Giant multiple vesical calculi: A case report.

Giant multiple vesical calculi are rare entities in modern urological practice. Very few cases of vesical calculi of more than 100 g has been reported in English literature. Largest vesical calculus was of weight 6294 g by Arthur et al. Bladder stones may be asymptomatic and discovered as incidental finding. However, when symptoms occur, these include lower abdominal pain, difficult urination, frequent urination, painful urination and blood in urine. Our CASE report demonstrated two vesical calculi weighing 194 g and 292 g which is a rare finding in today's urological practice.

Introduction

Giant and multiple vesical calculi are rare entities in modern urological practice. Very few numbers of cases of giant and multiple calculi have been reported in literature. The largest vesical calculus reported in literature is of 6294 g by Arthur et al. Our CASE report demonstrated two vesical calculi one weighing 298 g and another 194 g which are rarely seen in today's urological practice.

Report

A 30 year male patient presented with lower abdominal pain for last 1 month. Other complaints included frequency, hesitancy, burning sensation while passing urine for last 4 years. There was history of passage of blood in urine at different occasions.

On examination, a mildly tender, firm lump was palpable in hypogastric region. Per-urethral catheterization was done showing blood tinged urine. Routine urine examination showed multiple RBC's and WBC's and urine culture grew klebsiella. USG abdomen showed bilateral moderate to severe hydronephrosis with raised cortical echogenisity. Plain radiograph of KUB region showed two large radio opaque shadows in bladder. Renal function tests were deranged [urea-72 creatinine - 3.6] Plain Ct scan of abdomen and pelvis was done showing bilateral gross hydroureteronephrosis and confirmed the presence of two large calculi of size 92 × 52 mm and 25 × 57 mm in bladder lumen with thickened bladder wall(Fig. 1). open cystolithotomy was done and two yellowish brown hard stones measuring 10 × 7 × 6 cm and weighing 298 g and another measuring 6 × 5 × 5 cm weighing 194 g with rough surfaces were removed(Fig. 2, Fig. 3). Bladder wall was trabeculated. Supra-pubic catheterization was done and bladder wall was repaired in two layers. Supra pubic catheter was clamped on 14th post operative day and removed on 21st post operative day. Per urethral Catheter was removed one week later. Biochemical examination of stone showed 70% Magnesium Ammonium Phosphate Hexahydrate and 30% Carbonate Apatite.

Fig. 1

NCCT of patient showing two large bladder calculi.

Fig. 2

Stone being retrieved during open cystolithotomy.

Fig. 3

Two giant vesical calculi removed during Open Cystolithotomy.

Discussion

Bladder calculi account for 5% of all urinary calculi. A urinary bladder stone is usually defined as a giant calculus when its weight is > 100 g Giant and Multiple vesical calculi are very rare. Males are more commonly affacted than females. Bladder calculi most often occur in chronic urinary retention, bladder outlet obstruction, urinary tract infection, prolonged Catheterization, foreign body and neurogenic bladder. Ponerantz et al have reported a rare CASE of urinary bladder calculus around an arterial graft which was incorporated in bladder.

It is thought that giant vesical calculus develops from nidus of infected material or from single ureteric calculus with progressive layer wise deposition of calcified matrix.

Most of bladder calculi are composed of triple phosphate, calcium carbonate and calcium oxalate.The presentation of vesical calculi range from a complete absence of symptoms to presence of supra-pubic pain, dysuria, intermittency, frequency, hesitancy, nocturia and urinary retention. Other common signs include terminal gross hematuria and sudden termination of voiding with some degree of associated pain referred to tip of penis, scrotum, perineum, back or hip. The Majority of Bladder Calculi are radio opaque and detected by plain radiograph. Other investigations which can show Bladder calculi are ultrasound, CT scan, Magnetic resonance imaging and intravenous urogram.

Various surgical modalities are available for vesical calculi which include open surgical removal, extracorporeal fragmentation and endoscopic crushing followed by extraction of pieces. For giant stones open surgery has been recommended as best modality.

Conclusion

Giant and multiple vesical calculi are rarely seen these days. Bladder calculi most often occur in conditions of chronic urinary obstruction, Bladder outlet obstraction or urinary tract infection. CECT is the investigation of choice for giant stones. Open surgery has been recommended as best modality.