Bladder stone with bilateral nephroliasis

• 09 Mar 2020 04:59:32 PM
• |General Urology

58/M no medical comorbidities, h/o intermittency x 6-7 month, h/o hematuria x 3 days.

Comments(9)

• 

  Dr. Anil Takvani

  09 Mar 2020 05:29:12 PM

  An interesting case.  Thanks for sharing. 

  I would like to know post void residual urine volume if possible. 

  Practicing in peripheral area since >20 years I have treated similar cases in double digits. 

  Few were having flaccid bladders following spinal trauma or spinal surgeries. 

  But few cases were exactly similar to posted case. 

  I raise few more quarries here :

  Will you consider scopy prior to surgery? 

  Will you consider bladder wall biopsy if some suspicious lesion seen? 

  Will you consider treating  bladder neck in same sitting or you will investigate for bladder outflow obstruction after few months of stone removal? 

  Thanks 

• 

  Dr. Roy Chally

  09 Mar 2020 07:43:36 PM

  Open cystolithotomy has a high wound infection rate even if the urine is sterile.  PCCL may be time consuming but is better for large bladder stones and  this is my preference for this case. Since the stone is solitary it is likely to be secondary. I will not touch the bladder outlet in this sitting.  Such large smooth bladder stone need not cause pain or voiding dysfunction. In the absence of neurological deficits one can exclude a neurological pathology. Better to get the stone analysed. Bladder biopsy only if gross pathology is seen in bladder after the PCCL. 

  Roy Chally
  

  
  

  
  

  
  

  
  

• 

  Utsav Shah

  10 Mar 2020 09:28:48 AM

  To seniors: Can we do PCCL + B/L DJ stenting in first instance followed by B/L RIRS or Rt ESWL and Left PCNL(if RIRS not available)??

• 

  Gyanendra Sharma

  10 Mar 2020 10:26:52 AM

  Large vesical calculus can be treated with open suprapubic cystolithotomy/ PCCL or in females using Nephroscope through urethra after introducing an ampltaz sheath( the first article using this technique was published by Dr. Pankaj Maheshwari in BJU and Dr. Prashant Mulawkar has entered the Limca Book of records  for  removing a large  vesical calculus in a female )

  In this case I would prefer open suprapubic cystolithotomy for the vesical calculus but would like to add couple of things

  1. I would prefer doing an IVU / CT  to evaluate the renal calculi
  2. Density would give me a guide as regards feasibility of ESWL --especially on the right side
  3. I would do a cystoscopy prior to cystolithotomy
  4. I agree with Dr. Utsav that putting a DJ on either sides  would be a good idea  especially if one is planning for RIRS later
  5. Evaluation of prostate would not be correct till the vesical calculus is out.
  6. I would start the patient on alpha blockers after cystolithotomy

  My arguments for not doing a PCCL

  1. Will take a long time
  2. May need two sittings
  3. Not a huge advantage  over cystolithotomy as far as hospital stay  is concerned
  4. Cost to patient will be more with PCCL

• 

  Venugopal P

  10 Mar 2020 10:43:29 AM

  Dear All,

  I would like to place some historical observations. Bladder stones were quite common few decades ago and were seen in Paediatric age group as primary stone commonly. The reason for this high Incidence in children was nutritional and it was mentioned that it was due to Vitamin A Deficiency. In Adults, though we did see Vesical calculi in females, males predominated and triple phosphate stones predominated. I am sure Roy would be remembering those days of our practice.

  The largest Bladder stone reported in the literature weighed 1.9 Kg. The largest stone recorded in India was removed at Valsad, Gujarat in 2017 weighing 1.4 Kg. Most of us Septo or Octogenarians in Urology have seen such Bladder Stones frequently but as is usual with all of us, went unpublished. The largest Bladder stone that I had the opportunity to remove was very large that I needed the help of an obstetric forceps to get it out of bladder. It had an impression of the median lobe of the prostate on which it was sitting. I had kept it on my office table for long as a paper weight (varnished).

  Though today, most are fond of Endourological procedures, the treatment of Vesical calculi also changed with the present fashion.

  The optimal management of bladder calculi is still controversial. Currently, various approaches have been used, including Open Cystolithotomy, TUCL, PCCL, and ESWL. I had on an occasion disintegrated a bladder calculus with ESWL on a child who had Exstrophy repair done earlier. ESWL for bladder stones are generally done in prone position. Passage of fragments may need additional endoscopic procedures.

  Transurethral Cystolitholapaxy is a procedure still offered by many. But frequent excursions into urethra and out, can cause urethral damage but reported literature states that the incidence of Urethral Injury is hyped and may not be a problem if proper equipments are available. In patients with large prostate and those with Urethral pathologies, TUCL can cause urethral damage.

  Percutaneous Cystolitholapaxy is the most favoured procedures at present. But the time taken for disintegration of a large vesical calculus should be taken into consideration. Though it is mentioned that PCCL can be performed under Local anaesthetic, such large stones cannot be removed that way.

  Such large Bladder calculus is usually adherent to the bladder mucosa and the largeness itself may make entering the bladder by PCCL difficult. Additionally, association of Sq Cell Ca of bladder has been reported in the literature. A well centred KUB showing deviation from centre of the picture of the stone should cast suspicion of associated Sq Cell Ca.

  I have to disagree with my esteemed friend that PCCL is the way to go about for removal of large vesical calculus. The time taken at disintegration of the calculus must be borne in mind and it should also be remembered that such patients are usually in elderly age group and could have associated Comorbidities. A Simple cystotomy and removal saves considerable time in such large vesical calculus.

  I am sure many in the group will have differing views from what I have expressed and the various views of others will be appreciated.

  I am providing a picture with brief history of a case published by Santhosh Kumar (2015) of Chandigarh with a request as how such a case should be tackled. (Attached PDF)

  With warm regards,

  Venu    

  To answer Utsav’s query, anything can be done if one is competent and bold. Surgeons are said to possess ‘a lion’s heart and a ladies finger’. For small vesical calculus/i, what you said of J stenting can be performed at the time of tackling Vesical calculus. If upper tract calculi are obstructive, it will get the priority over vesical calculi unless the vesical calculi are obstructive. Though Primary Vesical calculi are reported in some instances as primary, more often they are secondary and quite often they are developed on migrated renal calculi. 

  I would not like to do all the procedures mentioned at one go but decide on which of these need priority and use my judgement in tackling.

  Venu

   

   

  View Document

• 

  Utsav Shah

  10 Mar 2020 12:16:25 PM

  Thank you Prof Venugopal sir 

• 

  Ashish parikh

  10 Mar 2020 03:45:28 PM

  Thank you teachers, sir and respected seniors,

  thank you for your valuable inputs.

  @Dr. Anil sir, USG PVR: 20 cc.

  i have also a question to the teachers, that, is biopsy necessary whenver there is a big bladder stone?. or shall it be taken when there is suspicious lesions?.

• 

  Dr. Anil Takvani

  10 Mar 2020 04:25:33 PM

  When there is suspicious lesion or lesions seen.  

  I do urethrocystosopy of all these patients before goahead with removal. 

  Let others speak their experiences,  their mind... 

• 

  Gyanendra Sharma

  10 Mar 2020 05:11:15 PM

  Agree with Anil-- Biopsy only if there is a suspicious lesion--But cystoscopy in all such cases