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Endoscopic extraction of urethral calculi
SURGEON'S WORKSHOP
ENDOSCOPIC EXTRACTION OF URETHRAL CALCULI WALTER L . GERBER, M .D . From the Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
Many of us have been faced with a stone or a prostatic chip that has lodged in the urethra . During the course of a recent transurethral resection of the prostate, a large number of prostatic calcifications had to be removed (Fig . 1). These calculi were pushed into the bladder to be evacuated at the conclusion of the operation . Three of these calculi proved to be too large to fit through the lumen of the 28-F resectoscope sheath . An attempt was made to pull the stones out one at a time by trapping them against the beak with the loop-electrode and pulling the entire instrument out with the stone . Unfortunately, when this was undertaken the stone bent the loop and escaped, becoming trapped within the bulbous urethra . The calculus could not be milked distally nor could it be pushed back through the sphincter into the bladder for crushing . The resectoscope could not be passed alongside the stone, and the size of the stone precluded further attempts at engaging it with the loop . The distance from the meatus made it impossible to use a clamp to grasp the stone . The only remaining recourse appeared to be a perineal urethrostomy ; instead, a simple procedure proved to work easily and well . The resectoscope was reintroduced under direct vision with a catheterization port attached and advanced until the stone could be seen . A Dormia . stone basket* was then passed through the resectoscope and opened at the level of the calculus . The stone was trapped tightly against the open end of the resectoscope which was
removed slowly as had been the original plan (Fig. 2) . Two additional calculi needed to be extracted from the bulbous urethra in a similar fashion . Urethroscopy revealed no murcosal injury from this maneuver . Most calculi in the urethra are secondary and result from bladder stones which are trapped as they attempt to navigate the channel with the flow of urine .' Prostatic calculi are relatively small, are imbedded within the gland, and usually pose no problem of obstruction . The
Kidney-ureter-bladder film showing extensive prostatic calcifications . FIGURE 1 .
+V . Mueller, Chiatgo . Illinois .
188
UROLOGY
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FEBRUARY 1941
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VOLUME XVII, NUMBER 2
diameter using a Dormia stone basket has
FIGURE 2 . (A) Prostatic calculi trapped within stone basket . (B) Stone (in basket) pulled within sheath, hiding many of rough edges and creating "wedge" shape .
treatment of urethral stones includes urethrostomy if the stone cannot be milked out by gentle inassage .t-a Removal by cystoseopic means is advised, it 'possible .' The removal of bladder calculi up to 1 .25 cin . in been described .' The author first dilated the urethra to 30 F to avoid traumatization, but made no mention of the cystoscopic appearance of the urethra afterward . By pulling the Dormia and stone well into the tip of the resectoscope in the patient described herein, a wedge shape was created which allowed removal easily and without damage . I believe this case illustrates a simple, effective, and safe method of removing calculi
UROLOGY ! FEBRUARY 1981
VOLUME XVII, NUMBER 2
esectoscope
trapped within the urethra . It can be applied to other foreign bodies, such as prostatic transurethral resection chips which are too large to be removed conveniently by other means . Iowa City, Iowa 52242 References 1 . Lowsley OS, and Kirwin TJ : Clinical Urology, 3rd ed ., Baltimore, Williams and Wilkins, 1956, vol . 1, pp . 317-319 and 334 . 2 . Drach GW : Urinary lithiasis, ire Campbell's Urology, 4th ed ., Philadelphia, W . B . Saunders Co ., 1978, p . 859. 3 . Flocks RH, and Culp DA : Surgical Urology, 4th ed ., Chicago, Year Book Medical Publishers, 1975, pp . 416-417 . 4 . Thompson IM : Transurethral surgery, in Glenn J (Ed) : Urologic Surgery, 2nd ed ., New York, Harper and Row, 1975, pp . 481-482 . 5 . Bapat SS : Endoseopic removal of bladder stones in adults, Br . J . Urol . 49 :527 (1977) .
