Marshall L. Stoller, Maxwell V. Meng-Urinary Stone Disease

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670 Schwartz

It is uncommon for bladder stones to form in the absence of obstruction, infection,

or stasis. In one of the largest reviews to date, Takasaki reviewed 273 bladder calculi

from 220 males and 53 females aged 2–89 yr (42). Overall, 142 (52%) of the stones

contained magnesium ammonium phosphate (MAP) with or without calcium. Calculi

in women were composed of MAP 71.6% (38/53) of the time compared to 47.2% of the

males. No uric acid calculi were found in women compared to 17 (7.7%) males. Calcium

was the major constituent in 101 (45.9%) calculi: 92 (41.8%) men and 10 (18.9%)

women. Associated lower urinary tract disorders consisted of 98 (44.6%) patients with

bladder outlet obstruction secondary to an enlarged prostate or previous prostate sur-

gery and 26 (11.8%) with a neurogenic bladder. Interestingly, 59 of 120 patients with

calcium stones (39.6% of the whole series) had no lower urinary tract abnormalities and

30 of the 59 had upper urinary tract stones. Urinary stasis and infection have a distinct

role in bladder calculus formation. However, some patients have developed bladder

calculi in the absence of upper tract stones and lower urinary tract disorders.

Bladder stones have been associated with vesicoureteral reflux in children (43) and

in spinal cord injury (SCI) patients (44). The majority of bladder calculi secondary to

female pelvic surgery (45–48) or genital prolapse (49–54) result either from obstruction

or foreign bodies left in the bladder during the repair. Stasis of urine, poor bladder

emptying, and neurogenic bladder physiology are implicated as etiologic factors. Dou-

enias et al. identified predisposing factors in 100 patients with bladder calculi; 83 were

attributed to various prostatic diseases or operations (55). Fifty per cent of the patients

had uric acid stones. They attributed this high percentage to the diet of the mostly Jewish

population they served. Gutman observed a high predilection of uric acid urinary calculi

in the Jewish population attributable to genetics and diet (56). In contrast, Smith and

O’Flynn found uric acid stones in 5.4% of 648 cases (57). Stones resulting from obstruc-

tion may be composed of several different constituents. Pickworth reported recovering

“thousands” of small bladder calculi while performing a transurethral resection of the

prostate (58). They were composed of calcium, ammonium, magnesium, carbonate,

oxalate, and phosphate without a central nidus.

Spinal cord injury increases the risk of bladder calculi formation. Hall et al. found 261

of 898 (29%) SCI patients to have bladder stones at their institution (59). 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 perma-

nent catheter drainage, Singh and Thomas found 22 (55%) who required treatment for

recurrent bladder calculi (60).

DeVivo and colleagues looked at 500 SCI patients being

followed at their institution (61). Thirty-six per cent developed bladder calculi over an

8-yr period with the greatest risk occurring in the first 3 mo after injury. Three factors

were significant in the predisposition of bladder calculi: a complete neurologic lesion,

urinary tract infection caused by Klebsiella species, and Caucasian race. There was not

a significant difference in bladder stone formation based on the methods of bladder

management. Statistical significance was not reached because patients regularly

changed bladder management from clean intermittent catheterization (CIC), external

condom catheter collection, and indwelling Foley catheter drainage. Bladder manage-

ment in this group of patients remains a challenge and should be a focus in their coun-

seling.

Leunissen et al. reported 4 of 80 (5%) renal transplant patients suffered from bladder

calculi (62). All of them formed on the ends of vicryl suture used in the ureterovesical

anastomosis. In a series of 312 renal transplant recipients, seven (2.2%) developed blad-

Chapter 35 / The “Other” Stones 671

der calculi (63). The first 196 patients underwent ureteroneocystostomy with polypro-

pylene suture. The following 116 anastomoses were performed with absorbable poly-

dioxanone (PDS) suture. All of the calculi formed on the nonabsorbable polypropylene

suture material and all seven were stone free after electrohydraulic lithotripsy (EHL) and

endoscopic removal of the suture nidus. Of 300 simultaneous kidney pancreas trans-

plants, nine (3%) developed bladder calculi (64). All of the stones developed on nonab-

sorbable suture material exposed to urinary constituents and were successfully treated

with EHL and endoscopic suture removal. The only case of nonsuture related calculus

formation was felt to arise from dystrophic calcification of an ischemic portion of the

cuff of the allograft ureter (65).

