3. Epidemiology
• Bladder stones are the most common
manifestation of lower urinary tract lithiasis,
accounting for 5% of all the urinary stone
diseases.
• In nonendemic areas adults and are
secondary to some other disease process.
• In endemic areas children and do not
exist with other anomalies.
4. Classification & Aetiology of
Bladder stones
Can be classified into
1. Primary idiopathic
2. Secondary
3. Migratory
5. Primary idiopathic :
Most common in children <10 yrs with a peak incidence at 2
to 4 years.
More common in boys than girls with ratios ranging from 9 : 1
to as high as 33: 1.
associated with nutritional deficiency.
Primary endemic bladder calculi develop in the absence of
in the absence of other urinary tract pathology.
Their exact pathogenesis is unclear, but a combination of
metabolic factors (decreased urine production( poor
hydration), low urine pH, low urine phosphate levels, and
increased uric acid, calcium oxalate, and ammonia
excretion) is most likely involved.
6. • Children in these geographic areas receive a
cereal-dependent diet that is deficient in
animal protein, while chronic dehydration,
excessive oxalate consumption, and multiple
vitamin deficiencies contribute to stone
formation, composed mainly of ammonium
acid urate alone or in combination with
calcium oxalate.
7. Secondary bladder stones:
• Always associated with an underlying bladder
pathology.
• Found in men older than 60
8. • Causes
The commonly implicated factors are
• Foreign bodies i.e. sutures, catheters, self-
introduced objects
• Factors leading to significant post void RV (BOO
resulting from stricture, benign prostatic
hyperplasia, neurogenic bladders, urinary
diversion, bladders, bladder neck contractions). In
adults, BOO is the most common predisposing
factor for bladder stone formation and accounts
for 45-79% of vesical calculi
9. • Uncommon causes of intravesical foreign bodies
leading to bladder calculi formation are
• erosion of wire used for cerclage,
• unrecognized anorectal impalement,
• eroded silk sutures used in dorsal vein complex,
• migration of brachytherapy seeds and
• hair as a nidus after clean intermittent
catheterization.
10. • Long-term urinary catheters are one of the
causative factors for bladder stone formation. The
incidence is 0.7% to 2.2% in chronic indwelling
catheters.
• Drugs
Triamterene, a diuretic, is associated with
urolithiasis because it inhibits sodium reabsorption in
the distal tubule.
• Indinavir, a protease inhibitor, has been implicated
as a causative factor for urolithiasis
11. • Migratory bladder stone
Migratory bladder stones are those which
have passed from the upper urinary tract
where they formed and may then serve as a
nidus for bladder stone growth. Patients with
bladder calculi are more likely to have a
history of upper tract stones and risk factors
for their formation.
12. Type of bladder
stone
Primary Secondary Migratory
Cause/Associations
Occur in the
absence of other
urinary tract
pathology, typically
in children in areas
with poor
hydration, recurrent
diarrhoea, and a
diet deficient in
animal protein
BOO (e.g., BPO,
urethral stricture)
Form in the upper
urinary tract, then
passed into the
bladder where they
may be a nidus for
stone growth
Neurogenic bladder
dysfunction
Chronic bacteriuria
Foreign bodies
(including
catheters)
Bladder diverticula
Bladder
augmentation
Urinary diversion
Bladder stones classified by aetiology
13. Presentation of Bladder Stones
• Terminal haematuria . Most common presentation
• Lower urinary tract symptoms
• Suprapubic pain
• Children: Abdominal discomfort, dysuria, frequency,
haematuria, enuresis and rectal prolapse (resulting
from straining due to bladder spasms)
• Pulling the penis, in children, is considered
pathognomonic of bladder stone.
• Acute retention. In Adults, rare children.
15. Diagnosing the cause of bladder
stones
• Physical examination of external genitalia, PNS
(including DRE, peri-anal tone, and sensation
in men);
• UFM, PVR
• Metabolic assessment. S creat, S/E, Ca, Uric
Acid,
• Urine PH
• Stone analysis. in first-time formers
16. Management of Bladder Stones
• The options for treatment of bladder stones
are
• Medical management
• Extracorporeal shock wave lithotripsy
• Transurethral lithotripsy
• Suprapubic cystolithotomy
• Suprapubic cystolithotripsy, and
• Open surgery
17. Medical Management
Chemo dissolution
as a sole treatment for bladder stones is time
consuming and not completely efficient.
• Urease inhibitor hemiacidrin, Suby’s G solution.
Dissolve struvite stones
• Alkaline citrate. Uric acid stones
• Adjunct treatment & prophylactic measure.
The treatment of chemodissolution is particularly
effective for encrustation over long-term
catheters. This can be considered as the
treatment modality as well as a
18. Extracorporeal Shock Wave
Lithotripsy
• Artificial urinary sphincters or a penile
prosthesis.(Jeopardize the integrity of the
prosthesis or sphincter device).