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ENDOSCOPIC EXTRACTION OF URETHRAL CALCULI WALTER L . GERBER, M .D . From the Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
Many of us have been faced with a stone or a prostatic chip that has lodged in the urethra . During the course of a recent transurethral resection of the prostate, a large number of prostatic calcifications had to be removed (Fig . 1). These calculi were pushed into the bladder to be evacuated at the conclusion of the operation . Three of these calculi proved to be too large to fit through the lumen of the 28-F resectoscope sheath . An attempt was made to pull the stones out one at a time by trapping them against the beak with the loop-electrode and pulling the entire instrument out with the stone . Unfortunately, when this was undertaken the stone bent the loop and escaped, becoming trapped within the bulbous urethra . The calculus could not be milked distally nor could it be pushed back through the sphincter into the bladder for crushing . The resectoscope could not be passed alongside the stone, and the size of the stone precluded further attempts at engaging it with the loop . The distance from the meatus made it impossible to use a clamp to grasp the stone . The only remaining recourse appeared to be a perineal urethrostomy ; instead, a simple procedure proved to work easily and well . The resectoscope was reintroduced under direct vision with a catheterization port attached and advanced until the stone could be seen . A Dormia . stone basket* was then passed through the resectoscope and opened at the level of the calculus . The stone was trapped tightly against the open end of the resectoscope which was
removed slowly as had been the original plan (Fig. 2) . Two additional calculi needed to be extracted from the bulbous urethra in a similar fashion . Urethroscopy revealed no murcosal injury from this maneuver . Most calculi in the urethra are secondary and result from bladder stones which are trapped as they attempt to navigate the channel with the flow of urine .' Prostatic calculi are relatively small, are imbedded within the gland, and usually pose no problem of obstruction . The
Kidney-ureter-bladder film showing extensive prostatic calcifications . FIGURE 1 .
+V . Mueller, Chiatgo . Illinois .
188
UROLOGY
/
FEBRUARY 1941
/
VOLUME XVII, NUMBER 2
diameter using a Dormia stone basket has
FIGURE 2 . (A) Prostatic calculi trapped within stone basket . (B) Stone (in basket) pulled within sheath, hiding many of rough edges and creating "wedge" shape .
treatment of urethral stones includes urethrostomy if the stone cannot be milked out by gentle inassage .t-a Removal by cystoseopic means is advised, it 'possible .' The removal of bladder calculi up to 1 .25 cin . in been described .' The author first dilated the urethra to 30 F to avoid traumatization, but made no mention of the cystoscopic appearance of the urethra afterward . By pulling the Dormia and stone well into the tip of the resectoscope in the patient described herein, a wedge shape was created which allowed removal easily and without damage . I believe this case illustrates a simple, effective, and safe method of removing calculi
UROLOGY ! FEBRUARY 1981
VOLUME XVII, NUMBER 2
esectoscope
trapped within the urethra . It can be applied to other foreign bodies, such as prostatic transurethral resection chips which are too large to be removed conveniently by other means . Iowa City, Iowa 52242 References 1 . Lowsley OS, and Kirwin TJ : Clinical Urology, 3rd ed ., Baltimore, Williams and Wilkins, 1956, vol . 1, pp . 317-319 and 334 . 2 . Drach GW : Urinary lithiasis, ire Campbell's Urology, 4th ed ., Philadelphia, W . B . Saunders Co ., 1978, p . 859. 3 . Flocks RH, and Culp DA : Surgical Urology, 4th ed ., Chicago, Year Book Medical Publishers, 1975, pp . 416-417 . 4 . Thompson IM : Transurethral surgery, in Glenn J (Ed) : Urologic Surgery, 2nd ed ., New York, Harper and Row, 1975, pp . 481-482 . 5 . Bapat SS : Endoseopic removal of bladder stones in adults, Br . J . Urol . 49 :527 (1977) .
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