Two giant stones located in the penile and prostatic urethra: a case report and review of the literature / Penil ve prostatik uretra yerlesimli iki dev uretra tasi: bir olgu sunumu ve literaturun gozden gecirilmesi.
Urethral stones account for less than 2% of all urinary stone diseases in developed countries. Most urethral stones are associated with abnormalities that predispose individuals to urinary stasis and infections, such as strictures, lower urinary tract surgery, congenital or acquired diverticula, chronic urinary infections, foreign bodies, and schistosomiasis. The aim of this case report was to present a fifty-nine-year-old man with two giant penile and prostatic ureteral stones who received a different treatment approach. After the impacted urethral stone was seen in the anterior urethra in ureteroscopy, urethrotomy was performed with a 3 cm vertical incision in the penile urethra. Pneumatic lithotripsy was performed extracorporeally via incision. The stone in the penile urethra was disintegrated and extracted using forceps. The prostatic stone was pushed back into the bladder and disintegrated by the same urethral incision with a lithotripter through a cystourethroscope. For large, impacted urethral stones, external urethrotomy combined with externally pneumatic lithotripsy may prevent long urethral incisions. Therefore, this technique may reduce the risk of postoperative stricture.
Key words: Giant urethral stone; urethrolithotomy; urolithiasis
Uretra taslari gelismis ulkerlerdeki tum tas hastaliginin %2'den azini olusturmaktadir. Uretral taslarin cogu striktur, alt uriner sistem cerrahisi, konjenital veya edinsel mesane divertikulu, kronik uriner enfeksiyonlar, yabanci cisimler ve sistozomiazis gibi stenoz ve enfeksiyona yol acan bozukluklarla iliskilidir. Bu olgu raporunda, iki dev penil ve prostatik uretra tasi olan olan 59 yasindaki erkek hastaya uyguladigimiz farkli bir tedavi yaklasimini sunmayi amacladik. Uretroskopide anterior uretrada impakte uretra tasi goruldukten sonra penil uretraya 3 cm'lik vertical insizyonla uretrotomi uygulandi. Pnomotik litotripsi ekstrakorporeal olarak insizyondan uygulandi. Penil uretradaki tas parcalandi ve forseps kullanilarak disari cikarildi. Prostatik uretradaki tas mesane icerisine itildi ve sistouretroskop vasitasiyla ayni uretral insizyondan girilerek litotriptor ile parcalandi. Buyuk uretra taslarinda uretrotomiyle birlikte eksternal pnomotik litotripsi uzun uretral insizyondan kacinarak postoperatif striktur riskini azaltabilir.
Anahtar sozcukler: Dev uretra tasi, uretrolitotomi, urolitiyazis
Urethral stones constitute less than 2% of all urinary stone diseases in developed countries. (1) The condition is most prominent in men rather than women because women have low rates of bladder calculi and a short urethra that permits passage of many smaller calculi. (2) Most urethral stones are associated with predisposing factors for urinary stasis and infections, such as strictures, lower urinary tract surgery, congenital or acquired diverticula, chronic urinary infections, foreign bodies, and schistosomiasis. These stones are frequently composed of struvite, calcium phosphate or calcium carbonate. The majority of urethral stones are migrated from the bladder or upper tract, and most of them locate to the posterior and anterior urethra. (3), (4) Urethral stones may present with acute urinary retention, frequency, dysuria, suprapubic pain with poor or interrupted urinary stream, incomplete emptying and dribbling or incontinence. Whereas urethroscopic lithotripsy is the first choice for all urethral stones, external urethrotomy is recommended for large, impacted anterior urethral stones, along with urethral strictures and diverticula. (5) However, external urethrotomy potentially places a patient at an increased risk for stricture. To eliminate the necessity of external urethrotomy, the authors performed a number of manipulations, including endoscopic pushback and cystolithotripsy, non-surgical expulsion with lidocaine gel and shock wave lithotripsy. (6), (7)
Our aim was to describe a patient with two large penile and prostatic urethral stones who received external urethrotomy combined with extracorporeal pneumatic lithotripsy, as well as discuss this treatment option according to the current literature.
A fifty-nine year old man was admitted to our outpatient clinic with lower urinary tract symptoms. The patient had received open bladder repair surgery after a motor vehicle accident 30 years ago. According to his statement, he experienced no urination problems after the surgery. The physical examination revealed two large solid masses, which were palpated in the penoscrotal region and prostatic urethra. Pelvic radiography, ultrasound and abdominal computed tomography (CT) were performed. The pelvic radiography detected the presence of 7x4 cm and 5.5x3 cm radioopacities behind the symphisis pubis (Figure 1). Bilateral hydroureteronephrosis and a distended bladder with a 35x78 mm anterior diverticulum were seen in the ultrasound. Abdominal CT revealed a 25x40x55 mm calcification lodged in the prostatic urethra, a 30x40x70 mm calcification lodged in the penile urethra and an anterior bladder diverticulum of the aforementioned size (Figure 2a-c).
