NONSURGICAL MANAGEMENT OF BENIGN PROSTATIC

HYPERPLASIA IN MEN WITH BLADDER CALCULI

R. COREY OCONNOR, BRETT A. LAVEN, GREGORY T. BALES, AND GLENN S. GERBER
ABSTRACT
Objectives. To assess the outcome of men with bladder calculi who did not undergo transurethral resection
of the prostate after endoscopic stone removal. Bladder calculi associated with benign prostatic hyperplasia
(BPH) have historically been an absolute indication for transurethral resection of the prostate.
Methods. A retrospective analysis of the results of 23 men who underwent endoscopic removal of bladder
calculi with subsequent medical management of BPH symptoms was performed. Inclusion criteria included
men with bladder stones secondary to BPH, serum creatinine 1.6 mg/dL or less, no evidence of hydrone-
phrosis, and no history of acute urinary retention or neurogenic bladder. The International Prostate Symp-
tomScore and postvoid residual urine volume before and after treatment and the incidence of bladder stone
recurrence and associated complications were recorded. All patients were treated with either an alpha-
receptor blocker or alpha-receptor blocker and nasteride after bladder stone removal.
Results. The follow-up after endoscopic removal of the bladder calculi averaged 30.0 months (range 6 to
96). The International Prostate Symptom Score before and after treatment was 18.3 and 9.4 (P 0.01),
respectively. The postvoid residual urine volume before and after treatment was 354 and 179 mL (P 0.01),
respectively. Urinary tract infection, acute urinary retention, recurrent calculi, chronic renal insufciency, or
renal failure developed in 21.7% (n 5), 17.4% (n 4), 17.4% (n 4), 4.3% (n 1), and 0% (n 0) of
the 23 men, respectively. Overall, 18 (78%) did not have any complications.
Conclusions. Many men with bladder stones can be successfully and safely treated with transurethral stone
removal and medical management of BPH. UROLOGY 60: 288291, 2002. 2002, Elsevier Science Inc.
I
n developed countries, the most prevalent cause
of bladder calculi is bladder outlet obstruction
owing to benign prostatic hyperplasia (BPH).
1
In
addition, approximately 2%of all patients who un-
dergo prostate surgery for BPH are found to have
bladder stones.
2
In most cases, the presence of
bladder calculi associated with BPH is considered
to be an absolute indication for transurethral resec-
tion of the prostate (TURP).
3
Overall, improved medical therapy for the treat-
ment of BPH has signicantly decreased the need
for surgical intervention. During the past decade,
pharmacologic treatments have become the rst-
line management option because they are noninva-
sive, are reversible, cause minimal side effects, and
signicantly improve symptoms.
4
Several random-
ized trials have demonstrated the short and long-
term efcacy of both alpha-blockers and 5-alpha-
reductase inhibitors in controlling the symptoms
and effects of BPH.
5,6
In the United States, the
number of men undergoing TURP has declined
more than 50% in the past decade, primarily be-
cause of the availability of medical therapy for
lower urinary tract symptoms (LUTS).
7,8
Because of the demonstrated efcacy and wide-
spread use of medical management in men with
BPH, some traditional indications for performing
TURP may need to be modied. The purpose of
this retrospective study was to review the outcome
of patients with bladder calculi who were treated
medically for symptoms of BPH after transurethral
stone removal.
MATERIAL AND METHODS
From August 1994 through September 2001, 65 men with
bladder calculi secondary to BPH underwent bladder stone
removal. Of the 65 men, 30 (46.2%), 6 (9.2%), 6 (9.2%), and
23 (35.4%) underwent TURP, suprapubic prostatectomy, in-
dwelling suprapubic tube placement, or medical management,
From the Section of Urology, Department of Surgery, University
of Chicago Hospitals, Chicago, Illinois
Reprint requests: R. Corey OConnor, M.D., Section of Urology,
Department of Surgery, University of Chicago Hospitals, 5841
South Maryland Avenue, MC 6038, Chicago, IL 60637
Submitted: January 3, 2002, accepted (with revisions): March
7, 2002
ADULT UROLOGY
2002, ELSEVIER SCIENCE INC. 0090-4295/02/$22.00
288 ALL RIGHTS RESERVED PII S0090-4295(02)01698-9
respectively, to treat bladder outlet obstruction due to BPH. A
retrospective analysis of the results of 23 men with bladder
calculi removed endoscopically without prostatectomy was
performed. Each of these 23 patients with bladder stones was
counseled regarding the indications for surgical treatment of
BPH and elected to receive medical therapy only after the
bladder stones were removed transurethrally. Patients in this
group who developed bladder calculi while already taking al-
pha-blockers either added nasteride to the medical manage-
ment regimen or increased the alpha-blocker dosage after
transurethral stone removal. Eligible patients included men
with bladder stones secondary to BPH, serum creatinine 1.6
mg/dL or less, no evidence of hydronephrosis, 1 or no episodes
of simple cystitis per year, and no history of urinary retention,
clot retention, or neurogenic bladder. The International Pros-
tate Symptom Score (IPSS) and postvoid residual (PVR) urine
volume before and after treatment were compared and ana-
lyzed using the paired Student t test. All post-treatment mea-
surements of PVR volume and IPSS were taken during each
patients most recent clinic visit. The incidence of bladder
stone recurrence and any associated complications were also
recorded.