• It has also been considered to be a treatment
option in stones in neobladders and medically
high-risk patients
19. • The protocol 22 for ESWL includes
• Prone positioning of the patient,
• Indwelling catheter in form of a three-way Foley.
The bladder is filled up to
• Once the session is over, the bladder is drained.
Intermittent irrigation further helps to localize
the stone. The
• Factors that affect the outcome of ESWL in
bladder stones include the amount of postvoid
residue, the stone composition, and the stone
size
20. Endourologic Approach to Bladder
Stone
Transurethral Approach:
• The transurethral route, because of its high
efficacy and minimal morbidity, has evolved as
the most frequently used approach.
21. • Mechanical stone crusher: Low bladder capcity,
hard stone, larger stone(>2cm)
• Intracorporal Pneumatic lithotripsy:
• Ultrasound lithotripsy: low cost and the
simultaneous evacuation of stone fragments.
• Holmium-YAG laser has led to successful
disintegration of large stones (diameter 4
cm),with minimal mucosal injury and hematueria
compared with mechanical lithotripsy
22. Shortcomings of transurethral stone
fragmentation
• Increased operative time, bleeding, loss of
vision, and potential urethral injury.
23. Percutaneous cystolithotomy
• Avoids urethral injuries and achieves high rates of clearance
for large or multiple stones.
• It can be safely and effectively performed under local
anesthesia or in combination with a simultaneous
transurethral approach, thus making fragment removal less
time-consuming.
• The use of large-bore Amplatz sheaths and instruments
(26-36 French) allows less time-consuming stone clearance,
with success rates in the 85-100%range.
• The use of a laparoscopic entrapment sac through a10-mm
laparoscopic trocar may achieve intact stone removal
without the need for intracorporeal fragmentation
24. Shortcomings
• Incision related morbidity,
• Bowel and vascular injury
• Contraindications (urothelial carcinoma, previous
abdominal or pelvic surgery).
• For patients with previous abdominal surgery or
reconstructed bladders, in-traoperative imaging-
guided percutaneous access (using ultra-
sonography or computed tomography) is
recommended to minimize the risk of bowel
injury.
25. Open Surgery for Bladder Stones
• Maximizes stone clearance rates in a single
surgical session, especially for large calculi
(4cm)
• Significant stone burden
• Minimally invasive procedures fails or
Contraindications.
26. BOO With Bladder
Lithiasis
• Traditional teachings
• Previous studies. BOO was the cause of
bladder stone in 88%
• Millán-Rodríguez et al questioned this theory.
• 50% have urodynamic evidence of BOO after
ESWL.
27. • O’Connor et al presented their experience with
23 patients treated with endoscopic stone
removal and medical treatment for BPH (blocker
finasteride), with a mean follow-up of 30 months.
They observed a 48.6% reduction in IPSS and 49%
decrease in PVR urine volume, as well as 14
complications involving only 5 patients.
• In this study, a majority of patients were treated
successfully by a combination of stone removal
and medical treatment
28. Bladder Calculi Augmented Bladder &
Urinary diversion
• Risk factors include
• Excess mucus production,
• Incomplete bladder emptying,
• Noncompliance with CIC or bladder irrigations,
• Bacteriuria or urinary tract infections,
• Foreign bodies (including staples, mesh, non-absorbable
sutures),
• Drainage by Mitrofanoff or Monti and
• Voiding by CISC compared with those voiding
spontaneously.
• Gastric segment augmentation confers a lower risk of
bladder stones than ileal or colonic segment cystoplasty.
29. Bladder Calculi in Augmented Bladder
& Urinary diversion
• Treatment
• For small stones. Transurethral approach
• For large stones. Percutaneous/Open approach.
• Stromal stenosis. Revision of stoma
• Prevention:
Daily, or three-times-weekly bladder irrigations
reduce the incidence of bladder stones following
bladder augmentation or continent urinary
diversion
30. Bladder Calculi in Patients With Spinal
Cord Injury
• Within 8-10 years, 15-36% of patients will develop a
bladder stone.
• The absolute annual risk of stone formation in spinal
cord injury patients with an indwelling catheter is 4%
compared with 0.2% for those voiding with clean
intermittent self-catheterisation (CISC)
• Different studies:
• Spinal cord injury patients with an indwelling urethral
catheter are six times more likely to develop bladder
stones than patients with normal micturition
33. MCQs
• Risk factors for the formation of stones in
patients with urinary diversions include all of
the following EXCEPT
• a hypocitruria.
• b hyperchloremic metabolic acidosis.
• c hypercalciuria.
• d hyperoxaluria.
• e urinary tract infection
34. • Appropriate treatment options for bladder
calculi include all of the following EXCEPT:
• a irrigation with Suby solution G.
• b shockwave lithotripsy.
• c electrohydraulic lithotripsy.
• d ultrasonic lithotripsy.
• e holmium laser lithotripsy
35. • What is the most accurate examination to
document the presence of a bladder stone?
• a Ultrasonography
• b Excretory urography
• c Computed tomography
• d Cystoscopy
• e Plain (kidney/ureter/bladder) radiography
