@UrologyQuiz

Quiz10 Answer: Bladder calculus (stone) This was a very large one not amenable to endoscopic
proceduresso was removed by small cystotomy the patient also had a greenlight laser TURP and is voiding
well (you could argue do open but patient not very fit)
Bladder calculi are uncommon in the Western world and occur almost
exclusively in men, may be single or multiple
They are well described in ancient medical literature e.g Hippocrates
wrote about the management of bladder stone
Pathophysiology
They are generally formed in bladder but are rarely migrated renal stones
that failed to pass
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
They vary in size and can be multiple
More common in elderly men but may be in children in Asia
Most stones in adults are formed of uric acid but with at least a small calcium component
Long-standing untreated bladder stones are associated with squamous cell carcinoma
Clinical features
Bladder calculi can be asymptomatic
However Common symptoms include: Suprapubic pain, Dysuria, Hematuria, Recurrent UTI
Abdominal examination generally normal unless retention found
Diagnosis
Bladder ultrasound- Reveal hyperechoism with 'post acoustic shadowing or 'mineshaft
Historically stones were diagnosed by the passage of urethral 'sounds'
Today thy can be identified on: Plain abdominal x-ray; CT scan and Cystoscopy
Uric acid stones are radiolucent but may have an opaque calcified layer
Management
May be conservative in elderly infirm but Indications for surgery:
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'
The three common approaches today are: Transurethral cystolitholapaxy (mechanical or laser);
Percutaneous cystolitholapaxy; Open suprapubic cystostomy [ESWL ineffective]
Teaching Points:
1) Bladder calculi composed predominantly of uric acid but often have calcium hence visible on KUB, almost always in men
2) May be investigated by ultrasound, KUB and/or direct visualisation at cystoscopy
3) Bladder calculi generally are formed in the bladder indicating other pathology- generally poor emptying due to BPH in
men ejaculation. Hence the underlying pathology must be corrected
4) Options for management range from observation, endoscopic with mechanical or laser devices, percutaneous access
and laser in the bladder through to open cystotomy

References:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002254/
http://www.surgical-tutor.org.uk/default-home.htm?specialities/urology/bladder_calculi.htm~right
By @lawrentschuk Editor-in-Chief @UrologyQuiz
Assoc. Professor Nathan Lawrentschuk, University of Melbourne AUSTRALIA