Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Bladder Stones Treatment & Management

  • Author: Joseph Basler, MD, PhD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Nov 11, 2014
 

Approach Considerations

Because a bladder stone is in itself a sign of an underlying problem, removal of the stone and treatment of the underlying abnormality are nearly always indicated. Management of the underlying cause of stone formation (eg, bladder outlet obstruction, infections, foreign body, or diet) is integral to prevention of recurrence. The only contraindication to bladder stone removal would be existence of the stone in a medically unstable or near-terminal asymptomatic patient.

In general, most vesical calculi procedures are performed via endoscopy. However, if the stone is too large or too hard or if the patient’s urethra is too small (eg, in children) or has been surgically altered in such a way as to complicate access to the bladder, an open or percutaneous suprapubic surgical approach is preferable.

Next

Pharmacologic Stone Dissolution

The only potentially effective medical treatment for bladder calculi is urinary alkalization for the dissolution of uric acid stones. Stone dissolution may be possible if the urinary pH can be made greater than or equal to 6.5. Potassium citrate 60 mEq/day is the treatment of choice. However, overly aggressive alkalization may lead to calcium phosphate deposits on the stone surface, making further medical therapy ineffective.[8]

Other agents for stone dissolution, such as Suby G or M solution, are rarely used. Renacidin can be used to dissolve phosphate or struvite calculi, but treatment is slow and invasive because it must be used in conjunction with indwelling irrigating catheters. Patients must also be monitored closely for signs of sepsis or hypermagnesemia. Further measures include irrigation of the bladder or continent diversions with saline for mechanical flushing of debris or with one of the above solutions for prevention of stone formation.[21]

When underlying errors of metabolism are discovered during 24-hour urine evaluation of stone disease, various treatments are available to prevent further calculus development. However, discussion of these treatments is beyond the scope of this article.

Previous
Next

Surgical Fragmentation and Removal

Currently, 3 different surgical approaches to this problem are used:

  • Transurethral cystolitholapaxy
  • Percutaneous suprapubic cystolitholapaxy
  • Open suprapubic cystotomy

In transurethral cystolitholapaxy, cystoscopy is performed to visualize the stone, an energy source is used to fragment it, and the fragments are then removed through the cystoscope. The energy sources may be a mechanical device (ie, a lithoclast [pneumatic jack hammer]), an ultrasonic device, an electrohydraulic device, a manual lithotrite, or a laser.

Unlike renal and most ureteral calculi, bladder calculi have not been effectively treated with electrohydraulic shock-wave lithotripsy (ESWL) in most centers[25] ; however, some studies suggest that ESWL performed with the patient in the prone position can be considered for treatment.[26] The pulsed-dye and other wavelength-specific light sources (eg, holmium laser) fracture the stone through direct absorption, vaporization, water absorption, and pressure-wave generation.[27]

Because of ongoing advances in instrumentation, the smaller caliber of the pediatric urethra can be accommodated; thus, these approaches are now applicable to selected children.[28]

In percutaneous suprapubic cystolitholapaxy (which now is often the primary approach in the pediatric population), the percutaneous route allows the use of shorter- and larger-diameter endoscopic equipment (usually with an ultrasonic lithotripter), thereby permitting rapid fragmentation and evacuation of the calculi.[29]

Often, a combined transurethral and percutaneous approach can be used to aid in stone stabilization and to facilitate irrigation of the stone debris. The authors favor a combined approach with the use of the ultrasonic lithotripter or the pneumatic lithoclast. The holmium laser is also effective but is generally slower, even with the 1000-µm fiber.[30]

The electrohydraulic lithotripsy (EHL) unit has been associated with a higher incidence of bladder mucosal injury. Options for accessing the bladder may be challenging in certain circumstances, such as in patients who have undergone prior bladder reconstruction or prior bladder neck procedures for improved continence.

