Cystolithiasis With Concentric Mural Calcification Following Transurethral Microwave Thermotherapy

Radiology Page Cystolithiasis With Concentric Mural Calcification Following Transurethral Microwave Thermotherapy 79-year-old male presented with a 1 ½-year history of gross hematuria and slowly increasing irritative voiding symptoms including frequency (up to every 10 minutes), nocturia and urinary incontinence. The patient did not have any significant travel history and did not pass visible amounts of stone material in urine. Prior history is significant for computerized tomography of the abdomen/pelvis that was performed approximately 1 year previously. It failed to demonstrate bladder calcifications but revealed a mildly thickened bladder wall and enlarged prostate. Subsequent cystoscopy similarly found no bladder stones or tumor and only mild bladder trabeculation. The patient underwent transurethral microwave thermotherapy for bladder outlet obstruction, and was seen 5 months later in the emergency department with the presence of left hydronephrosis, hydroureter and a calcified bladder wall. An extensive transurethral bladder resection with multiple calculi removal was performed, and stone analysis (including a 3.031 gm calculus) revealed a mixed composition of urate and magnesium ammonium phosphate (struvite). Pathological examination showed calcific and necrotic debris with the presence of cystitis cystica. Followup cystoscopy performed 2 months later found recurrent, severe cystolithiasis and the patient was referred for additional evaluation. At presentation urinalysis revealed a brown specimen with more than 100 red blood cells per high power field, 1 to 3 white blood cells, pH 9.0 and a protein-to-osmolality ratio of 4.42. Additional pertinent laboratory findings included blood urea nitrogen 65 mg/dl, creatinine 2.9 mg/dl, uric acid 9.8 mg/dl, hemoglobin 9.1 gm and urine magnesium 7 mg per specimen. Urine cytology was negative for malignancy and microbiological culture revealed Staphylococcus aureus without the presence of acid fast bacilli demonstrable on Gram stain. The scout radiograph from repeat computerized tomography of the abdomen/pelvis is remarkable for significant calci-

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0022-5347/07/1776-2339/0 THE JOURNAL OF UROLOGY® Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION

fications of the bladder wall and associated calcific densities present intrarenally bilaterally (part A of figure). Individual images revealed nearly circumferential diffuse mucosal calcifications with variable thickness and an irregular luminal margin (part B of figure). Findings represent a combination of mural calcification and cystolithiasis consistent with chronic inflammation. Contrast can be seen extending through the calcifications in only a few sites, and associated bilateral hydroureter and hydronephrosis are present along with numerous calcific densities in the bilateral intrarenal collecting systems (not shown). Following a second transurethral bladder resection that revealed calcific debris and completely infarcted/necrotic tissue of indeterminate significance, the patient underwent radical cystoprostatectomy with ileal conduit urinary diversion. On pathological examination bladder tissue exhibited extensive degeneration, necrosis, and inflammation of the mucosa and submucosa, as well as the absence of any identifiable tumor. The prostate was similarly without cancer and displayed benign prostatic hyperplasia. This case demonstrates an unusual and sudden appearance of cystolithiasis and concentric mural calcification of the bladder that emerged following transurethral microwave thermotherapy for bladder outlet obstruction.

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Landon W. Trost Department of Urology Tulane University School of Medicine New Orleans, Louisiana and Sameer A. Siddiqui and Matthew Gettman Department of Urology Mayo Clinic Rochester, Minnesota

Vol. 177, 2339, June 2007 Printed in U.S.A. DOI:10.1016/j.juro.2007.02.030