Vesical calculus

Introduction Bladder calculi are uncommon in the Western world They are well described in ancient medical literature Hippocrates wrote about the management of bladder stone Operations to remove stones via the perineum were described in the centuries BC Suprapubic lithotomy was described in the 15th century Transurethral lithotomy became popular in the 18th century Lithotripsy was first described in 1822 Surgery was often associated with significant morbidity and mortality

Pathophysiology 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 There is no recognized association with ureteric calculi

Pathophysiology Most bladder calculi form in the bladder and are not from the upper urinary tract They vary in size and can be multiple They are more common in elderly men In Asia, they are seen more commonly in children Most stones in adults are formed of uric acid Long-standing untreated bladder stones are associated with squamous cell carcinoma

Types Primary Secondary

Primary vesical calculus Develops in sterile urine Mostly originates in the kidney Usually of oxalate or uric acid or urate type

Secondary vesical calculus Associated with infection Mostly originates in the bladder Mostly made up of triple phosphate

Clinical features Bladder calculi can be asymptomatic Common symptoms include Suprapubic pain Dysuria Haematuria Abdominal examination may be normal

Diagnosis Historically stones were diagnosed by the passage of urethral 'sounds' Today thy can be identified on Plain abdominal x-ray Bladder ultrasound CT scan Cystoscopy Uric acid stones are radiolucent but may have an opaque calcified layer Patients may present in acute urinary retention

95% of the stones are radio- opaque

Management Basically surgical Suprapubic lithotomy Litholaplaxy

Surgery Indications for surgery include 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' This was via either a perineal or suprapubic approach The three common approaches today are Transurethral cystolitholapaxy Percutaneous cystolitholapaxy Open suprapubic cystostomy Extracorporeal shockwave lithotripsy is relatively ineffective Complications of cystolitholapaxy include Infection Haemorrhage Bladder perforation Hyponatraemia