THE VESICAL CALCULUS
Section snippets
COMPOSITION
The composition of bladder calculi has not been studied as extensively as that of renal calculi. Bladder stones rarely form spontaneously; there must be an inciting event, namely obstruction or infection, to promote stone formation. Takasaki et al105 reviewed 273 bladder calculi from patients aged 2 through 89 years. The group was divided between 220 men and 53 women. Overall, 142 (52%) of the stones contained magnesium ammonium phosphate (MAP), either pure or mixed with calcium. Calculi in
FOREIGN BODIES
Humans with normal voiding habits, no outlet obstruction, no infection, no intravesical foreign body, and an intact nervous system rarely form vesical calculi. A common cause of these calculi is the foreign body. The fundamental inciting event of calculus development is crystal formation. There are two types of nucleation in crystal development: Homogeneous and heterogeneous. Homogeneous nucleation is extremely uncommon in the bladder and usually implies an upper-tract origin, such as cystine
FEMALE UROLOGY
The majority of bladder calculi secondary to female pelvic surgery or genital prolapse result from either obstruction or foreign bodies. Special mention should be made of these patients, because of the increasing number of gynecologic procedures being performed by urologists. Johnson53 reported a bladder calculus in a woman with complete uterine prolapse, and similar cases followed.8, 17, 67, 84 A proposed mechanism of stone formation in these patients is bladder obstruction secondary to the
PROSTATE DISEASE
If one thinks of bladder calculi, the image that comes to mind is the elderly male with a long history of bladder-outlet obstruction presenting with the classic jack stones (Fig. 1). Indeed, the historic reports of famous statesmen chronicle a long history of bladder-outlet obstructive symptoms and lower urinary-tract complaints before diagnosis. To the British, the diary of Samuel Pepys, the eventual secretary to the Navy and president of the Royal Society, is a vivid reminder of bladder-stone
SPINAL-CORD INJURY
The urologic complications of spinal-cord injuries are well documented.25, 46, 94, 100 Bladder calculi in this group of patients represents significant cause of injury. Hall et al46 found 261 (29%) of 898 patients with SCI at their institution to have bladder stones. Of those with bladder calculi, 62.5% were managed with indwelling Foley catheters. The remainder wore external appliances for urinary collection. Of 40 female tetraplegics with permanent catheter drainage, Singh and Thomas94 found
TRANSPLANT
There has been an expansion in the use renal transplantation and improved graft survival. As a result, there has been an increased recognition of transplant-related complications. Although uncommon, bladder calculi have been reported in kidney and pancreaticoduodenal transplantation (Figs. 2 and 3). Leunissen et al63 reported 4 (5%) of 80 renal-transplant patients suffered from bladder calculi. All of them formed on the ends of vicryl suture used in the ureterovesical anastamosis. In a recent
DRUGS
Bladder calculi associated with oral medication deserve special mention. Although it can be argued that most drug-related stones originate in the upper tracts, there are some reports of bladder calculi in the absence of any upper-tract abnormalities or symptoms. Nakano et al73 report a bladder stone made of Tosufloxacin, an oral fluoroquinolone, in a woman on clean intermittent catheterization for a neurogenic bladder. Analysis consisted of infrared spectroscopy and inhibition patterns on blood
AUGMENTATION
Bladder calculi in the augmented bladder or bladder substitution is well recognized. Stone formation has been reported in all intestinal segments and is multifactorial. Khoury et al57 compared eight stone-forming and 10 non–stone-forming children who had bladder augmentation. They found a significant difference in the mucous calcium-to-phosphate ratio in the two groups. Because of the increased ratio in the stone formers, a local metabolic derangement with mucus as a nidus was hypothesized.
PEDIATRICS
The incidence of bladder calculi in children has decreased significantly in the past 100 years. Historically, the causes of endemic stones were diet, infection, and obstruction. Since the industrial revolution, improved nutrition and antimicrobial therapy essentially have eliminated pediatric bladder calculi in the Western world. With the advent of improved prenatal surveillance and technologic improvements, obstruction is identified earlier and treated before complications occur. In the
TREATMENT
Initially, when a bladder calculus is diagnosed, one considers taking it out. The most important principle of treating bladder calculi is prevention and eradication of the underlying cause. Rarely, however, is this adequate to eliminate the already present stone. Relieving obstruction, eliminating infection, meticulous surgical technique, and accurate diagnosis are paramount in treating bladder calculi. This section reviews the treatment options available for removing the bladder calculus
SUMMARY
Bladder calculi account for 5% of urinary calculi and usually occur because of foreign bodies, obstruction, or infection. Males with prostate disease or previous prostate surgery and women who undergo anti-incontinence surgery are at higher risk for developing bladder calculi. Patients with SCI with indwelling Foley catheters are at high risk for developing stones. There appears to be a significant association between bladder calculi and the formation of malignant bladder tumors in these
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2021, European Urology Open ScienceCitation Excerpt :This study includes data for all urinary stones, including lower urinary tract stones. However, the incidence of lower urinary tract stones has been decreasing and likely represents ≤5% of the sample [26]. Additionally, because our stone cohort is taken from stones submitted for chemical analysis, this disproportionately represents stones requiring intervention.
Address reprint requests to Marshall L. Stoller, MD, Department of Urology, University of California at San Francisco, 533 Parnassus, U575, San Francisco, CA 94143