CASE REPORT
RARE CASE OF GIANT VESICAL CALCULUS
Deepak Ramraj1, Swaroop S2, Jagadeesha B. V. C3, Mahesh K4
HOW TO CITE THIS ARTICLE:
Deepak Ramraj, Swaroop S, Jagadeesha B. V. C, Mahesh K. ”Rare Case of Giant Vesical Calculus”. Journal
of Evidence based Medicine and Healthcare; Volume 2, Issue 7, February 16, 2015; Page: 902-905.
ABSTRACT: Giant vesical calculus is a rare entity. Vesical calculi can be primary (stones form de
novo in bladder) or secondary to the migrated renal calculi, chronic UTI, bladder outlet
obstruction, bladder diverticulum or carcinoma, foreign body and neurogenic bladder. We report a
case of an 85year old male patient who presented with history of recurrent episodes of burning
micturition, pain abdomen, straining at micturition and diminished stream. Ultrasonography and X
ray KUB showed a large vesical calculus. Patient underwent an Open Cystolithomy and a large
calculus of size 9x13cm weighing 310gms was removed. Bladder wall hypertrophy was seen with
signs of inflammation. Bladder mucosal biopsy was taken which was normal on histopathological
examination. Post-operative recovery was uneventful.
KEYWORDS: Giant vesical calculus, cystolithotomy, urinary tract infection.
INTRODUCTION: Calculus disease of urinary tract is a common entity, but giant vesical calculus
weighing more than 100grams is very rare in modern urologic practice. Vesical calculi are
commonly secondary to the chronic UTI, renal stones, bladder outlet obstruction, bladder
diverticulum or carcinoma.[1] They are more commonly seen in men. The presenting complaints
can be burning micturition, intermittent painful voiding, terminal hematuria, urinary retention and
straining while micturition. Fewer than 30 reports are available in the literature having weight of
the stone more than 100 gm.[2]The largest vesical calculus of 6294 grams was reported till now is
by Arthure et al.[3] We present a case of an 85year old male with vesical calculus of weight
310grams operated with open cystolithotomy.
CASE REPORT: An 85year old male patient presented with history of pain abdomen, burning
micturition since 2 years. Difficulty and straining at micturition since 2 weeks and history of
increased urge to micturate on lying down. On per abdomen examination there was tenderness in
hypogastrium and per rectal examination revealed no significant prostatomegaly. Routine blood
investigations were normal with normal serum calcium and uric acid. Urine routine showed pus
cells and red blood cells.
Plain radiograph of the KUB region (Fig. 1) showed a large radio-opaque shadow in the
pelvis. Ultrasonography showed a large vesical calculus of size 9x13 cm with features of cystitis
and no prostatomegaly. Suprapubic extraperitoneal cystolithotomy (Fig. 2) was done and a giant
vesical calculus of size 9x13x8 was extracted. The calculus weighed 310 grams and was free from
bladder wall. The calculus showed progressive layering of calcified matrix (Fig. 3) Bladder wall
was thickened and congested. A biopsy of the same was taken and sent for histopathology.
Thorough bladder wash was given, bladder was primarily sutured in two layers, suprapubic
cystostomy was done and bladder was drained by 18Fr per urethral Foley’s catheter which was
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 7/Feb 16, 2015
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CASE REPORT
kept for ten days. Post-operative recovery was uneventful. Biochemical examination of stone
showed a mixed stone containing calcium oxalate, triple phosphate and calcium carbonate.
DISCUSSION: Calculus disease of the urinary system is known since a long time. Vesical calculi
though commonly found, giant vesical calculi are rare. Vesical calculi are commonly secondary to
the renal stones, bladder outlet obstruction, bladder diverticulum or carcinoma bladder.[1] These
calculi are seen commonly in males due to benign prostatic hypertrophy or urethral stricture.
