Bladder Stone

Introduction

• Bladder calculi are uncommon in the Western world

• They are well described in ancient medical literature
• Hippocrates wrote about the management of bladder stone
• Operations to remove stones via the perineum were described in the centuries BC
• Suprapubic lithotomy was described in the 15th century
• Transurethral lithotomy became popular in the 18th century
• Lithotripsy was first described in 1822
• Surgery was often associated with significant morbidity and mortality

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Pathophysiology

• Bladder calculi are usually associated with urinary stasis

• Urinary infections increase the risk of stone formation

• Foreign bodies (e.g. suture material) can also act as a nidus for stone formation

• They can however form in a normal bladder

• There is no recognized association with ureteric calculi

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Pathophysiology

• Most bladder calculi form in the bladder and are not from the upper urinary tract

• They vary in size and can be multiple

• They are more common in elderly men

• In Asia, they are seen more commonly in children

• Most stones in adults are formed of uric acid

• Long-standing untreated bladder stones are associated with squamous cell carcinoma

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Bladder stone
• Bladder calculi usually are a manifestation of an underlying
pathologic condition, including voiding dysfunction or a foreign body
Bladder stone
• Voiding dysfunction may be due to a urethral stricture, benign
prostatic hyperplasia, bladder neck contracture, or flaccid or spastic
neurogenic bladder, all of which result in static urine.
Bladder stone
• Foreign bodies such as Foley catheters and forgotten double-J
ureteral catheters can serve as nidi for stones
Epidemiology
• Most bladder calculi are seen in men
Stone analysis
Stone analysis frequently reveals
• Ammonium urate
• Uric acid (large percentage, radiolucent)
• Calcium oxalate stones.
Types

• Primary
• Secondary

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Primary vesical calculus

• Develops in sterile urine

• Mostly originates in the kidney
• Usually of oxalate or uric acid or urate type

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Secondary vesical calculus

• Associated with infection

• Mostly originates in the bladder
• Mostly made up of triple phosphate

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Patients present
• Irritative voiding symptoms
• Intermittent urinary stream
• Urinary tract infections
• Hematuria
• Pelvic pain
Diagnosis

• Historically stones were diagnosed by the passage of urethral 'sounds'

• Today thy can be identified on

• Plain abdominal x-ray
• Bladder ultrasound
• CT scan
• Cystoscopy

• Uric acid stones are radiolucent but may have an opaque calcified layer

• Patients may present in acute urinary retention

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Ultrasound
• The stone with its characteristic acoustic shadowing.
• The stone moves with changing body
position.
Management
• Mechanical lithotrites should be used with caution to prevent bladder
injury when the jaws are closed. Ensuring a partially full bladder and
endoscopic visualization of unrestricted lateral movement before forceful
crushing of the stones helps reduce this troublesome complication.
• Cystolitholapaxy allows most stones to be broken and subsequently
removed through a cystoscope.
• Electrohydraulic, ultrasonic, laser, and pneumatic lithotrites similar to
those used through a nephroscope are effective.
• Cystolithotomy can be performed through a small abdominal incision.
Surgery

• Indications for surgery include

• Recurrent urinary tract infections
• Acute urinary retention
• Frank haematuria
• Any underlying bladder abnormality should be sought
• Historically the surgical approach involved 'cutting for a stone'
• This was via either a perineal or suprapubic approach
• The three common approaches today are
• Transurethral cystolitholapaxy
• Percutaneous cystolitholapaxy
• Open suprapubic cystostomy
• Extracorporeal shockwave lithotripsy is relatively ineffective
• Complications of cystolitholapaxy include
• Infection
• Haemorrhage
• Bladder perforation
• Hyponatraemia

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