Various drugs have been implicated in bladder calculi formation. Nakano et al. report

a bladder stone made of tosufloxacin, an oral fluoroquinolone, in a woman on CIC for

a neurogenic bladder (66). The sole report of a triamterene bladder calculus in the

absence of upper tract stones or abnormalities was in a patient with significant infravesical

obstruction and high post void residuals from benign prostatic hyperplasia (67).

The

protease inhibitor indinavir sulfate (Crixivan) has been shown to cause renal lithiasis

(68,69). It is possible that with the increased use of this drug, and the increasing fre-

quency of urinary manifestations of the acquired immunodeficiency syndrome, indinavir

bladder calculi may be encountered in the future.

Symptoms

Patients with bladder calculi present similarly to those with urethral calculi. Stran-

guria, decreased force of stream, recurrent urinary tract infection, dysuria, urgency,

frequency, and intermittency are common presenting complaints in patients who have

bladder calculi. Often, microscopic or gross hematuria are the presenting signs of blad-

der calculi. Three patients with postoperative dysuria, urgency, and pain following a

Stamey anti-incontinence procedure were found to have calculi on the ends of intravesi-

cal sutures (48).

Diagnosis

Most patients with bladder calculi have either gross or microscopic hematuria. As a

result, both radiographic and cystoscopic evaluations are usually performed. Despite the

accuracy of modern imaging, the diagnosis of bladder calculi is best confirmed with

cystoscopy. The anatomy of the urethra, prostate, and bladder as well as the presence of

coinciding pathology can be identified.

Treatment

Although the ancient Greeks described the perineal vesicolithotomy 3000 yr ago, it

was not until the fifth century

BCE that Hippocrates thoroughly documented vesicolithi-

asis. The first true “lithotomists,” Ammonius of Alexandria, emerged about 200

BCE. He

used the perineal approach and invented the hand held lithotrite (70). The latter half of

the 20th century saw a technological explosion in lithotripsy technology. The emergence

of laser, pneumatic, ultrasonic, and extracorporeal shockwave lithotripsy devices has

lessened the need for open surgery and made the handheld lithotrite almost obsolete.

Historically, manual lithalopaxy with or without cystoscopic assistance was the only

treatment method available short of open cystolithotomy. As early as 1963, routine open

cystolithotomy was challenged as the optimal treatment for vesical calculi (71). As late

672 Schwartz

as 1990, tactile lithalopaxy was employed in a series of 45 patients with a 91.1% success

rate but a complication rate of 31% including one bladder perforation (72).

Bladder neck contracture after open prostatectomy was the cause of a large dumbbell

shaped calculus reported in a 67-yr-old man 12 mo postoperatively (73). The authors

combined extracorporeal shockwave lithotripsy (SWL) and percutaneous suprapubic

ultrasonic lithotripsy. They were able to fragment the prostatic calculus with SWL, push

the remainder of the stone into the bladder, and then perform the suprapubic procedure.

Some time later, the patient underwent transurethral incision of the bladder neck contrac-

ture. The stone consisted of struvite and hydroxyapatite.

The use of SWL has revolutionized the management of urinary calculi. Its use in the

upper tracts is undeniable. However, its success and practicality in treating bladder

calculi has been questioned. Thirty-six males underwent SWL monotherapy with

the HM-4 lithotriptor (Dornier Medical Systems, Inc., Marietta, GA) achieving a 72%

stone-free rate (74). Ten (28%) patients required eventual cystoscopic removal of non-

or poorly fragmented calculi. Husain et al. performed primary bladder stone reduction

therapy with the HM-3 (Dornier Medical Systems) in 24 patients (75). This procedure

was followed immediately by cystolitholapaxy with a manual lithotrite in all patients.

