutive 24-hour
urine samples. For the initial specific metabolic workup,
the patient should be stone-free. A minimum of
20 days is recommended between stone expulsion or
removal and 24-hour urine collection.26 Preanalytical
inaccuracies can be min-imized by carrying out urinalysis immediately after urine collection has finished.
Urine pH should be assessed during the collection of
freshly voided urine 4 times daily.27,28 The evaluation includes blood test for electrolytes (creatinine,
sodium, potassium, calcium, uric acid, chloride, and
phosphate) and 24-hour urine collection (pH, creatinine,

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721

FIG. 2. Bladder stones visualized during cystoscopy.

calcium, oxalate, uric acid, citrate, magnesium, inorganic phosphate, ammonium, cystine).27,28
TREATMENT
The current literature is lacking of studies on
women with BS, most likely because of the low incidence of the disease in the Western world. There
are numerous case reports and only 1 case series on
women with BS,29 which make it almost impossible to conclude and produce recommendations and
guidelines regarding management and treatment of
BS specifically in women. However, with the increasing use of cystoscopy during pelvic surgery, and
synthetic grafts for urinary stress incontinence and
pelvic organ prolapse, gynecologists will need to deal
with this complication more and more.
Because BS is a sign of an underlying problem,
removal of the stone and definite treatment of the
underlying abnormality are nearly always indicated.
Recurrence of BS is likely if the primary etiology is
not addressed.
The only potentially effective medical treatment
for BS is urinary alkalinization for the dissolution
of uric acid and cystine stones. Stone dissolution may
be possible if the urinary pH is equal to or greater
than 6.5. Sodium bicarbonate can be used as the
alkalizing agent, but potassium citrate (60 mEq/d) is
usually preferred because of the availability of slowrelease tablets and the avoidance of a high sodium
load. The dosage of the alkalizing agent should be
adjusted to maintain the urinary pH between 6.5 and
7.0. Urinary pH of more than 7.5 should be avoided
because of the potential deposition of calcium phosphate around the uric acid calculus, which would make
it nondissolvable.25
Small BS can be irrigated out of the bladder
through the cystoscope sheath or may be grasped

with a basket or endoscopic forceps. Any associated


suture or synthetic mesh can be removed or cut flush
with the bladder mucosa. Usually, there is no need
to remove the entire mesh. If transurethral resection
failed to remove the exposed mesh, then partial resection with cystotomy should be considered. In most
of the cases, some form of energy will be required to
break the stone.
Lithotripsy refers to the physical destruction
of stones in the body. The term is derived from the
Greek words meaning breaking stones. Cystolithotripsy means breaking BS into small fragments under
vision using endoscopic device. Some use the term
cystolitholapaxy which means wash away BS,
but both refer to the same procedure.
The type of the scope may be cystoscope, ureteroscope, or nephroscope, depending on the number
and size of the stones and on the surgeon preference.
An energy source is used to break the stone, and
the fragments are extracted through the cystoscope.
The energy source is usually introduced through the
working channel. Sources of energy may be mechanical (ie, lithoclast [pneumatic jack hammer]), ultrasonic,
electrohydraulic (ie, EHL [spark-induced pressure
wave]), manual lithotrite, and holmium:YAG laser.30,31
Electrohydraulic should be used with caution in
patients with small-capacity bladders and those with
cardiac-pacing or defibrillation devices. Common complications of endoscopic lithotripsy include urinary infection (11%), fever (9%), bladder perforation (2%),
hyponatremia (2%), and hemorrhage (1%).32,33 Instruments generally used for cystolithotripsy are illustrated in Figure 3.
Extracorporeal shockwave lithotripsy (ESWL)
uses shock waves to break stones into small pieces that
can more easily travel through the urinary tract and
pass out from the body. Extracorporeal shockwave
lithotripsy is the criterion standard treatment for kidney