[FIGURE 1 OMITTED]
[FIGURE 2 OMITTED]
The surgery was started endoscopically by using a 22F cystourethroscope. In the endoscopic view, the impacted urethral stone was seen 10 cm from urethral meatus. After an attempt to push the stone back into the bladder failed, a urethrotomy was performed by creating a 3 cm vertical incision in the penile urethra. To avoid extending the incision, a pneumatic lithotripsy was performed extracorporeally via incision. The stone in the penile urethra was disintegrated and extracted using forceps. Then, the prostatic stone was pushed back into the bladder and disintegrated using the same urethral incision with a lithotripter through a cystourethroscope. The incision was closed with a double layer suture using 4/0 absorbable poliglycolic acid, and a urethral catheter was inserted. The patient had no postoperative complications. The catheter was withdrawn on the 14th day after surgery. At follow-up, no residual stone was observed in pelvic radiography, and no pathology was found during urethrography (Figure 3, 4). A photo of the extracted stones is shown in Figure 5. The stones were composed of calcium phosphate.
[FIGURE 3 OMITTED]
[FIGURE 4 OMITTED]
[FIGURE 5 OMITTED]
Selli et al. (5) and Sharfi (8) reported that 56% of urethral stone patients had anatomical abnormalities in the urethra. However, stones originating from the urethra do not generally cause acute symptoms because of their slow growth and subsequent spontaneous passage. Additionally, Koga et al. (1) found that urethral stones were associated with upper urinary tract stones, such as kidney, ureter and bladder stones, and were found in 32% of the patients. According to studies, urethral stones are generally located in the posterior urethra (26.2-88%) and anterior urethra (8-68.4%) (Table 1).
Table 1. Characteristics of urethral stone treatmets in the literture Author Number of Most prominent Presenting associated symptoms male urological patients abnormalities (n) (number of (%) patients) (%) Koga et al. 54 Dysuria 54 Urolithiasis 18 (1) (100) (32) Gross hematuria Urethral stricture 10 (18.5) 5 (9.3) Urinary Benign prostatic retention 7 hyperplasia 5 (13) (9.3) Sharfi (5) 34 Dysuria 12 Urethral stricture (35.3) 15 (44.1) Interruption of Urinary urinary stream bilharziasis 4 10 (29.4) (11.7) Urinary Urethral retention 8 diverticulum 4 (23.5) (11.7) El-Sherif and 18 Any urologic Not specified El-Hafi (6) symptoms Al-Ansari et 62 Urinary Upper urinary al. retention 62 tract stones (100) 62 (100) Durazi and 7 Urinary Ureteral stricture Samiei (9) retention 7 by schistosomiasis (100) 2 (28.5) Verit et al. 15 Urinary Hypospadias 2 (10]) retention 7 (13.3) (46.7) Meatal stenosis 2 Interrupted or (13.3) weak stream 4 Renal Calculi 2 (26.7) (13.3) Pain (penile, urethral) 3 (20) Kamal et al. 50 Urinary Not specified 0 (11]) retention 40 (78) Interrupted or weak stream 11 (22) Pain (penile, urethral and perineal) 23 (45) Hemal and 26 Urinary Recurrent Urinary Sharma (12) retention 12 infection 14 (46.1) (53.8) Dysuria and Urethral stricture weak stream 11 7 (27) (42.3) Transvesical Pain (penile, prostatectomy urethral and perineal) 26 (100) Hassan et al. 19 Urinary Posterior urethral (13) retention 9 valve 4 (21.1) (47) Urethral stricture Dysuria 7 4 (21.1) (36.8) Maheshwari 42 Urinary Upper tract and Shah retention 28 urinary stones 17 (14) (66.6) (40.4) Ahmed and 7 Dysuria 7 Urolithiasis 1 Saeed (15) (100) (14.2) Pain (penile) 7 (100) Author Location of Largest Treatment types (n) urethral diameter of (%) stones stone (mm) Koga et al. Posterior Not Retrograde (1) urethra 37 specified manipulation and (68.5) litholapaxy32 Anterior (59.2) urethra 9 External (16.6) urethrotomy 6 Fossa (11.1) navicularis 6 Meatotomy and (11.1) forceps extraction Bulbous 7 (13) urethra 2 (3.7) Sharfi (5) Anterior Not Endoscopically urethra 10 specified push-back and (29.4) litholapaxy 12 Posterior (35.3) urethra 20 Retrograde (58.8) manipulation and Fossa litholapaxy 9 navicularis 4 (26.4) (11.7) Retrograde manipulation