THE VESICAL CALCULUS

https://doi.org/10.1016/S0094-0143(05)70262-7Get rights and content

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners (specialists in this art).
HIPPOCRATIC OATH

Bladder calculi have plagued mankind since time eternal. Archeologists discovered a stone resting in the pelvis of an ancient Egyptian skeleton dating back more than 7000 years.91 Although the ancient Greeks described the perineal vesicolithotomy 4000 years later, it was not until the 5th century bce that Hippocrates thoroughly documented this aggravating malady. The first true “lithotomist,” Ammonius of Alexandria, emerged about 200 bce. He utilized the perineal approach and invented the handheld lithotrite.92 Many of the principles developed by early pioneers are still in use today and can be studied in many excellent historical references.1, 11, 40, 64, 87, 103, 109, 110, 111

Fortunately, in the past 50 years, the incidence of vesical calculi in developed countries has declined significantly. Currently, they represent roughly 5% of all urinary calculi in the Western world.104, 116 Underdeveloped nations still suffer from endemic bladder calculi, especially children. Few contemporary series of bladder calculi exist in the English literature. What prevails however, is an abundance of fascinating case reports and treatises on novel treatment methods. The following is a compilation of the English literature on the causes, treatments, and preventions of vesical calculi.

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

References (117)

  • H. Choi et al.

    Urolithiasis in childhood: Current management

    J Pediatr Surg

    (1987)
  • S. Chow et al.

    Urinary incontinence secondary to a vaginal pessary

    Urology

    (1997)
  • D.C. Dalton et al.

    Foreign bodies and urinary stones

    Urology

    (1975)
  • R. Douenias et al.

    Predisposing factors in bladder calculi: Review of 100 cases

    Urology

    (1991)
  • M.C. Dupont et al.

    Erosion of an inflatable penile prosthesis reservoir into the bladder, presenting as bladder calculi

    J Urol

    (1988)
  • M.D. Ehrenpreis et al.

    Case profile: Large bladder calculus postcervical circlage

    Urology

    (1986)
  • J.S. Elder

    Percutaneous cystolithotomy with endotracheal tube tract dilation after urinary tract reconstruction

    J Urol

    (1997)
  • M. Fox

    The natural history and significance of stone formation in the prostate gland

    J Urol

    (1963)
  • M.G. Garzotto et al.

    Uric acid stone and gastric bladder augmentation

    J Urol

    (1995)
  • D.L. Gentle et al.

    Protease inhibitor-induced urolithiasis

    Urology

    (1997)
  • M. Grasso

    Experience with the Holmium laser as an endoscopic lithotrite

    Urology

    (1996)
  • A.B. Gutman et al.

    Uric acid nephrolithiasis

    Am J Med

    (1968)
  • L.E. Hahnfeld et al.

    Endourologic therapy of bladder calculi in simultaneous kidney-pancreas transplant recipients

    Urology

    (1998)
  • N.S. Hakim et al.

    Duodenal complications in bladder-drained pancreas transplantation

    Surgery

    (1997)
  • M.K. Hall et al.

    Renal calculi in spinal cord-injured patient: Association with reflux, bladder stones, and foley catheter drainage

    Urology

    (1989)
  • J.B. Hollander

    Triamterene bladder calculus

    Urology

    (1987)
  • C. Huggins et al.

    The course of the prostatic ducts and the anatomy, chemical and x-ray diffraction analysis of prostatic calculi

    J Urol

    (1944)
  • J.M. Kaufman et al.

    Bladder cancer and squamous metaplasia in spinal cord injury patients

    J Urol

    (1977)
  • A.E. Khoury et al.

    Stone formation after augmentation cystoplasty: The role of intestinal mucus

    J Urol

    (1997)
  • R.R. Landrigan et al.

    Postoperative complications from hemostatic clips

    Urology

    (1987)
  • U. Maier et al.

    Bladder stone as a rare complication one year after laparoscopic herniorrhaphy

    Surgery

    (1996)
  • M. Nakano et al.

    Fluoroquinolone associated bladder stone

    J Urol

    (1997)
  • A.M. Nieder et al.

    Total vaginal prolapse with multiple vesical calculi after hysterectomy

    J Urol

    (1998)
  • L.S. Palmer et al.

    Urolithiasis in children following augmentation cystoplasty

    J Urol

    (1993)
  • L.S. Palmer et al.

    Endoscopic management of bladder calculi following augmentation cystoplasty

    Urology

    (1994)
  • F.E. Pickworth et al.

    Case report: Limey urine

    Clin Radiol

    (1992)
  • K. Pranikoff et al.

    Procidentia incarcerated by vesical calculi

    J Urol

    (1982)
  • G. Richet

    The chemistry of urinary stones around 1800: A first in clinical chemistry

    Kidney Int

    (1995)
  • A.A. Shokeir et al.

    Further experience with the modified ileal ureter

    J Urol

    (1995)
  • D. Staskin et al.

    Urological complications secondary to a contraceptive diaphragm

    J Urol

    (1985)
  • J.P. Stein et al.

    Complications of the afferent antireflux valve mechanism in the Kock ileal reservoir

    J Urol

    (1996)
  • W.H. Stonehill et al.

    Risk factors for bladder tumors in spinal cord injury patients

    J Urol

    (1996)
  • R.E. Abdel-Halim

    Paediatric urology 1000 years ago

    Prog Pediatr Surg

    (1986)
  • O. Adsan et al.

    A giant bladder stone: Managed with osteotome

    Int Urol Nephrol

    (1996)
  • J.J. Ballesteros et al.

    Urinary infection and stone formation as complications of Gil-Vernet's antireflux procedure

    Int Urol Nephrol

    (1992)
  • A. Basu et al.

    Spontaneous bladder rupture resulting from giant vesical calculus

    Br J Urol

    (1994)
  • E. Batislam et al.

    A new application of laparoscopic instruments in percutaneous bladder stone removal

    Journal of Laparoscopy and Advances in Surgical Technology

    (1997)
  • S.K. Bera et al.

    A rare case of cystolithiasis in procidentia

    J Indian Med Assoc

    (1996)
  • V.L. Chamary

    An unusual cause of iatrogenic bladder stone

    Br J Urol

    (1995)
  • J.K.S. Chia

    Gallstones exiting the urinary bladder: A complication of laparoscopic cholecystectomy

    Arch Surg

    (1995)
  • Cited by (194)

    • Vesicovaginal fistula with bladder and vaginal stone

      2022, International Journal of Surgery Case Reports
    • Influence of Age and Geography on Chemical Composition of 98043 Urinary Stones from the USA

      2021, European Urology Open Science
      Citation 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.

    View all citing articles on Scopus

    Address reprint requests to Marshall L. Stoller, MD, Department of Urology, University of California at San Francisco, 533 Parnassus, U575, San Francisco, CA 94143

    View full text