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722

Obstetrical and Gynecological Survey

stones (nephrolithiasis) smaller than 25 mm and for


upper ureteral stones. However, studies on ESWL as
treatment for BS are scarce. Unlike in renal and most
ureteral stones, ESWL has shown little efficacy for
BS in most centers.34 Husain et al35 used the Dornier
HM3 lithotripter for initial BS reduction preparatory to transurethral lithotripsy. The logic behind this
protocol was that breaking large stones with endoscopic devices can be time-consuming or even hazardous. They described their experience on 24 patients
(23 men, 1 women) presenting 31 large BS (mean
size, 35.6 mm). In all patients, primary transpelvic

ESWL was followed immediately by endoscopic evacuation of stone debris or cystolithotripsy. They reported a success rate of 83% with minimal morbidity
and a mean hospital stay of 3.5 days.35 Several other
studies have demonstrated that results are similar between the different types of lithotripters.36Y38 However, because ESWL does not address etiology nor
does it usually remove all fragments, it should not
be considered as a first-line treatment for the vast
majority of adults with BS. Pregnancy is a relative
contraindication to ESWL, EHL, and mechanical
lithotripsy. Nonetheless, the benefits of eliminating a

FIG. 3. Instruments commonly used for cystolithotripsy. A, Rigid cystoscope. B, Rigid nephroscope. C, Endoscopic grasper. D, Manual
endoscopic lithotrite stone crusher. E, Lithoclast. F, Ultrasonic lithotripter. G, Laser fiber. H, Electrohydraulic lithotripter (EHL). I,
Endoscopic basket.

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723

source of infection or discomfort with other modalities (eg, holmium laser) may outweigh the risk of
intervention.39
In general, most BS procedures are performed
in transurethral approach. However, when the stone
burden is large, or the stone is too hard, or if the
patients urethra is too small or deformed, the suprapubic open or endoscopic approaches are preferable.40
The percutaneous route allows the use of shorterand larger-diameter endoscopic equipment (usually
with an ultrasonic lithotripter), which allows rapid
fragmentation and evacuation of the stones. Success
rates for percutaneous procedures range from 85% to
100% with various energy sources.41 Contraindications to percutaneous procedure include a history of
bladder malignant disease, prior abdominal or pelvic
surgeries, prior pelvic radiotherapy, active urinary or
abdominal wall infection, and pelvic prosthetic devices
(eg, mesh for hernia repair, artificial urinary sphincter).42
In open procedure, the stones are extracted
through an incision of the bladder (cystolithotomy)
(Fig. 4). For very large stone burdens or hard stones,
cystolithotomy is certainly the most efficient. Other
indications are abnormal anatomy precluding safe access, failure of an endoscopic approach, and concomitant open bladder diverticulectomy.6
Comparative studies concerning the treatment
of BS are scanty. Bhatia and Biyani6 treated 128
patients with open cystolithotomy (5 patients), manual litholapaxy (80 patients), or ESWL (43 patients).
Open surgery resulted in 100% stone removal at
1 session, but required mean hospital stay of 5.2
days. Manual litholapaxy had the biggest complication rate (25%), including bladder perforation, intraoperative bleeding, and urethral stricture, whereas
it resulted in a mean hospital stay of 2.4 days. Extracorporeal shockwave lithotripsy had the shortest

