Bladder Stone.pptx

bladder stone

1. Bladder stone By Dr I rfan Malik PGR, Urology (Team C), IKD

2. Objectives Epidemiology Classification Aetiology Management Special conditions MCQs

3. Epidemiology Bladder stones are the most common manifestation of lower urinary tract lithiasis , accounting for 5% of all the urinary stone diseases. I n nonendemic areas adults and are secondary to some other disease process. In endemic areas children and do not exist with other anomalies.

4. Classification & Aetiology of Bladder stones Can be classified into Primary idiopathic Secondary Migratory

5. Primary idiopathic : Most common in children <10 yrs with a peak incidence at 2 to 4 years. More common in boys than girls with ratios ranging from 9 : 1 to as high as 33: 1 . associated with nutritional deficiency. Primary endemic bladder calculi develop in the absence of in the absence of other urinary tract pathology. Their exact pathogenesis is unclear, but a combination of metabolic factors (decreased urine production( poor hydration), low urine pH, low urine phosphate levels, and increased uric acid, calcium oxalate, and ammonia excretion) is most likely involved.

6. Children in these geographic areas receive a cereal-dependent diet that is deficient in animal protein, while chronic dehydration, excessive oxalate consumption, and multiple vitamin deficiencies contribute to stone formation, composed mainly of ammonium acid urate alone or in combination with calcium oxalate.

7. Secondary bladder stones: A lways associated with an underlying bladder pathology. Found in men older than 60

8. Causes The commonly implicated factors are F oreign bodies i.e. sutures , catheters, self-introduced objects Factors leading to significant post void RV (BOO resulting from stricture, benign prostatic hyperplasia, neurogenic bladders, urinary diversion , bladders, bladder neck contractions ). In adults, BOO is the most common predisposing factor for bladder stone formation and accounts for 45-79% of vesical calculi

9. Uncommon causes of intravesical foreign bodies leading to bladder calculi formation are erosion of wire used for cerclage , unrecognized anorectal impalement, eroded silk sutures used in dorsal vein complex, migration of brachytherapy seeds and hair as a nidus after clean intermittent catheterization.

10. Long-term urinary catheters are one of the causative factors for bladder stone formation. The incidence is 0.7% to 2.2% in chronic indwelling catheters. Drugs Triamterene , a diuretic, is associated with urolithiasis because it inhibits sodium reabsorption in the distal tubule. Indinavir , a protease inhibitor, has been implicated as a causative factor for urolithiasis

11. Migratory bladder stone Migratory bladder stones are those which have passed from the upper urinary tract where they formed and may then serve as a nidus for bladder stone growth. Patients with bladder calculi are more likely to have a history of upper tract stones and risk factors for their formation.

12. Type of bladder stone Primary Secondary Migratory Cause/Associations Occur in the absence of other urinary tract pathology, typically in children in areas with poor hydration, recurrent diarrhoea, and a diet deficient in animal protein BOO (e.g., BPO, urethral stricture) Form in the upper urinary tract, then passed into the bladder where they may be a nidus for stone growth Neurogenic bladder dysfunction Chronic bacteriuria Foreign bodies (including catheters) Bladder diverticula Bladder augmentation Urinary diversion Bladder stones classified by aetiology

13. Presentation of Bladder Stones Terminal haematuria . Most common presentation Lower urinary tract symptoms Suprapubic pain Children: A bdominal discomfort, dysuria , frequency, haematuria, enuresis and rectal prolapse (resulting from straining due to bladder spasms) Pulling the penis, in children, is considered pathognomonic of bladder stone . Acute retention. In Adults , rare children.

14. Diagnostic evaluation Plain X-ray of KUB sensitivity of 21%-78 % Ultrasound sensitivity 20-83%, specificity 98-100 % Computed tomography Cystoscopy

15. Diagnosing the cause of bladder stones Physical examination of external genitalia, PNS (including DRE, peri -anal tone, and sensation in men ); UFM, PVR Metabolic assessment. S creat , S/E, Ca , Uric Acid, Urine PH Stone analysis. in first-time formers

16. Management of Bladder Stones The options for treatment of bladder stones are Medical management Extracorporeal shock wave lithotripsy Transurethral lithotripsy Suprapubic cystolithotomy Suprapubic cystolithotripsy , and Open surgery

17. Medical Management Chemo dissolution as a sole treatment for bladder stones is time consuming and not completely efficient. Urease inhibitor hemiacidrin , Suby’s G solution. Dissolve struvite stones Alkaline citrate. Uric acid stones A djunct treatment & prophylactic measure . The treatment of chemodissolution is particularly effective for encrustation over long-term catheters. This can be considered as the treatment modality as well as a

18. Extracorporeal Shock Wave Lithotripsy Artificial urinary sphincters or a penile prosthesis.(Jeopardize the integrity of the prosthesis or sphincter device). It has also been considered to be a treatment option in stones in neobladders and medically high-risk patients

19. The protocol 22 for ESWL includes Pron e positioning of the patient , Indwelling catheter in form of a three-way Foley. The bladder is filled up to Once the session is over, the bladder is drained. Intermittent irrigation further helps to localize the stone. The Factors that affect the outcome of ESWL in bladder stones include the amount of postvoid residue, the stone composition, and the stone size

20. Endourologic Approach to Bladder Stone Transurethral Approach: The transurethral route, because of its high efficacy and minimal morbidity, has evolved as the most frequently used approach .