RESULTS
The mean patient age was 70.4 years (range 38 to
82). The largest stone removed from each patient
averaged 2.8 cm(range 0.5 to 7.0). The mean num-
ber of calculi extracted was 9.3 (range 1 to 80) per
patient. The follow-up after endoscopic removal of
bladder calculi averaged 30.0 months (range 6 to
96). The IPSS before and after treatment was 18.3
and 9.4 (P 0.01), respectively. The PVR urine
volume before and after treatment was 354 and 179
mL (P 0.01), respectively. Complications after
calculi removal and the mean time of occurrence
are tabulated in Table I. Recurrent bladder stones
developed in 4 (17.4%) of 23 men. Urinary tract
infection or acute urinary retention was noted in 5
(21.7%) and 4 (17.4%) men, respectively. One pa-
tient developed chronic renal insufciency, with a
creatinine of 3.2 mg/dL (normal range 0.5 to 1.4),
owing to bladder outlet obstruction. After TURP,
the patients serum creatinine decreased and stabi-
lized at 2.1 mg/dL. Renal failure was not seen in
any patient. Of the 23 men, 18 (78%) did not have
any complications during follow-up.
Alpha-blockers or nasteride, or a combination,
had been previously used by 6 (26.1%) of 23 men.
No patient who developed recurrent bladder
stones had previously been taking medical therapy
for BPH. Of the 4 patients with recurrent stones, 3
underwent repeat endoscopic stone removal and
continued medical therapy. With a mean follow-up
of 12 months after recurrent stone removal, no
complications have been reported. One patient
with recurrent bladder stones underwent TURP.
COMMENT
The formation of bladder calculi secondary to
BPH has traditionally been an absolute indication
for TURP.
3
However, the introduction of alpha-
blockers and 5-alpha reductase inhibitors has dras-
tically altered the overall treatment of men with
LUTS. As a result, it is not clear that all men with
bladder stones require surgical treatment for BPH.
In the present study, we retrospectively reviewed
the outcome of men with BPH and bladder calculi
who were treated medically after transurethral
stone removal.
Twenty-three men with bladder stones second-
ary to BPH were included in this retrospective re-
view. To assess the impact of stone formation on
the necessity for surgical treatment, we excluded
patients with other indications for more aggressive
therapy, such as those with urinary retention, renal
failure, hydronephrosis, or recurrent urinary tract
infections. Although some of these excluded men
may have beneted from medical therapy for BPH,
we believed that the presence of these complicating
factors warranted more aggressive therapy. With a
mean follow-up of 30 months, only 4 (17%) of 23
men developed recurrent stones an average of 44
months after original bladder stone removal. In
each of these cases, patient compliance with the
medical management of BPH was poor. Although
TURP was recommended for all four of these pa-
tients, three elected to continue with medical man-
agement after transurethral removal of the recur-
rent stones. One patient with severe hypertension
and recurrent bladder calculi developed chronic
TABLE I. Complications of men with bladder calculi treated
medically after endoscopic transurethral stone removal
Complication Patients (%)
Postoperative Follow-up
(mo)
Urinary tract infection 5/23 (21.7) 47.6 (876)
Urinary retention 4/23 (17.4) 43.8 (876)
Recurrent calculi 4/23 (17.4) 43.8 (876)
Chronic renal insufciency 1/23 (4.3) 76
Renal failure 0/23 (0)
No complications 18/23 (78.3) 23.8 (696)
Numbers in parentheses are the range, unless otherwise noted.
UROLOGY 60 (2), 2002 289
renal insufciency with a creatinine of 3.2 mg/dL
(normal range 0.5 to 1.4) and mild to moderate
bilateral hydronephrosis. He subsequently under-
went TURP. To date, no patient in our study has
formed bladder stones on three separate occasions.