hospitalization time (20 hours), but in 4 patients, additional ESWL was required for complete fragmentation.
Razvi et al43 compared the efficacy of several endoscopic lithotripsy devices in 106 patients
(97 men and 9 women): manual lithotripsy (n = 53),
ultrasonic (n = 17), EHL (n = 16), and Lithoclast
(n = 20). The success rates were 90%, 88%, 63%,
and 85%, whereas the complication rates were 10%,
12%, 8%, and 33%, respectively.
A recent randomized study44 compared 3 different lithotripsy techniques in 67 patients: transurethral removal using a nephroscope (n = 22),
transurethral removal using a cystoscope (n = 20),
and percutaneous removal using a nephroscope
(n = 23). A significant difference was observed in
operating time: group 1 (32.1+ 8.5 minutes), group 2
(69.2 +16.3 minutes), and group 3 (46 + 7.3 minutes).
Statistically significant difference was also observed
in the postoperative stay of the patient, which was
highest for the group 3 patients. Complete clearance
was achieved in all the patients. The male-to-female
ratio was 3:1. No statistical significance was found in
all the groups regarding age, sex, and stone size.
Maheshwari45 described a novel and efficient
transurethral technique treating 2 women with large
BS (96 cm). A 26F nephroscope and intracorporeal
ultrasonic lithotripsy were used in both. The urethra
was gradually dilated to 28F using female urethral
dilators; an Amplatz Teflon dilator was gradually
introduced in the urethra. A 28F Amplatz sheath was
slowly guided into the bladder over the Amplatz dilator, which was then removed, leaving the Amplatz
sheath in the urethra. Advantages of this method include atraumatic entry as the sheath protects the
urethra; fragments can be easily washed out of the
bladder because of the wide-access sheath and reduced procedural time.

FIG. 4. Bladder stones extracted through abdominal open approachVsuprapubic cystolithotomy. A, a spiculated jackstone. B, Multiple
round stones.

Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

724

Obstetrical and Gynecological Survey

PREVENTION

& IN

THE ABSENCE OF ANATOMIC ABNORMALITIES, OB-

STRUCTION, OR INFECTION, ONE MUST CONSIDER DYS-

Because BS can often relapse, it is vital to reduce the chances of this happening. Primarily, it is
essential that any pathology or abnormality of the
urinary tract should be treated. Moreover, any underlying medical condition, such as gout, should be
controlled and treated properly. All stone formers,
independent of their individual risk, should follow
general preventive measures. The main focus of these
general preventive measures is normalization of the
patients dietary habits and lifestyle risks.
Patients should be instructed to increase fluid
intake (2.5Y3 L/d), drink natural pH beverages, and
maintain circadian drinking. Patients should avoid
excessive salt (4Y5 g/d), calcium (1000Y1200 mg/d),
protein intake (0.8Y1.0 g/kg/d), and vitamin supplements.46Y50 Reducing dietary calcium beyond normal
in patients with hypercalciuria may worsen their stone
disease, because more oxalate is absorbed from the
gastrointestinal tract in the absence of sufficient intestinal calcium to bind with it. This results in an increase in oxalate absorption and hyperoxaluria, which
tends to increase new stone formation.50
Prophylaxis of uric acid and cystine stones
consists of long-term alkalinization of urine.51 If a
patient with pure uric acid stones has hyperuricosuria
or hyperuricemia, allopurinol (300 mg every day) is
recommended because it reduces uric acid excretion.52
Pharmaceuticals that can bind free cystine in the
urine (eg, D-penicillamine, 2->-mercaptopropionylglycine) help reduce stone formation in cystinuria.53
Intraoperative cystoscopy is appropriate during
anti-incontinence surgery, prolapse surgery, and any
other pelvic surgery where the lower urinary tract is
at risk of injury or inadvertent placement of synthetic
suture or graft. Likewise, women who present after
urogynecological procedures with significant lower
urinary tract symptoms especially with recurrent urinary tract infections undergo a cystoscopic examination
to rule out this complication.19 A complete excision of
the intravesical foreign body is advised to prevent
recurrent stone formation.
CONCLUSIONS AND RECOMMENDATIONS
Bladder stones remain a clinical problem in
both developing and developed countries. Currently,
there are no studies that evaluated the management
and treatment of BS specifically in women. However, several recommendations for management and
treating BS in women can be made by extracting information from available studies:

FUNCTIONAL VOIDING OR METABOLIC DISORDER AS


ETIOLOGIES FOR

& IN

BS.
BS

WOMEN WITH

AND A HISTORY OF PREVIOUS

PELVIC FLOOR SURGERY WITH SYNTHETIC MESHES OR


SLINGS, INTRAVESICAL FOREIGN BODY SHOULD BE RULED
OUT AS PRIMARY CAUSE FOR

BS

FORMATION WITH

DIAGNOSTIC CYSTOURETHROSCOPY.

