Giant Vesical Calculus, Bilateral Hydronephrosis: A Case Report

Giant Vesical Calculus, Bilateral Hydronephrosis: A Case Report

THE JOURNAL OF UROLOGY Vol. 68, No. 1, July 1952 Printed in U.S.A. GIANT VESICAL CALCULUS, BILATERAL HYDRONEPHROSIS: A CASE REPORT JOHN W. DORSEY G...

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THE JOURNAL OF UROLOGY

Vol. 68, No. 1, July 1952 Printed in U.S.A.

GIANT VESICAL CALCULUS, BILATERAL HYDRONEPHROSIS: A CASE REPORT JOHN W. DORSEY

Giant vesical calculus with advanced infected bilateral hydronephrosis presents a problem in surgical management. It is felt by many urologists that the danger in suprapubic lithotomy arises not from the actual removal of the calculus, but rather from the acute exacerbation of an existing pyelonephritis. The two-stage suprapubic prostatectomy has demonstrated that proper diversion of the urine will enhance the ultimate recovery of the patient. The development of chemotherapy and antibiotics has increased the safety of many urological procedures, but in our opinion they are an adjunct to treatment and cannot supplant adequate preoperative drainage. It would seem therefore that preliminary decompression of the upper urinary tract prior to suprapubic lithotomy should be performed in certain cases. In 1921 Randall reported the surgical removal of a vesical calculus weighing 4 pounds; the patient expired 36 hours later. This is the largest human vesical calculus of authentic record. In 1919 E. C. Smith reported the successful removal of a vesical calculus weighing 2 pounds, 6½ ounces. The largest vesical calculus removed surgically with complete recovery of the patient was that reported by F. J. Lepreau and R. H. Jenkins in 1943. It weighed 2½ pounds. In both of the above cases transurethral resection of the vesical neck was performed as a secondary procedure. The pathogenesis of vesical calculus varies in different sections of the world. P. B. Price reporting on 121 cases observed over a five year period at the University Hospital, Tsinan, China, found evidence of infravesical obstruction in only four patients, and concluded that vitamin imbalance and deficiency were the primary etiologic factors involved. Calculus and obstructive uropathy occurred in 55 per cent of American cases, according to Caulk. CASE REPORT

J. vV. N., a 35 year old white man, consulted his family physician because of a generalized exfoliative dermatitis. Incident to his general examination a scout film of the abdomen revealed a mass of calcific density occupying the true pelvis. The patient was referred to a dermatologist who felt that the dermatitis was on an allergic basis, and strongly advised against the use of excretory urography as a diagnostic measure. He gave a history of occasional nocturia. In cold weather there was frequency of one half to one hour, and the urine voided was small in amount. He would occasionally have a bilateral costovertebral angle pressure sensation which was relieved by voiding. Five years ago he noted painless gross hematuria once, and he had been told on one occasion that he had hypertension. The history otherwise was negative. Physical examination revealed the following significant findings: Early retinal Read at annual meeting, Western Section, American Urological Association, Sun Valley, Idaho, June 28, 1951. 201

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changes were present. The blood pressure was 230 systolic, and 140 diastolic. A firm, insensitive, relatively fixed mass was palpated in the suprapubic region. The prostate was small in size, smooth and regular in contour, and resilient in consistency. A large hard mass was palpated above the prostate. This mass was relatively fixed and on bimanual examination was found to be continuous with the previously noted suprapubic mass. A sound was introduced through the urethra easily, but encountered an obstruction at the vesical neck which imparted a grating sensation suggestive of vesical calculus. Blood studies revealed a nonprotein nitrogen of 43 mg. per cent, calcium 9.6 mg. per cent and phosphorus 3.6 mg. per cent. The urine contained albumin 2 plus and many pus and blood cells. Plain films (fig. 1) and a cystogram showed a bladder with intact walls that was completely filled with a giant calculus. A cystoscope was passed to the bladder by deflecting the beak beneath the stone; leverage upon the scope then made it possible to visualize the ureteral

Fm. 1. A, plain urogram showing giant vesical calculus in AP view. B, right oblique position shows anterior projection of calculus.