Paez et al, in a study of percutaneous removal of bladder stones via ultrasound-assisted access of the bladder through prior suprapubic tube tracts (a Mitrofanoff catheterization channel with a 30-French Amplatz sheath was used in 1 case) reported no complications and concluded that percutaneous treatment was a safe alternative in this population subset.[31] This same procedure has also been described in continent diversions with urethral closure.[32]

First described in 1963 by Barnes et al and supported by numerous subsequent articles, transurethral lithotripsy combined with transurethral resection of the prostate (TURP) or transurethral incision of the prostate (TUIP) can be accomplished easily and safely.[33, 34] It is advisable to complete the stone ablation before carrying out these prostatic interventions; hemorrhage and excess fluid absorption are potential complications when the procedures are performed in the reverse order.

In a study by Tugcu et al, 64 patients underwent TURP in addition to concomitant bladder calculi surgery.[35] Participants were treated with either (1) a percutaneous suprapubic approach with a 30-French access sheath or (2) transurethral cystolitholapaxy with a 23-French sheath and pneumatic lithotripter; those who underwent percutaneous stone removal had a statistically significantly larger stone burden, and the mean operating time for the percutaneous approach was nearly half that for transurethral removal.

In open suprapubic cystotomy, stones are not fragmented but are removed intact. This approach can be used with larger and harder stones and in cases where open prostatectomy or bladder diverticulectomy is indicated. Open prostatectomy is generally indicated when the prostate volume exceeds 80-100 g.

The advantages of suprapubic cystolithotomy include rapidity, easy removal of several calculi at 1 time, the ability to extract calculi that are adherent to bladder mucosa, and the ability to remove large stones that are too hard or dense to fragment expeditiously via transurethral or percutaneous techniques. The major disadvantages include postoperative pain, longer hospital stay, and longer bladder catheterization times.

Previous
Next

Long-Term Monitoring

Typical follow-up is 3-4 weeks postoperatively with kidney-ureter-bladder (KUB) radiography or bladder ultrasonography to document clearing of all the fragments. Thereafter, metabolic evaluation may be pursued as indicated, and KUB radiography may be done at 6- to 12-month intervals is warranted. A metabolic stone profile analysis is indicated in patients with uric acid stones, concurrent upper tract calculi, a strong family history of stone disease, calculi without obstruction, and recurrent calculi.

Previous
 
 
Contributor Information and Disclosures
Author

Joseph Basler, MD, PhD Thomas P Ball Residency Education Professor, Urology Residency Program Director, Department of Urology, University of Texas Health Science Center at San Antonio; Chief, Section of Urology, Audie Murphy Veterans Affairs Hospital

Joseph Basler, MD, PhD is a member of the following medical societies: American Urological Association, Society of University Urologists, SWOG, Texas Medical Association, Society for Basic Urologic Research, Society of Urologic Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

Joel A Leon-Becerril, MD 

Joel A Leon-Becerril, MD is a member of the following medical societies: American Medical Association, Pan American Trauma Society

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Acknowledgements

Christopher H Cantrill, MD Resident Physician, Department of Urology, University of Texas Health Sciences Center at San Antonio

Christopher H Cantrill, MD is a member of the following medical societies: American Association of Clinical Urologists, American Urological Association, and Endourological Society

Disclosure: Nothing to disclose.

Aldo Ghobriel, MD Staff Physician, Department of Surgery, Division of Urology, University of Texas Health Sciences Center at San Antonio

Aldo Ghobriel, MD is a member of the following medical societies: American Medical Association and American Urological Association

Disclosure: Nothing to disclose.

Leonard Gabriel Gomella, MD, FACS The Bernard W Godwin Professor of Prostate Cancer Chairman, Department of Urology, Associate Director of Clinical Affairs, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Leonard Gabriel Gomella, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Urological Association, Sigma Xi, Society for Basic Urologic Research, Society of University Urologists, and Society of Urologic Oncology

Disclosure: GSK Consulting fee Consulting; Astra Zeneca Honoraria Speaking and teaching; Watson Pharmaceuticals Consulting fee Consulting

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Douenias R, Rich M, Badlani G, Mazor D, Smith A. Predisposing factors in bladder calculi. Review of 100 cases. Urology. 1991 Mar. 37(3):240-3. [Medline].

  2. Hammad FT, Kaya M, Kazim E. Bladder calculi: did the clinical picture change?. Urology. 2006 Jun. 67(6):1154-8. [Medline].