21. Mechanical stone crusher: Low bladder capcity , hard stone, larger stone(>2cm) Intracorporal Pneumatic lithotripsy : Ultrasound lithotripsy: low cost and the simultaneous evacuation of stone fragments. Holmium-YAG laser has led to successful disintegration of large stones (diameter 4 cm),with minimal mucosal injury and hematueria compared with mechanical lithotripsy

22. Shortcomings of transurethral stone fragmentation Increased operative time, bleeding, loss of vision, and potential urethral injury.

23. Percutaneous cystolithotomy Avoids urethral injuries and achieves high rates of clearance for large or multiple stones . It can be safely and effectively performed under local anesthesia or in combination with a simultaneous transurethral approach, thus making fragment removal less time-consuming. The use of large-bore Amplatz sheaths and instruments (26-36 French) allows less time-consuming stone clearance, with success rates in the 85-100%range. The use of a laparoscopic entrapment sac through a10-mm laparoscopic trocar may achieve intact stone removal without the need for intracorporeal fragmentation

24. Shortcomings Incision related morbidity, Bowel and vascular injury Contraindications ( urothelial carcinoma , previous abdominal or pelvic surgery ). For patients with previous abdominal surgery or reconstructed bladders, in- traoperative imaging-guided percutaneous access (using ultra- sonography or computed tomography) is recommended to minimize the risk of bowel injury.

25. Open Surgery for Bladder Stones Maximizes stone clearance rates in a single surgical session, especially for large calculi ( 4cm) Significant stone burden Minimally invasive procedures fails or Contraindications.

26. BOO With Bladder Lithiasis Traditional teachings Previous studies. BOO was the cause of bladder stone in 88% Millán -Rodríguez et al questioned this theory. 50% have urodynamic evidence of BOO after ESWL.

27. O’Connor et al presented their experience with 23 patients treated with endoscopic stone removal and medical treatment for BPH (blocker finasteride ), with a mean follow-up of 30 months. They observed a 48.6% reduction in IPSS and 49 % decrease in PVR urine volume , as well as 14 complications involving only 5 patients. In this study, a majority of patients were treated successfully by a combination of stone removal and medical treatment

28. Bladder Calculi Augmented Bladder & Urinary diversion Risk factors include Excess mucus production , Incomplete bladder emptying, Noncompliance with CIC or bladder irrigations, Bacteriuria or urinary tract infections, F oreign bodies (including staples, mesh, non-absorbable sutures), Drainage by Mitrofanoff or Monti and Voiding by CISC compared with those voiding spontaneously. Gastric segment augmentation confers a lower risk of bladder stones than ileal or colonic segment cystoplasty .

29. Bladder Calculi in Augmented Bladder & Urinary diversion Treatment For small stones. Transurethral approach For large stones. Percutaneous/Open approach. Stromal stenosis. Revision of stoma Prevention: Daily, or three-times-weekly bladder irrigations reduce the incidence of bladder stones following bladder augmentation or continent urinary diversion

30. Bladder Calculi in Patients With Spinal Cord Injury Within 8-10 years, 15-36% of patients will develop a bladder stone. The absolute annual risk of stone formation in spinal cord injury patients with an indwelling catheter is 4% compared with 0.2% for those voiding with clean intermittent self-catheterisation (CISC ) Different studies: Spinal cord injury patients with an indwelling urethral catheter are six times more likely to develop bladder stones than patients with normal micturition

31. Immobilization hypercalciuria Infection Prevention

32. MCQs Risk factors for the formation of stones in patients with urinary diversions include all of the following EXCEPT a hypocitruria . b hyperchloremic metabolic acidosis. c hypercalciuria . d hyperoxaluria . e urinary tract infection

33. Appropriate treatment options for bladder calculi include all of the following EXCEPT : a irrigation with Suby solution G. b shockwave lithotripsy. c electrohydraulic lithotripsy. d ultrasonic lithotripsy. e holmium laser lithotripsy

34. What is the most accurate examination to document the presence of a bladder stone ? a Ultrasonography b Excretory urography c Computed tomography d Cystoscopy e Plain (kidney/ureter/bladder) radiography

35. Thank You