orifices. Indigo carmine appeared in faint concentration from both ureters 15 minutes after injection. Catheters were advanced with difficulty for a limited distance on both sides, and 140 cc of residual urine was aspirated from the left ureter. Cultures from the segregated kidney and bladder urines showed a heavy growth of Proteus vulgaris. The combined retrograde pyelograms (fig. 2) indicated advanced bilateral pyelonephrosis with dilated and redundant ureters. On completion of x-ray and laboratory studies a left nephrostomy was performed by inserting a No. 18 bag catheter through the lower calyx of the kidney. Ten days later the same procedure was carried out on the right kidney, whose parenchyma had undergone marked atrophy. One week later a 2 hour differential phenolsulfonphthalein excretion showed 4 per cent from the right kidney and 25 per cent from the left. On the twentieth hospital day a suprapubic lithotomy was performed. The vertex and lateral walls of the bladder were mobilized by a combination of blunt and sharp dissection. An elliptical incision crossing the vertex of the

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bladder was extended down each lateral wall in a slightly concave manner toward the base of the bladder neck. This incision created a flap of the anterior bladder wall and greatly increased the exposure. The immense calculus was firmly grasped with an abdominal tape and gently rotated as it was extracted

Fm. 2. Combined retrograde urogram illustrates advanced bilateral hydronephrosis, ureteral dilation and redundancy. Calcified mesenteric lymph nodes are visible over left renal outline.

Fm. 3. Giant vesical calculus weighing 1 pound, 2 gm.

from the pelvis. The bladder mucosa showed no evidence of neoplastic change. The fibrotic bladder neck would not admit an examining finger. A Malecot catheter was introduced through a stab wound and a tight closure of the bladder incision was effected. The removed calculus (fig. 3) weighed 455 gm.

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Transurethral resection of the fibromuscular tissue surrounding the bladder neck was carried out on the forty-second hospital day. Convalescence was without incident. Bilateral nephrostomy drainage was maintained for 17 days following lithotomy. At the time of release from the hospital on the forty-ninth day the patient was afebrile, ambulatory and voiding freely. Six months following hospitalization, follow-up excretory urography showed good visualization of the left calyceal system at 30 minutes, but no visualization of the right system on the one hour exposure. However one year later retrograde urograms (fig. 4) revealed approximately a 50 per cent decrease in the degree of hydronephrosis with a corresponding change in the ureters. There has been no appreciable change in the hypertensive state, and prolonged use of the newer

Frn. 4. Postoperative combined retrograde urogram reveals marked decrease in degree of hydronephrosis and hydro-ureter as noted in figure 2.

antibiotics has not altered the moderate infection in the residual prostate tissue. The patient is asymptomatic and has worked steadily since his release from the hospital. COMMENT

In view of the hypertension and high normal blood chemistry values this patient had undoubtedly suffered extensive renal damage. On an allergic basis a dermatologist had strongly advised against the use of excretory urography. Initial retrograde urograms were made with a realization that any instrumentation might precipitate acute pyelonephritis and that prior knowledge of the condition of each kidney would materially aid in the management of such complications. Bilateral nephrostomy made the difference between success and failure in this case. The elliptical vesical incision decreased the amount of dissection and greatly facilitated the delivery of the calculus without undue

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trauma to vesical mucosa and musculature. The contracted vesical neck was the probable etiological factor in the production of this calculus. The persistence of pyuria coincides with the recorded experience of other authors in the management of giant vesical calculi. SUMMARY

A case of giant vesical calculus with advanced bilateral hydronephrosis is reported. Bilateral nephrostomy drainage preliminary to suprapubic lithotomy was utilized. An elliptical incision of the bladder greatly facilitated the removal of a calculus weighing 455 gm. The etiological factor in the production of this calculus was undoubtedly the contracted vesical neck.

125 E. 8th Street, Long Beach, Calif. REFERENCES CAULK, J. R.: Ann. Surg., 93: 891-898, 1931. LEPREAU, F. J. AND JENKINS, R.H.: New Eng. J. Med., 229: 937-938, 1943. MASLOW, L.A. AND GARNELLO, J.: J. Urol., 58: 441-443, 1947. PRICE, P. B.: Arch. Surg., 50: 82-86, 1945. RANDALL, A.: J. Urol., 5: 119-125, 1919. SMITH, E. C.: Surg., Gynec. & Obst., 29: 481-484, 1919. WISHARD, W. N. AND NouRSE, M. H.: J. Urol., 63: 794-801, 1950.