They reported an 83% success rate with minimal complications. However, the mean

hospital stay was 3.5 d.

Treating large calculi over 4 cm in diameter have traditionally been surgical. Two

reports using the Holmium:yttrium-aluminum-garnet (Ho:YAG) laser have been reported

recently. Grasso treated 12 patients with calculi averaging 55.8 mm in one sitting with

no complications (76). Teichman et al. successfully cleared 14 patients of their stones

averaging 6 cm and none less than 4 cm without complications (77). The laser is a very

effective tool to manage bladder calculi. The fiber is flexible and comes in different

sizes. They can fit through virtually any endoscope. The laser machines are small and

mobile. Although there is limited data in the literature, the laser is the author’s preferred

choice for treatment of bladder stones because of its unparalleled power and ability to

“dust” large stones efficiently.

Pneumatic lithotripsy is a relatively new technology that has proven quite effective

in fragmenting large, hard calculi with minimal tissue injury. The Swiss Lithoclast (EMS

Lithoclast, Nyon, Switzerland) was used in 17 patients with neurogenic bladder and

bladder calculi (78). Stones cleared within 1 wk in all patients. One patient suffered

bleeding requiring continuous irrigation for 3 d. The biggest limitation to pneumatic

lithotripsy is the inability to clear the large remnants that remain. The introduction of the

Lithoclast Ultra lithotriptor (Boston Scientific, Natick, MA), which combines pneu-

matic and ultrasonic lithotripsy with suction capabilities, should prove exceptional in

treating bladder calculi. One drawback to this technology is the need for an offset scope

to perform cystoscopy.

There are two reports in the literature that compare various methods of cystolithotripsy.

Bhatia and Biyani reviewed 128 bladder calculi treated with open cystolithotomy (5),

manual lithalopaxy (80), and SWL (43) (79). Open surgery resulted in 100% stone

removal at one setting but required the longest hospital stay (5.2 d). The only complica-

tion was a fever of greater than 100F in one patient. Manual lithotripsy had a compli-

cation rate of 25% and included urethral stricture, bladder perforation and failure.

Hospitalization averaged 2.4 d and intraoperative bleeding resulting in poor visualiza-

tion required retreatment in two patients. SWL had the shortest hospital stay (20 h) but

suffered two cases of urethral fragment impaction (4.8%). Four patients required two

Chapter 35 / The “Other” Stones 673

SWL sessions for complete fragmentation. Razvi et al. compared manual lithotripsy

(53), ultrasonic lithotripsy (17), electrohydraulic lithotripsy (16), and pneumatic litho-

tripsy (20) (80). The success rates were 90%, 88%, 63%, and 85% respectively whereas

the complication rates were 10%, 2.5%, 8%, and 10% respectively. Finally, a host of

novel percutaneous and “laparoscopic” methods of stone extraction have been reported

recently (81–84).

When determining the optimal treatment modality for bladder calculi, there are sev-

eral considerations: size and composition of stone, underlying etiology, comorbid con-

ditions, previously operated lower urinary tract, patient morphology, cost, patient

compliance and follow-up risk, available instrumentation, experience of the surgeon,

and risk to the patient for each option being considered. All of these items need to be fully

evaluated and the risks weighed against each other to eradicate the stone and the under-

lying condition with the least complication and cost.

Prevention

Removing a bladder calculus is not usually difficult. On diagnosis of a bladder cal-

culus, the initial thought is to remove it. The most important principle of treating bladder

calculi, however, is prevention and eradication of the underlying cause. Relieving ob-

struction, eliminating infection, meticulous surgical technique, and accurate diagnosis

are paramount in treating bladder calculi.