and open cystolithotomy 5 (14.7) External urethrotomy 7 (20.5) El-Sherif and Anterior 12 Intraurethral 2% El-Hafi (6) urethra 10 lidocaine jelly (55.5) instillation for Posterior spontaneous urethra 7 passage (38.8) Fossa navicularis 1(5.7) Al-Ansari et Posterior 25 SWL 62 (100) al. urethra Retrograde 62 (100) manipulation and re-SWL 3 (4.8) Cystourethroscopy and lithotripsy 1 (1.6) Durazi and Anterior 19 24 F nephroscope Samiei (9) urethra 2 and lithot (28.5) Posterior urethra 4 (57) External meatus 1 (14.5) Verit et al. Posterior 10 Retrograde (10]) urethra 6 manipulation and (39.9) lithotripsy 4 Anterior (26.6) urethra 5 Retrograde (33.3) manipulation and Fossa cystolithotomy 2 navicularis 4 (13.3) (26.6) Meatotomy 4 (26.6) Cystourethroscopy and lithotripsy 2 (13.3) Kamal et al. Posterior 13 Cystourethroscopy (11]) urethra 45 and lithotripsy (88) Cystourethroscopy Anterior and forceps urethra 4 extraction (8) Non surgical Fossa expulsion navicularis 2 (4) Hemal and Posterior 60 Retrograde Sharma (12) urethra 16 manipulation and (61.5) cystolithotomy 13 Anterior (50) urethra 7 Cystourethroscopy (26.9) and lithotripsy 3 Fossa (11.5) navicularis 3 Cystourethroscopy (11.5) and forceps extraction 3 (11.5) Meatotomy 3 (11.5) External urethrotomy 2 (7.6) Hassan et al. Anterior Not Retrograde (13) urethra 13 specified manipulation and (68.4) open cystolithotomy Posterior 4 (21.1) urethra 6 Cystourethroscopy (31.6) and lithotripsy 4 (21.1) External Urethrotomy 3 (15.7) Maheshwari Not specified 22 Retrograde and Shah 24 (57.1) manipulation and (14) Posterior cystolithotripsy 24 urethra 11 (57.1) (26.2) Cystourethroscopy Anterior and lithotripsy 18 urethra 7 (42.8) (16.6) Ahmed and Posterior 35 Retrograde Saeed (15) urethra 2 manipulation and (28.4) cystolithotomy 7 Anterior (100) urethra 5 (71.4) Author Type of Overall Lithotripsy Success (%) Koga et al. Litholapaxy (1) Sharfi (5) Litholapaxy El-Sherif and N/A 77.7 El-Hafi (6) Al-Ansari et SWL 98.4 al. Durazi and Ultrasonic Samiei (9) Verit et al. Electrohydrolic (10]) Kamal et al. Electrohydrolic (11]) 80 Litholapaxy Hemal and Ultrasonic Sharma (12) Hassan et al. Litholapaxy 100 (13) Maheshwari Holmium Laser and Shah (14) Ahmed and N/A Saeed (15)
The symptoms of urethral stones depend on the size and location of the stones. Male patients with urethral calculi may present with acute retention if a stone is lodged in the penile urethra. Frequency, dysuria, weak urinary stream, incomplete emptying, dribbling or incontinence are shown if a stone is situated in the prostatic or membranous urethra. Pelvic radiography and CT are the most appropriate imaging procedures despite the technical challenges. Paulk et al. (3) noted that only 42% of urethral calculi were detected at urethrography. Cystourethroscopy is a diagnostic and therapeutic tool.
According to studies, the most prominent urethral stone-associated urologic abnormalities are urethral stricture (9.3-44.1%), urolithiasis (13.3-100%) and urethral diverticulum (10.5-11.7%) (Table 1). However, we only found a bladder diverticulum measuring 35x78 mm. We hypothesized that the stones originated in the anterior bladder diverticulum in our case.
Treatment for urethral stones depends on the size and location of the stone and on the condition of the urethra. The main objective of treatment is to remove the stones without damaging the urethra and periurethral tissues in order to avoid urethral stricture. Over the years, numerous techniques have been described for urethral stone removal. The success rates of these treatments were 77.7-100%. The characteristics of the urethral stone treatments in these studies are shown in Table 1. Although endoscopic treatments with different types of lithotripsy are the accepted standard therapies, external urethrotomy can be performed for large and impacted stones with or without thral stricture and diverticula. (5) Gogus et al.(16) extracted a 2x1 cm anterior urethral stone by urethrolithotomy through a 2 cm lateral coronal incision in the dorsal urethra.
