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CASE REPORT GIANT VESICAL CALCULUS

Mohsin Shakil Department of Urology, AJK Medical College, Muzaffarabad, Azad Kashmir

Vesical calculi are relatively rare, and most of them are secondary, migrating down to bladder from upper urinary tract. Few are formed due to bladder outlet obstruction or presence of a nidus. Occasionally these calculi grow into enormous size and are labelled as ‘giant vesical calculus’. Case of a 44-year-old man, with lower urinary tract symptoms is presented who was diagnosed to be having giant vesical calculus on ultrasonography and plain radiography. His biochemical profile was normal. He was having urinary tract infection which was treated and controlled before surgery. Supra-pubic extra-peritoneal vesicolithotomy was performed and a huge stone measuring 10×9×5 Cm weighing 250 gm was removed. Postoperative recovery was uneventful. The possibility of bladder stones, which can induce renal dysfunction should be considered in patients complaining of lower urinary tract symptoms and frequently recurring urinary tract infections. Keywords: Vesical, Calculus, Vesicolithotomy, Bladder outlet obstruction, Urolithiasis

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INTRODUCTION Among urolithiases vesical calculi are a rare entity comprising of only 5% of the urinary stones. Most of the calculi are calcium oxalate, and they migrate down from kidneys and ureters to the bladder. Few are formed in the bladder due to bladder outlet obstruction or grow on a nidus. Rarely they grow to a huge size weighing more than 100 gm and are called ‘Giant Vesical Stones’.1–3 Vesical stones may present as lower urinary tract symptoms (LUTS), recurrent urinary tract infection, and renal dysfunction.

CASE REPORT A 44-year-old man reported to Urology OPD at Abbas Institute of Medical Sciences, Muzaffarabad, complaining of LUTS for many years and gradually getting worse. He was having mild tenderness of supra-pubic region, a hard bladder mass palpable on per rectum examination, and its upper limit was not reachable.

His X-Ray film revealed a large radio-opaque shadow in pelvis. Ultrasonography confirmed a large vesical calculus, 10×9 Cm in size with bilateral mild hydroureteronephrosis and normal sized prostate. His renal functions were optimum and urine routine examination showed numerous pus and red blood cells.

Supra-pubic, extra-peritonial vesico-lithotomy under spinal anaesthesia was performed. A yellowish-white stone weighing 250 gm was removed. Catheter was retained and bladder was closed in two layers. Surgery and postoperative recovery were uneventful. Catheter was removed on 8th postoperative day.

After passing urine comfortably with good calibre stream, he couldn’t resist to say ‘I had forgotten voiding without pain; I really enjoyed pissing now!’ These were the remarks of the poor man, who could not manage himself treated due to poverty and lack of guidance.

Figure-1: X-Ray KUB showing a large radio-

opaque shadow in the pelvis

Figure-2: Large yellowish brown stone being

extracted from the urinary bladder

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Figure-3: Large stone with smooth surface

DISCUSSION Any stone, weighing more than 100 gm is labelled as ‘giant vesical calculus’ and 30 such cases are already on record. Patients with calculi, even bigger than the present case have been reported. Arther et al reported the largest vesical stone, which weigh 6,294 grams.1 It is thought that a giant vesical calculus can develops as a primary stone on some infected material serving as a nidus, or on a small calculus migrating to urinary bladder from upper tract by progressive deposition of calcified matrix in layers.2

Vesical calculi are made up of ammonium acid urate, calcium oxalate, uric acid and calcium phosphate, or calcium carbonate.3 Vesical calculus with uric acid as the major component with a symmetrical calcium oxalate deposition are reported by Becher RM et al.4

Patient with giant vesical calculus usually present with recurrent urinary tract infections, lower urinary symptoms, bilateral hydronephrosis, deranged renal functions, and even azotaemia.5,6 Bladder perforations have also been reported.7,8

The most of the calculi are radio-opaque and visible on plain X-Ray, Ultrasonography, Computerised Tomography (CT), Magnetic Resonance Imaging (MRI), Intravenous Urography (IVU). Contrast enhanced CT is highly sensitive, and it can even show the concentric nature of the stone.9

Despite availability of different surgical modalities for management of vesical calculi, open surgery is believed to be the best approach for giant stones as it can be combined with procedures for bladder outlet obstruction, if required.

CONCLUSION The possibility of bladder stones, which can induce renal dysfunction should be considered in patients complaining of lower urinary tract symptoms and frequently recurring urinary tract infections.

REFERENCES 1. Harrison JH. Cambell’s Urology. 4th ed. Philadelphia: WB

Sauders Co; 1978. pp 853–4. 2. Schwartz BF, Stoller MZ. The vesical calculus. Urol Clin North

Am 2000;27:333–46. 3. Wein Alan J, Kavoussi Louis R, Partin Alan W, Novick

Andrew C, Peters Craig A. Walsh Urology. 10th ed. USA: Elsevier Saunders; 2012. p. 2522

4. Becher RM, Tolia BM, Newman HR. Giant vesical calculus. JAMA 1978;239(21):2272–3.

5. Ofluoglu Y, Aydin HR, Kocaaslan R, Adanur S, Ziypak T. A cause of renal dysfunction: A giant bladder stone. Eurasian J Med 2013;45:211–3.

6. Celik O, Suelozgen T, Budak S, Ilbey YO. Post-renal acute renal failure due to a huge bladder stone. Archivio Italiano di Urologia e Andrologia 2014;86(2):146–7.

7. Kaur N, Attam A, Gupta A, Amratash. Spontaneous bladder rupture caused by a giant vesical calculus. Int Urol Nephrol 2006;38:487–9.

8. Basu A, Mojahid I, Williamson EP. Spontaneous bladder rupture resulting from giant vesical calculus. Br J Urol 1994;74:385–6.

9. Maheshwari PN, Oswal AT, Bansal M. Percutaneous cystolithotomy for vesical calculi: A better approach. Tech Urol 1999;5(1):40–2.

Address for Correspondence: Dr. Mohsin Shakil, Department of Urology, AJK Medical College, Muzaffarabad, AJK, Pakistan. Cell: +92-300-8111371. Email: mohsin59@gmail.com