The necessity to perform intraoperative cystoscopy during anti-incontinence surgery

cannot be over emphasized. Likewise, it is imperative that women who present after

urogynecological procedures with significant lower urinary tract symptoms with or

without recurrent urinary tract infections undergo a thorough cystoscopic examination

to rule out inadvertent intravesical suture placement. If the suture is observed before

stone formation, it may be cut without significant morbidity. Calculogenesis in these

patients is secondary to the foreign body in contact with urine.

The key to prevention of prostate disease-related bladder calculi is relief of obstruc-

tion. Any procedure performed on the bladder neck, prostate or prostatic urethra may

result in obstructive changes, incomplete bladder evacuation, secondary infection, and

calculus formation. Aggressive medical and/or surgical therapy aimed at decreasing

high postvoid residuals, enhanced bladder emptying, and decreased voiding pressures

will help prevent bladder stone formation.

Bladder calculi reported in transplant patients have been associated with a foreign

body or tissue ischemia. Transplant recipients do not have an increased risk of bladder

stone formation if care is taken to limit intravesical sutures and minimize perivesical

clips. Diagnosis of bladder calculi in these patients can be difficult and should be sus-

pected in patients with irritative voiding symptoms, unexplained urinary tract infection,

or stranguria. Dietary modifications and antibiotic therapy will help prevent bladder

calculi formation in those areas where they are endemic.

Pediatric bladder stones deserve special mention. The most interesting aspect of

pediatric cystolithiasis is the pathophysiology of stone formation. In the absence of

obstruction, infection or neurologic disease, pediatric stones can be considered endemic

in certain geographic areas and most likely result from multiple factors. Johnson looked

at Ethiopian children and found a significant increase in bladder stones in males of low

socioeconomic classes (85). Nutritional deficiencies in vitamin A, magnesium, phos-

phate, and vitamin B6 combined with a low protein and high carbohydrate diet is impli-

674 Schwartz

cated in lithogenesis. The majority of his patients consumed minimal meat and a staple

of carbohydrates: injera, kotcho, and sorghum.

It is known that the saturation of uric acid in solution is bimodal with 50% ionization

at a pH of 5.5 and 90% solubility at a pH greater than 7.0. Dehydration, diarrhea, fever,

and infection decrease urine production, thereby increasing the concentration of uric

acid and enhancing crystallization. These conditions, in addition to decreased phospho-

rous intake and a carbohydrate staple, acidify the urine, further compounding the prob-

lem. Increased conversion of glutamine to ammonia in combination with the already

saturated uric acid environment will precipitate ammonium acid urate calculi. These

factors increase calcium oxalate excretion leading to calcium oxalate precipitation. The

resulting calculi are composed of a mixture of varying amounts of calcium oxalate and

ammonium acid urate (86).

Hydration remains important in bladder stone formation. The effect of water constitu-

ents and additives on vesicolithiasis has been addressed. Twenty children with endemic

stones and 20 age-matched controls were evaluated for the effect of fluoride on stone

formation (87). No differences were found in the composition of the drinking water,

daily dietary intake constituents, plasma biochemistry parameters, or urinary excretion

parameters between the two groups. Also, the fluoride content in the center of the stones

was no different than the periphery, indicating fluoride does not act as a nidus in stone

formation.

Finally, there is a fascinating concept pioneered by researchers in Thailand. Bladder

stones are endemic in the north and northeast regions of the country. Suphiphat et al.

evaluated the effect of pumpkin seeds, a dietary staple in this region, on the incidence

of bladder calculi (88). Consumption of dietary phosphorous is only 35% of the recom-

mended level in Thai adolescents. Pumpkin seeds are very rich in phosphorous and are

cheaper than other sources. The levels of the crystal inhibitors, urinary pyrophosphates

and glycosaminoglycans, were significantly higher in the pumpkin seed group. Unfor-

tunately, urinary pH decreased, and urinary oxalate levels increased significantly in the

same study group creating an acid-urine rich in oxalates. A long prospective trial is

needed to determine if pumpkin seed supplementation lessens the occurrence of bladder

calculi in this population.