Previous studies of men with LUTS treated with
alpha-blockers demonstrated an improvement in
symptoms of up to 42%.
9
Our study showed simi-
lar results, with a 48.6% reduction in symptoms
after initiation or optimization of medical manage-
ment and transurethral stone removal as measured
by IPSS results. TURP has been shown to improve
the symptom scores by an average of 71%.
10
Al-
though medical therapy does not improve symp-
toms to as great a degree as seen after TURP, most
patients in this study remained satised with treat-
ment and were pleased that they were able to avoid
prostate surgery and its associated risks. It is also
likely that some of the symptoms in our patients
before endoscopic stone removal were due to the
stones themselves, rather than the bladder outlet
obstruction. Therefore, in some cases, LUTS may
have improved because of the elimination of the
stones, rather than from the introduction of medi-
cal therapy for BPH. A data review by Maders-
bacher and Marberger
10
found an average of 60.5%
decrease in the PVR urine volume after TURP. Our
results are comparable, with the PVR urine vol-
umes signicantly decreasing by 49% (from 354 to
179 mL) after stone removal and initiation of med-
ical management.
In our study, a total of 14 complications were
reported. Most complications occurred within the
same group of patients (14 total complications oc-
curred in 5 patients). Thus, those who developed
recurrent bladder stones were the same men who
had urinary tract infections and acute urinary re-
tention. Therefore, the vast majority of patients
(78%) were treated successfully using medical
therapy alone without complications. All urinary
tract infections were simple cystitis or epididymi-
tis, without evidence of pyelonephritis or sepsis.
No criteria, such as PVR urine volume or IPSS,
were useful in predicting which patients would
have complications. The complication rate associ-
ated with TURP is 13% to 34%, including urinary
tract infection (3.9% to 6.1%), bladder neck con-
tracture/urethral stricture (3% to 5%), and hemor-
rhage requiring transfusion or reoperation (1.4%
to 6.4%).
3,1113
The complication rate in our study
was slightly higher, although the complications
themselves tended to be minor. Other complica-
tions/side effects fromTURP, including urinary in-
continence, retrograde ejaculation, urethral and
bladder neck strictures, and impotence, are also
avoided or minimized by using medical manage-
ment. In addition, the average length of follow-up
in our patients was 30 months (range 6 to 96).
Because the natural history of BPH-induced blad-
der calculi is not well understood, the ideal fol-
low-up for this study is not known. Therefore, it is
conceivable that some patients would develop re-
current bladder calculi or other complications, but
not in the time frame studied. The limitations of
our retrospective study include the lack of prostate
size measurement. Patients with larger prostates
may or may not respond the same as patients with
smaller prostates, LUTS, and bladder stones.
It is generally believed that bladder calculi form
in men with BPH because of poor bladder empty-
ing, with resultant stasis of urine. It is clear, how-
ever, that other undened factors must play a role,
because many patients with large PVR urine vol-
umes never form stones within their bladders. In
the present study, the PVR urine volume decreased
signicantly among men treated medically after
stone removal. However, the mean residual vol-
umes remained elevated and such patients will
continue to be at risk of developing renal insuf-
ciency, infections, and recurrent calculi. In addi-
tion, there is evidence that a delay in performing
TURP may adversely affect the long-term outcome
of surgery. Specically, in a Veterans Affairs coop-
erative study, Flanigan et al.
14
randomized 556
men with BPHand LUTS to either watchful waiting
or TURP. Although both cohorts did well, the men
initially in the watchful waiting arm who under-
went delayed TURP showed less improvement in
overall bladder function and urinary symptoms
than did the men who underwent immediate
TURP. Therefore, it is clear that longer follow-up
in larger groups of patients is necessary before con-
clusions can be drawn regarding the appropriate-
ness of medical therapy alone in patients with blad-
der stones. In addition, although we were unable to
identify any predictive parameters, it is possible
that stone size, patient age, prostate size, or other
factors may have an impact on the choice of ther-
apy in men with bladder stones and BPH.
CONCLUSIONS
In the past, the presence of bladder stones sec-
ondary to BPH has been an absolute indication for
TURP. On the basis of our study results, however,
most men without a history of urinary retention,
hydronephrosis, or renal insufciency can be suc-
cessfully treated with transurethral stone removal
and medical management of BPH without signi-
cant risk of stone recurrence or other complica-
tions. This may be an option for poor surgical can-
didates, as well as for selected patients who
experience their rst episode of bladder stone for-
mation.
290 UROLOGY 60 (2), 2002
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