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GIANT VESICAL CALCULUS

SAMEER A REGE*, QUENTIN M NUNES**, ABHAY N DALVI***
Department of General Surgery, Seth GS Medical College and KEM Hospital, Parel, Mumbai - 12.

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Massive or giant vesical calculus is a rare entity in the recent urological practice. Vesical calculi are usually secondary to bladder outlet obstruction. These patients present with recurrent urinary tract infection, haematuria or with retention of urine. We report a female patient who presented with azotaemia due to giant vesical calculus.

INTRODUCTION

Giant vesical calculus weighing more than 100 g is a rare entity. [1] Fewer than 30 reports are available in the English literature having weight of the stone more than 100 gm. [1] The largest vesical calculus is of 6294 gram reported by Arthure et al. [2] We report a case of vesical calculus weighing 528 gram in a female patient without any predisposing factors.

CASE REPORT

A 45 year old female patient presented to us with inability to pass urine with hypogastric pain since 2 days. She had no history of previous recurrent urinary tract infection, catheterisation or trauma. There was no history of lithuria, haematuria or symptoms suggestive of hyperparathyroidism. She was postmenopausal and had delivered 2 issues normally.

On examination, she was well built and nourished. Her vital parameters wee normal. Her skin was dry and lax and showed signs of chronic dehydration. On palpation, abdomen was soft. A firm, nontender lump was palpable in the hypogastric region. Per rectal examination was normal while per vaginal examination revealed a hard mass pressing over the anterior fornix. Per urethral catheterisation was attempted but failed. On investigations, complete haemogram was normal. Plain radiograph revealed a huge radio-opaque shadow in the pelvis. (Fig. 1) Abdominal Ultrasonography confirmed the finding of the vesical calculus with evidence of bilateral hydronephrosis along with hydroureter. She had no urine output for six hours and the renal function tests revealed raised blood urea nitrogen of 76 gm% with serum creatinine of 6.6 gm%. Serum potassium was 5.4 meq/litre. Arterial blood gases showed acidosis. In view of obstructive uropathy with impending renal failure the patient was taken up for emergency suprapubic exploration. The bladder was opened extraperitoneally, when a yellowish gray hard calculus was seen with fine spicules occupying the entire cavity of the urinary bladder. It was free from the bladder mucosa and weighed 528 gram. A suprapubic cystostomy was kept. The patient had a good urine output in the postoperative period.

Fig 1 : Plain radiograph of pelvis showing a radio opaque shadow of gaint vesical calculus.

The renal function tests returned to normal gradually on the sixth postoperative day. On clamping the suprapubic catheter on the 4th post operative day, patient had no difficulty in passing urine per urethra. The suprapubic catheter was removed on the 10th day after the surgery and she was discharged on the next day. Chemical analysis of the stone revealed a mixed stone.

DISCUSSION

Calculus disease of the urinary system is known since a long time. Vesical calculi though commonly found, giant vesical calculi are rare. Vesical calculi are commonly secondary to the renal stones or to the bladder outlet obstruction and bladder diverticulum. [3] These calculi are seen commonly in males due to benign prostatic hypertrophy or urethral stricture. Rarer causes as trauma, catheterisation, neurogenic bladder, foreign body have also been reported. Bladder stones are reported around a foreign body, sutures, catheters or other objects introduced in the bladder. Pomerantz et al have reported massive or giant vesical calculus formed around arterial graft, which was incorporated in the bladder. [3]

These giant calculi are thought to develop from a single ureteric calculus or from the nidus of the infected material with a progressive layering of the calcified matrix. Lewi et al have reported formation of a large vesical calculus as a result of coalescence of 2 or more calculi. [4]

Majority compositions of the vesical calculi include triple phosphate, calcium carbonate, and calcium oxalate. Becher et al have reported massive or giant vesical calculus of 235 gram with uric acid as the major component with asymmetrical calcium oxalate. [1] Our patient had vesical calculus consisting of calcium oxalate, triple phosphate and calcium carbonate.

Patients with giant vesical calculus usually present with recurrent urinary tract infection, azotaemia and retention of urine. Our patient presented with azotaemia along with inability to pass urine. Sundaram et al have reported a case with giant vesical calculus presenting with renal failure in addition to other three similar cases. [5]

Surgical treatment of vesical calculi has evolved over years from ‘blind’ insertion of crushing forceps into the bladder to open surgical removal or extracorporeal fragmentation. Open surgery has been the best-recommended modality for large stones. [5] In small or moderate calculi, endosurgical procedures as optical mechanical cystolithotripsy have an added advantage as it can be combined with corrective procedure for bladder outlet obstruction. [6] Zhaowu et al have recommended that Electrohydraulic shockwave lithotripsy (EHSWL) preferably to be avoided in large, hard vesical calculi and if the stone is in the diverculum or stuck to the mucosa. [7]

ACKNOWLEDGEMENT

We are thankful to Dr. Shirahatti, Dean, KEM Hospital for allowing to publish the hospital data.

REFERENCES

1.Becher RM, Tolia BM, Newman HR. Giant vesical calculus. JAMA 1976; 239 (21) : 2272-3.

2.Harrison JH, et al. Campbell’s Urology. 4th ed., Philadelphia WB Saunders Co. 1978; 853-4.

3.Pomerantz PA. Giant vesical calculus formed around arterial graft incorporated into bladder. Urology 1989; 33 (1) : 57-8.

4.Lewi HJE, White A, Abel BJ, Hutchinson AG. Fused vesical calculi. Urology 1987; 30 (3) : 267-8.

5.Maheshwari PN, Oswal AT, Bansal M. Percutaneous cystolithotomy for vesical calculi : a better approach. Tech-Urol 1999; 5 (1) : 40-2.

6.Asci R, Aybek Z, Sarikaya S, Buyukalpelli, Yilmaz AF. The management of vesical calculi with optical mechanical cystolithotripsy and transurethral prostatectomy is it safe and effective? BJU Inter 1999; 84 : 332-6.

7.Zhaowu Z, Xiwen, Fenling Z. Experience with electrohydraulic shockwave lithotripsy in the treatment of vesical calculi. BJU 1988; 61 : 498-9.

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