In the absence of anatomic abnormalities, obstruction, and infection, one must con-

sider dysfunctional voiding as a cause of bladder calculi. In a series of 100 children with

bladder calculi from the United States, three (3%) exhibited dysfunctional voiding pat-

terns (89). Hassan identified 5 of 22 (23%) Nigerian children with bladder calculi have

no predisposing factors (90). He does not specifically address dysfunctional voiding,

however, it is quite possible these children suffered from some type of abnormal voiding

habits predisposing them to bladder calculi formation. The use of diapers in western

countries may promote frequent and complete emptying of the urinary bladder in chil-

dren. Developing countries may ostracize those children who remain wet discouraging

them to void more frequently leading to larger post void residuals and chronic urinary

retention. When a child presents with a bladder calculus it is imperative to rule out

voiding dysfunction as a cause.

If infectious, obstructive and neurogenic conditions can be addressed early, bladder

calculi can be avoided in most situations. The addition of phosphorous, protein, vita-

mins, and magnesium to the diets of children where stones are endemic can significantly

decrease the incidence and attendant morbidity of pediatric vesical calculi. Treatment of

dehydration states is crucial in the prevention of such stones.

Chapter 35 / The “Other” Stones 675

ENCRUSTED FOREIGN BODIES

The initial event in stone formation is probably crystallization. There are two types

of nucleation in crystal development: homogeneous and heterogeneous. In the pres-

ence of a foreign body, heterogeneous nucleation occurs. Additionally, aggregation is

required for crystal growth and proliferation and eventual stone formation. It is impera-

tive to remove the foreign body and the calculus if further stone formation is to be

prevented.

The most common foreign bodies to calcify in the urinary tract are Foley catheters,

ureteral stents, nephrostomy tubes, and suprapubic catheters. There are a host of other

objects that have been reported to be a nidus for stone formation. Removal of these

“stones” can be challenging.

It is well known that indwelling Foley catheters place patients at risk for urinary

infection, bladder and urethral erosion, and calculus formation. A recent study looked

at the prevalence and morbidity of long-term catheterization (indwelling urethral Foley

catheter greater than 3 mo) in a population approaching one million people (91). A total

of 773 patients were identified as utilizing long-term catheterization, a prevalence of

0.07% (0.5% for patients greater than 75 yr of age). The reasons for catheterization

varied but the majority were spinal cord injured patients. Seventeen patients (2.2%) with

chronic indwelling catheters were found to have bladder calculi.

Derry reported formation of a vesical calculus forming over a hair nidus in a spinal

cord injured patient undergoing frequent catheter changes (92). The follicle was presum-

ably introduced during one of the catheter exchanges emphasizing attention to detail

when performing this procedure.

There are numerous reports in the literature concerning migration of intrauterine

devices and intravaginal gynecological accessories including pessaries, diaphragms,

and cerclages into the bladder (93–100). Insight into crystal growth on foreign bodies

was provided by Khan and Wilkinson (97). They performed open cystolithotomy on a

24-yr-old woman who had an IUD placed 4 yr earlier. Scanning electron micrography

revealed deposits of calcium phosphate crystals along various parts of the IUD. Stones

grew individually around each nidus in different areas until they coalesced into one large

stone. The stone also contained struvite, indicating that the nidus became secondarily

infected with urease-splitting organisms. This may help explain the “spread” of crystal

“growth.”

Autoerotic behavior has been practiced by all ages and sexes for centuries. Dalton

reported a large assortment of items found in bladders of patients practicing autoeroti-

cism including chewing gum, hairpins, and thermometers (101). Basu reported a case of

bladder rupture secondary to calculus formation around an unidentified foreign body

introduced in the urethra 14 yr earlier (102). Fishing line has been implicated in two cases

(103,104). Finally, there is the case of a 23-yr-old male who practiced autoerotic manipu-

lation with a 25-cm piece of polyethylene tubing. The bladder stone surrounding the

tubing measured 7.5 cm  7.5 cm  5 cm. Unfortunately, the embarrassment of seeking

medical attention led to his ultimate demise caused by pyelonephritis, pneumonia, and

sepsis (105).