& PELVIC

ULTRASOUND IS A GOOD IMAGING MODALITY

FOR SCREENING.

HOWEVER, CT IS PROBABLY THE MOST


BS.

ACCURATE AND SENSITIVE MODALITY FOR

& REMOVAL OF THE STONE AND DEFINITE TREATMENT OF


THE UNDERLYING ABNORMALITY ARE NEARLY ALWAYS
INDICATED.
& IF INFECTIOUS, OBSTRUCTIVE, AND NEUROGENIC CONDITIONS CAN BE ADDRESSED EARLY, BS CAN BE AVOIDED
IN MOST SITUATIONS.
& THE PREFERRED TREATMENT FOR BS IS ENDOSCOPIC TRANSURETHRAL FRAGMENTATION OF THE STONE

(CYSTOLITHOTRIPSY). USUALLY, ENERGY IS REQUIRED


TO BREAK THE STONE (LASER, ULTRASONIC, MECHANICAL, LITHOCLAST, OR EHL).
& ANY ASSOCIATED SUTURE OR SYNTHETIC MESH CAN BE
REMOVED OR CUT FLUSH WITH THE BLADDER MUCOSA.
PARTIAL RESECTION OF THE MESH WITH CYSTOTOMY
SHOULD BE CONSIDERED WHENEVER TRANSURETHRAL
TREATMENT FAILED.

& WHEN

STONE BURDEN IS LARGE, PERCUTANEOUS ENDO-

SCOPIC DISINTEGRATION OR OPEN SUPRAPUBIC CYSTOLITHOTOMY IS PREFERABLE.


& EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY HAS BEEN
DEMONSTRATED TO BE SIMPLE, EFFECTIVE, AND WELL
TOLERATED. HOWEVER, ANCILLARY PROCEDURES ARE
REQUIRED IN A SIGNIFICANT NUMBER OF PATIENTS.
& PREGNANCY IS A RELATIVE CONTRAINDICATION TO
ESWL, EHL, AND MECHANICAL LITHOTRIPSY.

REFERENCES
1. Shattock SG. A prehistoric or predynastic Egyptian calculus.
Trans Pathol Soc Lond. 1955;6:275.
2. Ellis H. A History of Bladder Stone. Blackwell Scientific
Publications. Oxford: England; 1969.
3. Schwartz BF, Stoller ML. The vesical calculus. Urol Clin North
Am. 2000;27:333Y346.
4. Bouchet H. Surgery of bladder lithiasis in the 19th century.
Ann Chir. 1999;53:908Y914.
5. Ganem JP, Carson CC. Fre`re Jacques Beaulieu: from rogue
lithotomist to nursery rhyme character. J Urol. 1999;161:
1067Y1069.
6. Bhatia V, Biyani CS. Vesical lithiasis: open surgery versus
cystolithotripsy versus extracorporeal shock wave therapy. J
Urol. 1994;151:660Y662.
7. Huffman JL, Ginsberg DA. Calculi in the bladder and urinary
diversions. In: Coe FL, Favus MJ, Pak CY, et al, eds. Kidney
Stones: Medical and Surgical Management. Philadelphia, PA:
Lippincott-Raven; 1996:1025Y1034.

Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

725
8. Yoshida O. A chronological and geographical study on
urolithiasis in Japan. Jpn J Endourol ESWL. 1990;3:5.
9. Drach GW. Urinary lithiasis: etiology, diagnosis, and medical
management. In: Walsh PC, Retick AB, Stamey TA, et al,
eds. Campbells Urology. 6th ed. Philadelphia, PA: WB
Saunders; 1992:2085Y2156.
10. Ali SH, Rifat UN. Etiological and clinical patterns of childhood
urolithiasis in Iraq. Pediatr Nephrol. 2005;20:1453.
11. Wai CY, Margulis V, Baugh BR, et al. Multiple vesical calculi
and complete vaginal vault prolapse. Am J Obstet Gynecol.
2003;189:884Y885.
12. Grenabo L, Hedelin H, Petterson S. Adherence of ureaseinduced crystals to rat bladder epithelium. Urol Res. 1988;
16:49.
13. Vermeulecn W, Grove WJ, Goetz R, et al. Experimental urolithiasis. Development of calculi upon foreign bodies surgically
introduced into bladders of rats. J Urol. 1950;64:541Y548.
14. Hick EJ, Hernandez J, Yordan R, et al. Bladder calculus
resulting from the migration of an intrauterine contraceptive
device. J Urol. 2004;172:1903.
15. Rafique M. Vesical calculus formation on permanent sutures.
J Coll Physicians Surg Pak. 2005;15:373Y374.
16. Arunkalaivanan AS, Smith AR. Bladder calculus after laparoscopic colposuspension. J Coll Physicians Surg Pak. 2005;
15:373Y374.
17. Papatsoris AG, Varkarakis I, Dellis A, et al. Bladder lithiasis:
from open surgery to lithotripsy. Urol Res. 2006;34:163Y167.
18. Irer B, Aslan G, Cimen S, et al. Development of vesical calculi
following tension-free vaginal tape procedure. Int Urogynecol
J Pelvic Floor Dysfunct. 2005;16:245.
19. Dwyer PL, Carey MP, Rosamilia A. Suture injury to the urinary
tract in urethral suspension procedures for stress incontinence. Int Urogynecol J. 1999;10:15Y21.
20. Richard SB, Fergus VC. Imaging of urinary stone disease. In:
Marshall LS, Maxwell VM, eds. Urinary Stone Disease: The
Practical Guide to Medical and Surgical Management. New
Jersey: Humana Press; 2007:371Y402.
21. Pais VM Jr, Payton AL, LaGrange CA. Urolithiasis in pregnancy. Urol Clin North Am. 2007;34:43Y52.
22. Huang WC, Yang JM. Sonographic appearance of a bladder
calculus secondary to a suture from a bladder neck suspension. J Ultrasound Med. 2002;21:1303Y1305.
23. Jindal G, Ramchandani P. Acute flank pain secondary to
urolithiasis: radiologic evaluation and alternate diagnoses.
Radiol Clin North Am. 2007;45:395Y410.
24. Chevreau G, Troccaz J, Conort P, et al. Estimation of urinary
stone composition by automated processing of CT images.
Urol Res. 2009;37:241Y245.
25. Ho K, Segura J. Lower urinary tract calculi. In: Wein A,
Kavoussi L, Novick A, et al, eds. Campbell-Walsh Urology.
9th ed. Philadelphia, PA: Saunders Elsevier; 2007:2663Y2673.
26. Shekarriz B, Stoller ML. Uric acid nephrolithiasis: current
concepts and controversies. J Urol. 2002;168:1307Y1314.
27. Tiselius HG. Aetiological factors in stone formation. In:
Davison AM, Cameron JS, Grunfeld J-P, et al, eds. Oxford
Textbook of Clinical Nephrology. 3rd ed. Oxford: Oxford
University Press; 2005:1201Y1223.
28. Low RK, Stoller ML. Uric acidYrelated nephrolithiasis. Urol Clin
North Am. 1997;24:135Y148.
29. Mhiri MN, Bayoudh H, Mhiri C, et al. Bladder calculi in women.
10 cases. J Gynecol Obstet Biol Reprod. 1990;19:979Y982.
30. Teichman JM, Rogenes VJ, McIver BJ, et al. Holmium:
yttrium-aluminum-garnet laser cystolithotripsy of large bladder
calculi. Urology. 1997;50:44Y48.