  3. Kamoun A, Daudon M, Abdelmoula J, Hamzaoui M, Chaouachi B, Houissa T, et al. Urolithiasis in Tunisian children: a study of 120 cases based on stone composition. Pediatr Nephrol. 1999 Nov. 13(9):920-5; discussion 926. [Medline].

  4. Hodgkinson A. Composition of urinary tract calculi from some developing countries. Urol Int. 1979. 34(1):26-35. [Medline].

  5. Van Reen R. Geographical and nutritional aspects of endemic stones. Urinary Calculus. Littleton, Mass: PSG Publishing Co; 1981.

  6. Bakane BC, Nagtilak SB, Patil B. Urolithiasis: a tribal scenario. Indian J Pediatr. 1999 Nov-Dec. 66(6):863-5. [Medline].

  7. Bartel P, Krebs J, Wöllner J, Göcking K, Pannek J. Bladder stones in patients with spinal cord injury: a long-term study. Spinal Cord. 2014 Apr. 52(4):295-7. [Medline].

  8. Ho K, Segura J. Lower Urinary Tract Calculi. Wein A, Kavoussi L, Novick A, Partin A, Peters C. Campbell-Walsh Urology. 9th. Philadelphia, Pa: Saunders Elsevier; 2007. 3: 2663-73.

  9. Ng AC, Leung AK, Robson WL. Urinary bladder calculi in a sliding vesical-inguinal-scrotal hernia diagnosed preoperatively by plain abdominal radiography. Adv Ther. 2007 Sep-Oct. 24(5):1016-9. [Medline].

  10. Mathoera RB, Kok DJ, Nijman RJ. Bladder calculi in augmentation cystoplasty in children. Urology. 2000 Sep 1. 56(3):482-7. [Medline].

  11. Rub R, Madeb R, Morgenstern S, Ben-Chaim J, Avidor Y. Development of a large bladder calculus on sutures used for pubic bone closure following extrophy repair. World J Urol. 2001 Aug. 19(4):261-2. [Medline].

  12. Godbole P, Mackinnon AE. Expanded PTFE bladder neck slings for incontinence in children: the long-term outcome. BJU Int. 2004 Jan. 93(1):139-41. [Medline].

  13. Eichel L, Allende R, Mevorach RA, Hulbert WC, Rabinowitz R. Bladder calculus formation and urinary retention secondary to perforation of a normal bladder by a ventriculoperitoneal shunt. Urology. 2002 Aug. 60(2):344. [Medline].

  14. Hick EJ, Hernández J, Yordán R, Morey AF, Avilés R, García CR. Bladder calculus resulting from the migration of an intrauterine contraceptive device. J Urol. 2004 Nov. 172(5 Pt 1):1903. [Medline].

  15. Rafique M. Vesical calculus formation on permanent sutures. J Coll Physicians Surg Pak. 2005 Jun. 15(6):373-4. [Medline].

  16. Arunkalaivanan AS, Smith AR. Bladder calculus after laparoscopic colposuspension. J Obstet Gynaecol. 2002 Jan. 22(1):101. [Medline].

  17. Lau S, Zammit P, Bikhchandani J, Buchholz NP. The unbreakable bladder stone--Munchhausen's tale. Urol Int. 2006. 77(3):284-5. [Medline].

  18. Russinko PJ, Agarwal S, Choi MJ, Kelty PJ. Obstructive nephropathy secondary to sulfasalazine calculi. Urology. 2003 Oct. 62(4):748. [Medline].

  19. Childs MA, Mynderse LA, Rangel LJ, Wilson TM, Lingeman JE, Krambeck AE. Pathogenesis of bladder calculi in the presence of urinary stasis. J Urol. 2013 Apr. 189(4):1347-51. [Medline]. [Full Text].

  20. Mizuno K, Kamisawa H, Hamamoto S, Okamura T, Kohri K. Bilateral single-system ureteroceles with multiple calculi in an adult woman. Urology. 2008 Aug. 72(2):294-5. [Medline].

  21. Huffman JL, Ginsberg DA. Calculi in the Bladder and Urinary Diversions. Coe FL, Favus MJ, Pak CY, Parks JH, Preminger GM, eds. Kidney Stones: Medical and Surgical Management. Philadelphia, Pa: Lippincott-Raven; 1996. 1025-34.