Bladder calculi have been reported as complications of several nonurologic surgical

procedures, all caused by foreign body migration from the original surgery. Chole-

vesical lithiasis resulted from a dropped gallstone during a laparoscopic cholecystec-

tomy. During the case, several stones were dropped and presumably landed in the

676 Schwartz

retrovesical location causing an intense inflammatory reaction and eventual fistula for-

mation. Cystoscopic extraction of several cholesterol stones and long-term antibiotics

were curative (106).

Maier reported the intravesical migration of a surgical clip used in a laparoscopic

hernia repair causing stone formation (107). Removal was performed endoscopically

with pneumatic lithotripsy and the analysis revealed 100% calcium phosphate.

Encrustation is a well-known complication of indwelling ureteral stents. The rela-

tively new urethral stents can also stimulate intravesical lithogenesis. Squires reported

a 6-cm bladder calculus that formed on the proximal portion of a titanium stent that

protruded into the bladder (108). Analysis revealed 100% struvite implying an infectious

etiology.

Edwards removed a 156-g hour-glass-shaped bladder calculus protruding through a

2-cm midline abdominal hernia presumably from a midline cesarean section performed

40 yr earlier (109). She presented with recurrent urinary tract infections and the stone

was composed entirely of magnesium ammonium phosphate.

Eroding foreign bodies may find their way into the bladder and promote stone forma-

tion. An inflatable penile prosthesis reservoir from a patient who had symptomatic relief

by inflating the prosthesis was reported by Dupont (110). The stones were removed at

the same time as the device explant. Pomerantz reported a large calculus formation on

an eroded ilioiliac arterial graft placed 4 yr previous (111). On electrohydraulic litho-

tripsy of the bladder calculus, a large rush of blood was encountered and emergent

laparotomy performed. The calculus was removed and immediate axillofemoral bypass

was required.

Methylmethacrylate cement, used in orthopedic surgery, was found to be the cause of

“bladder stones” in a 71-yr-old male with recurrent urinary tract infections. The chroni-

cally infected hip fistulized to the bladder, facilitating cement migration. Interestingly,

the Staphylococcus aureus repeatedly growing out of his hip wound was never cultured

from the urine. Only Gram-negative organisms were recovered from his urinary tract

(112). Finally, Pajor reported a 38-yr-old imprisoned women who attempted suicide by

swallowing a knife blade (113). After 4 yr of being asymptomatic, she was evaluated for

lower urinary tract symptoms. Abdominal radiograph and cystoscopy confirmed that the

calcified knife blade had perforated the bowel and came to rest in the bladder. The patient

refused surgery and 2 d later, the “knifestone” passed through a vesicovaginal fistula

without incident!

Encrusted ureteral stents are of particular interest to those managing urologic patients

(Figs. 3 and 4). There are a number of excellent articles in the literature describing

complex problems managed with a multifaceted approach (114–116). The most recent

review emphasizes the multimodal approach necessary to treat encrusted ureteral stents

(117).

Four patients with a mean stone burden of 807 mm

and an indwelling stent

underwent two to four procedures each to render them stone-free. Extracorporeal

shockwave lithotripsy, cystolitholapaxy, antegrade, and retrograde ureteroscopy, and

percutaneous nephrolithotomy were used in combination to treat these stones. Open

surgery is reserved for those calculi and stents not removable endoscopically.

In summary, any foreign body placed within the urinary tract has lithogenic potential.

Most stones are mixed composition and if infection is present, struvite is a major con-

stituent. The processes of heterogeneous nucleation and aggregation are central to the

formation of calculi that form on foreign bodies. As a result, the best treatment of these

stones is prevention.

Chapter 35 / The “Other” Stones 677

Fig. 4. Forgotten stent 5 yr after insertion. He presented in renal insufficiency and left flank pain.

Fig. 3. Original stone for which a stent was placed before extracorporeal shockwave lithotripsy

678 Schwartz

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