Rarer causes such as trauma, prolonged catheterisation, neurogenic bladder, foreign body have
also been reported. Bladder stones are reported around a foreign body, sutures, catheters or
other objects introduced in the bladder. Pomerantz et al have reported massive or giant vesical
calculus formed around arterial graft, which was incorporated in the bladder.[1]
Compositions of the vesical calculi include triple phosphate, calcium carbonate and calcium
oxalate. Becher et al have reported massive or giant vesical calculus of 235 gram with uric acid as
the major component with asymmetrical calcium oxalate.[2]
Patients with vesical calculi usually present with recurrent urinary tract infection and
dysuria. Though in neglected cases patient may present with retention of urine, hydronephrosis,
azotemia and renal failure. Sundaram et al have reported a case with giant vesical calculus
presenting with renal failure in addition to other three similar cases.[4] Chronic obstruction to urine
flow due to a vesical calculus rarely can cause bladder perforation.[5,6]
The majority of bladder calculi are radiopaque and detected by plain radiograph. Other
investigations which can show bladder calculi are ultrasound, CT-scan, magnetic resonance
imaging and intravenous urogram but contrast-enhanced CT is the investigation of choice as it
has remarkable sensitivity in detecting urinary tract stones, including uric acid stones. It can
reveal the concentric nature of stones and other pathologies of bladder predisposing to calculi.
Surgical treatment of vesical calculi has evolved over years from ‘blind’ insertion of
crushing forceps into the bladder to open surgical removal or extracorporeal fragmentation. Open
surgery has been the best recommended modality for large stones.[4] In small or moderate
calculi, endosurgical procedures such as optical mechanical cystolithotripsy have an added
advantage as it can be combined with corrective procedure for bladder outlet obstruction.[7]
Zhaowu et al have recommended that Electrohydraulic shockwave lithotripsy (EHSWL) preferably
to be avoided in large, hard vesical calculi and if the stone is in the diverticulum or stuck to the
mucosa.[8]
CONCLUSION: Possibility of a urinary bladder stone in patients presenting with recurrent
urinary symptoms should be stressed because obstructive lesions and infection seem to play a
role in formation and growth of vesical calculi, their eradication will minimize the occurrence of
stones. These patients should be evaluated to rule out other underlying disease or causes.
REFERENCES:
1. Pomerantz PA; Giant vesical calculus formed around arterial graft incorporated into bladder.
Urology 1989; 33 (1): 57-58.
2. Becher RM, Tolia BM, Newman HR; Giant vesical calculus. JAMA, 1978; 239(21): 2272-2273.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 7/Feb 16, 2015
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CASE REPORT
3. Harrison JH; Campbell’s Urology. 4th ed, WB Sauders Co., Philadelphia, 1978: 853-854.
4. Maheshwari PN, Oswal AT, Bansal M. Percutaneous cystolithotomy for vesical calculi: a
better approach. Tech-Urol 1999; 5 (1): 40-2.
5. Kaur N, Attam A, Gupta A, Amratash. Spontaneous bladder rupture caused by a giant
vesical calculus. Int Urol Nephrol 2006: 38: 487-489.
6. Basu A, Mojahid I, Williamson EP. Spontaneous bladder rupture resulting from giant vesical
calculus. Br J Urol 1994; 74: 385-386.
7. Asci, R. Aybek, Z. Sarikaya, S. Buyukalpelli, Yilmaz, AF. The management of vesical calculi
with optical mechanical cystolithotripsy and transurethral prostatectomy is it safe and
effective? BJU Inter 1999; 84, 332-6.
8. Zhaowu, Z. Xiwen, Fenling, Z. Experience with electrohydraulic shockwave lithotripsy in the
treatment of vesical calculi. BJU 1988; 61, 498-9.
Fig. 1: X-ray KUB showing
radiopaque calculus in pelvis
Fig. 2: Intraoperative image
of calculus in bladder
Fig. 3: Giant vesical calculus weighing 310 grams
cut surface showing layering of calcified matrix (A)
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 7/Feb 16, 2015
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CASE REPORT
AUTHORS:
1. Deepak Ramraj
2. Swaroop S.
3. Jagadeesha B. V. C.
4. Mahesh K.
PARTICULARS OF CONTRIBUTORS:
1. Post Graduate, Department of General
Surgery, J. J. M. M. C, Davangere.
2. Post Graduate, Department of General
Surgery, J. J. M. M. C, Davangere.
3. Professor, Department of General
Surgery, J. J. M. M. C, Davangere.
4. Professor, Department of General Surgery,
J. J. M. M. C, Davangere.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Deepak Ramraj,
# 12, J. J. M. M. C Boys Hostel,
M. C. C. B Block, Davangere-577004.
E-mail: drdeepakramraj@gmail.com
Date
Date
Date
Date
of
of
of
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Submission: 09/01/2015.
Peer Review: 10/01/2015.
Acceptance: 16/01/2015.
Publishing: 13/02/2015.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 7/Feb 16, 2015
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