  22. Su CM, Lin HY, Li CC, Chou YH, Huang CH. Bladder stone in a woman after cesarean section: a case report. Kaohsiung J Med Sci. 2003 Jan. 19(1):42-4. [Medline].

  23. Huang WC, Yang JM. Sonographic appearance of a bladder calculus secondary to a suture from a bladder neck suspension. J Ultrasound Med. 2002 Nov. 21(11):1303-5. [Medline].

  24. Webb M, Fong W. A large bladder calculus and severe vesicoureteric reflux as seen on Tc-99m MAG3 renography. Clin Nucl Med. 2002 Nov. 27(11):803-4. [Medline].

  25. Losty P, Surana R, O'Donnell B. Limitations of extracorporeal shock wave lithotripsy for urinary tract calculi in young children. J Pediatr Surg. 1993 Aug. 28(8):1037-9. [Medline].

  26. Bhatia V, Biyani CS. Vesical lithiasis: open surgery versus cystolithotripsy versus extracorporeal shock wave therapy. J Urol. 1994 Mar. 151(3):660-2. [Medline].

  27. Bapat SS. Endoscopic removal of bladder stones in adults. Br J Urol. 1977 Nov. 49(6):527-30. [Medline].

  28. Shokeir AA. Transurethral cystolitholapaxy in children. J Endourol. 1994 Apr. 8(2):157-9; discussion 159-60. [Medline].

  29. Ikari O, Netto NR Jr, D'Ancona CA, Palma PC. Percutaneous treatment of bladder stones. J Urol. 1993 Jun. 149(6):1499-500. [Medline].

  30. Wollin TA, Singal RK, Whelan T, Dicecco R, Razvi HA, Denstedt JD. Percutaneous suprapubic cystolithotripsy for treatment of large bladder calculi. J Endourol. 1999 Dec. 13(10):739-44. [Medline].

  31. Paez E, Reay E, Murthy LN, Pickard RS, Thomas DJ. Percutaneous treatment of calculi in reconstructed bladder. J Endourol. 2007 Mar. 21(3):334-6. [Medline].

  32. Franzoni DF, Decter RM. Percutaneous vesicolithotomy: an alternative to open bladder surgery in patients with an impassable or surgically ablated urethra. J Urol. 1999 Sep. 162(3 Pt 1):777-8. [Medline].

  33. BARNES RW, BERGMAN RT, WORTON E. Litholapaxy vs. cystolithotomy. J Urol. 1963 May. 89:680-1. [Medline].

  34. Nseyo UO, Rivard DJ, Garlick WB, Bennett AH. Management of bladder stones: should transurethral prostatic resection be performed in combination with cystolitholapaxy?. Urology. 1987 Mar. 29(3):265-7. [Medline].

  35. Tugcu V, Polat H, Ozbay B, Gurbuz N, Eren GA, Tasci AI. Percutaneous versus transurethral cystolithotripsy. J Endourol. 2009 Feb. 23(2):237-41. [Medline].

 
Previous
Next
 
Multiple laminated bladder calculi in patient with neurogenic bladder.
Endoscopic view of spiculated "jack" stone with erythematous bladder mucosa in background.
Large calculus visible on plain film of intravenous pyelogram performed for hematuria.
Ex vivo photograph of bladder stone.
Two delicate "jack" stones removed before open prostatectomy.
Bladder stone accretion on matrix. Patient had history of urinary tract infections and presented with irritative voiding symptoms and microscopic hematuria. Upper-tract evaluation findings were normal, but cystoscopy demonstrated calculus. Upon laser treatment of stone, soft matrix core was encountered beneath glistening outer core. Exposed matrix core is visible in crevices.
Bladder stone accretion on matrix. Patient had history of urinary tract infections and presented with irritative voiding symptoms and microscopic hematuria. Upper-tract evaluation findings were normal, but cystoscopy demonstrated calculus. Upon laser treatment of stone, soft matrix core was encountered beneath glistening outer core. Exposed matrix core is visible in crevices.
Laser destruction of stone. Note small lacuna generated in stone as result of laser energy. At lower power settings, stone can be quickly reduced to dust.
Layered nature of bladder calculus exposed as laser strips away surface.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.