31. Raney AM. Electrohydraulic cystolithotripsy. Urology. 1976;7:


379Y381.
32. Tugcu V, Polat H, Ozbay B, et al. Percutaneous versus
transurethral cystolithotripsy. J Endourol. 2009;23:237Y241.
33. Stoller ML, Gentle DL. Transurethral cystolitholapaxy. In:
Graham SD, ed. Glenns Urologic Surgery, 5th ed. Philadelphia, PA: Lippincott-Raven, 1998:979Y983.
34. Losty P, Surana R, ODonnell B. Limitations of extracorporeal
shock wave lithotripsy for urinary tract calculi in young
children. J Pediatr Surg. 1993;28:1037Y1039.
35. Husain I, el-Faqih SR, Shamsuddin AB, et al. Primary
extracorporeal shockwave lithotripsy in management of large
bladder calculi. J Endourol. 1994;8:183Y186.
36. Kostakopoulos A, Stavropoulos NJ, Makrichoritis C, et al. Extracorporeal shock wave lithotripsy monotherapy for bladder
stones. Int Urol Nephrol. 1996;28:157.
37. Bhatia V, Biyani CS. Extracorporeal shock wave lithotripsy for
vesical lithiasis: initial experience. Br J Urol. 1993;71:695.
38. Kojima Y, Yoshimura M, Hayashi Y, et al. Extracorporeal shock
wave lithotripsy for vesical lithiasis. Urol Int. 1998;61:35.
39. Egwuatu VE. Bladder calculus with pregnancy. J Urol.
1980;123:954Y955.
40. Tzortzis V, Aravantinos E, Karatzas A, et al. Percutaneous
suprapubic cystolithotripsy under local anesthesia. Urology.
2006;68:38Y41.
41. Ikari O, Netto NR Jr, DAncona CA, et al. Percutaneous
treatment of bladder stones. J Urol. 1993;149:1499Y1500.
42. Badlani GH, Douenias R, Smith AD. Percutaneous bladder
procedures. Urol Clin North Am. 1990;17:67Y73.
43. Razvi HA, Song TY, Denstedt JD. Management of vesical
calculi: comparison of lithotripsy devices. J Endourol. 1996;
10:559.
44. Singh KJ, Kaur J. Comparison of three different endoscopic
techniques in management of bladder calculi. Indian J Urol.
2011;27:10Y13.
45. Maheshwari PN. The Amplatz sheath in the female urethra: a
safe and effective approach for cystolitholapaxy. Br J Urol.
1998;82:754.
46. Borghi L, Meschi T, Amato F, et al. Urinary volume, water and
recurrences in idiopathic calcium nephrolithiasis: a 5-year
randomized prospective study. J Urol. 1996;155:839Y843.
47. Siener R, Ebert D, Nicolay C, et al. Dietary risk factors for
hyperoxaluria in calcium oxalate stone formers. Kidney Int.
2003;63:1037Y1043.
48. Gettman MT, Ogan K, Brinkley LJ, et al. Effect of cranberry
juice consumption on urinary stone risk factors. J Urol.
2005;174:590Y594.
49. Auer BL, Auer D, Rodger AL. The effects of ascorbic acid
ingestion on the biochemical and physicochemical risk factors
associated with calcium oxalate kidney stone formation. Clin
Chem Lab Med. 1998;36:143Y147.
50. Fink HA, Akornor JW, Garimella PS, et al. Diet, fluid, or
supplements for secondary prevention of nephrolithiasis: a
systematic review and meta-analysis of randomized trials.
Eur Urol. 2009;56:72Y80.
51. Barcelo B, Wuhl O, Servitge E, et al. Randomized double-blind
study of potassium citrate in idiopathic hypocitraturic calcium
nephrolithiasis. J Urol. 1993;150:1761Y1764.
52. Favus MJ, Coe FL. The effects of allopurinol treatment on
stone formation in hyperuricosuric calcium oxalate stoneformers. Scand J Urol Nephrol. 1980;53:265Y271.
53. Dolin DJ, Asplin JR, Flagel L, et al. Effect of cystinebinding
thiol drugs on urinary cystine capacity in patients with
cystinuria. J Endourol. 2005;19:429Y432.

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