We performed external urethrotomy for a penile urethral stone after failed endoscopic treatment, and pneumatic lithotripsy was performed via incision. Then, the posterior urethral stone was pushed back into the bladder and treated endoscopically as a bladder calculi through same incision. According to studies, external urethrotomy was performed for 7.6-20.5% of urethral stones (Table 1). No study reported complications associated with external urethrotomy, however most did not specify the surgical complications. In addition, the largest diameters of the stones reported in these studies were 10-60 mm, whereas the largest diameter of the penile urethral stones was 70 mm in our case. If external urethrotomy was performed alone, we had to lengthen the incision along the stone, which might have increased the risk of urethral stricture.
Although urethrocystoscopy and lithotripsy in situ or treatment in the bladder with push-back and lithotripsy provide the best treatment alternatives for most urethral stones, external urethrotomy in combination with external pneumatic lithotripsy may be a useful technique to prevent long urethral incisions and the risk of postoperative stricture for large, impacted urethral stones.
Conflict of interest
No conflict of interest was declared by the authors.
Department of Urology, Doc. Dr. Yasar Eryilmaz Dogubayazit State Hospital, 04400 Dogubayazit, Agri, Turkey
Phone: +90 505 638 30 10
[c]Copyright 2012 by Turkish Association of Urology
Available online at www.turkishjournalofurology.com
(1.) Koga S, Arakaki Y, Matsuoka M, Ohyama C. Urethral calculi. Br J Urol 1990;65:288-9. [CrossRef]
(2.) Faydaci G, Tarhan F, Eryildirim B, Ozgul A, Yucetas U, Kuyumcuoglu U. Female Urethral Diverticulum and Diverticular Stones. Turkiye Klinikleri J Gynecol Obst 2008;18:331-5.
(3.) Paulk SC, Khan AU, Malek RS, Greene LF. Urethral calculi. J Urol 1976;116:436-9.
(4.) Englisch J. Ueber eingelagerte und eingesackte Steine der Harnrohre. Arch Klin Chir 1904;72: 487-556.
(5.) Sharfi AR. Presentation and management of urethral calculi. Br J Urol 1991;68:271-2. [CrossRef]
(6.) El-Sherif AE, El-Hafi R. Proposed new method for nonoperative treatment of urethral stones. J Urol 1991;146:1546-7.
(7.) Al-Ansari A, Shamsodini A, Younis N, Jaleel OA, Al-Rubaiai A, Shokeir AA. Extracorporeal shock wave lithotripsy monotherapy for treatment of patients with urethral and bladder stones presenting with acute urinary retention. Urology 2005;66:1169- 71. [CrossRef]
(8.) Selli C, Barbagli G, Carini M, Lenzi R, Masini G. Treatment of male urethral calculi. J Urol 1984;132:37-9.
(9.) Durazi MH, Samiei MR. Ultrasonic Fragmentation in the Treatment of Male Urethral Calculi. Br J Urol 1988;62:443-4. [CrossRef]
(10.) Verit A, Savas M, Ciftci H, Unal D, Yeni E, Kaya M. Outcomes of urethral calculi patients in an endemic region and an undiagnosed primary fossa navicularis calculus. Urol Res 2006;34:37-40. [CrossRef]
(11.) Kamal BA, Anikwe RM, Darawani H, Hashish M, Taha SA. Urethral calculi:presentation and management. BJU Int 2004;93:549-52. [CrossRef]
(12.) Hemal AK, Sharma SK. Male urethral calculi. Urol Int 1991;46:334-7. [CrossRef]
(13.) Hassan I, Mahammed I. Urethral calculi: a rewiev. East Afr Med J 1993;70:523-5.
(14.) Maheshwari PN, Shah HN. In-situ holmium laser lithotripsy for impacted urethral calculi. J Endourol 2005;19:1009-11. [CrossRef]
(15.) Ahmed A, Saeed NM. Experience with the management of urethral stones presenting with urinary retention at Gusau. Niger J Clin Pract 2008;11:309-11.
(16.) Gogos O, Isikay L, Yaman O, Sarica K, Bozlu M. An unusually large anterior urethral stone. BJU 1995;76:801-2.
Deniz Bolat (1), Ismail Cenk Acar (2), Omer Levent Tuncay (2)
(1) Department of Urology, Doc. Dr. Yasar Eryilmaz Dogubayazit State Hospital, Agri, Turkey
(2) Department of Urology, Faculty of Medicine, Pamukkale University, Denizli, Turkey
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|Title Annotation:||Case Report|
|Author:||Bolat, Deniz; Acar, Ismail; Tuncay, Omer|
|Publication:||Turkish Journal of Urology|
|Date:||Dec 1, 2012|
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