Turkish Journal of Urology 2014; 40(3): 189-91 • DOI:10.5152/tud.2014.

02603
189
GENERAL UROLOGY
Case Report

Giant bladder stone: A case report and review of the literature

İbrahim Nüvit Tahtalı1, Turgay Karataş2

ABSTRACT
Bladder stones comprise 5% of urinary tract stones. Generally, they occur in the presence of bladder neck
obstruction, urinary tract infections associated with neurogenic bladder and foreign objects. They are more
common among men than women. Infection stones comprise approximately 15% of urinary tract stones. A
giant bladder stone is a rare finding in contemporary urological practice. The general clinical setting is re-
current urinary tract infections, hematuria and urinary retention. We performed an open cystolithotomy on a
mentally impaired patient who had a giant bladder stone. The stone removed weighed 465 grams. There was
no evidence of any infravesical obstruction on the cystoscopy performed before the operation or during the
operation. The stone consisted of 75% carbonate apatite and 25% struvite. Given that such a stone was found
in a mentally impaired patient indicates that infection stones can form without infravesical obstruction.
Key words: Ammonium phosphate (struvite); carbonate apatite; giant vesical calculus; magnesium.

Introduction liver function tests were normal. Urine analysis

indicated a very high white blood cell count.
Giant vesical calculi weighing more than 100
gm are rare.[1-3] Of the reports written in We learned that the patient had a history
English, fewer than 85 involve a stone more of anemia resulting from geophagy. He was
than 100 gm. Almost all of the articles pub- admitted to the hospital ten years ago due to
lished in Pubmed are about giant bladder anemia; then, five units of blood were trans-
stones that developed secondary to infravesi- fused, and he was given oral iron supplemen-
cal obstruction. We report a giant stone found tation. In addition, the patient had received
in the pelvic region of a mentally impaired medical treatment for frequent urinary tract
patient. infections and urinary incontinence over the
past 15 years.
Case presentation
Department of Urology,
1 After treating the urinary tract infection with
Malatya State Hospital,
A 43-year-old mentally impaired patient who intravenous antibiotics, an open cystolithoto-
Malatya, Turkey
had lower abdominal pain, moderate to severe my operation was planned. Our patient under-
Department of General
went a cystoscopic examination before open
2

Surgery, Malatya State dysuria, pollakiuria, nocturia (8-10 times) and

Hospital, Malatya, Turkey hematuria for a many years first presented to surgery on the same operation day. Then, we
the general surgery clinic. After listening to performed an open cystolithotomy. During
Submitted:
30.10.2013 the patient’s complaints, he was sent to the the operation, digital rectal manipulation was
Accepted: urology clinic and was subsequently hospital- needed to remove the stone, which was adher-
06.01.2014 ized. The required consent for publishing this ent to the bladder mucosa. No anatomical
case was obtained from the patient’s relatives urethral obstruction was observed.
Correspondence: because the patient is mentally impaired.
İbrahim Nüvit Tahtalı,
Department of Urology, Malatya A stone 11x6x7 cm in size and approximately
State Hospital, Malatya, Turkey An X-ray showed a radio-opacity in the pel- 465 grams in weight was removed (Figure 2).
Phone: +90 422 326 15 69
E-mail: nuvit_tahtali@hotmail.com vic region measuring 6x7 cm in size (Figure 1). Biochemical analysis indicated that the stone
Ultrasonography revealed bilateral hydrone- consisted of 25% struvite and 75% carbon-
©Copyright 2014 by Turkish
Association of Urology phrosis along with a giant vesical calculus. ate apatite. The stratified lamellae stone was
Digital rectal examination revealed a normal composed of carbonate apatite and magnesium
Available online at
www.turkishjournalofurology.com prostate. Likewise, blood counts and renal and ammonium phosphate.
 Turkish Journal of Urology 2014; 40(3): 189-91
190 DOI:10.5152/tud.2014.02603

Figure 2. 11x7x6 cm bladder stone was extracted by open cys-

tolithotomy

Bladder stones are mostly associated with renal or ureteral

calculi, and they rarely ever occur without associated upper
urinary tract calculi, as in our patient.[1] Primary vesical calcu-
losis is quite commonplace in Asia, with calculi consisting of
ammonium urate and calcium oxalate. Because of malnutrition
in the very early years of life, vesical calculosis is now common
in Turkey, Iran, India, China, and Indonesia; however, there
Figure 1. Large pelvic stone in direct ultrasonography is a decrease in the incidence as social conditions gradually
improve.[5]
The post-operative period was uneventful. The urethral catheter
was removed on the 8th postoperative day, and the patient’s Infected stones make up approximately 15% of urinary stone
urinary output was normal. The patient was discharged on post- diseases and are thus an important group.[5,9] These stones
operative day 8. The patient was voiding normally, despite com- are composed of struvite and/or carbonate apatite. The basic
plaining of mild lower urinary tract symptoms (LUTS), mostly precondition for the formation of infected stones is a urease-
irritative, and the bilateral hydronephrosis improved markedly positive urinary tract infection. As a result, ammonium ions
within 3 weeks. can form, and at the same time, alkaline urine develops. Both
are preconditions for the formation of struvite and carbonate
Discussion apatite crystals. When these crystals deposit, infected stones
form.[9]
Epidemiological surveys of urolithiasis have shown a preva-
lence between 4 and 20% in developed countries.[4,5] Mostly The preferred method for diagnosis is cystoscopy, but an X-ray
resulting from bladder outlet obstruction, neurogenic voiding or an ultrasound is sometimes enough. Because of its size, cys-
dysfunction, urinary tract infection or foreign bodies, bladder tolithotomy is the correct treatment for a giant bladder stone.[1,3,6]
calculi account for 5% of urinary calculi.[1,3] Children remain at
high risk for bladder stone development in endemic areas.[6] In There are a number of techniques and modalities available to
non-endemic regions, bladder calculi are often found in adults. remove bladder stones. Relieving the obstruction, eliminating
Females are less affected than males.[1,4,6] Recurrent urinary the infection, meticulous surgical technique, and accurate diag-
tract infection, hematuria and urinary retention are common nosis are essential in their treatment.[6,10]
disorders in these patients.[1,3] Nevertheless, in endemic areas,
in children in whom a major anatomic abnormality does not In recent urological practice, a giant bladder calculus is rare,
coexist, bladder calculi can occur; in these regions, the primary especially those greater than 100 grams.[1,2] When searching
influential factors are dietary intake and socio-economic factors Pubmed for articles on this topic in the last 30 years, less than
leading to the formation of bladder calculi.[7,8] 85 relevant articles were found.
Tahtalı and Karataş
Giant bladder stone: A case report and review of the literature 191

Our aim in this report is to show that this rare clinical presenta- Conflict of Interest: No conflict of interest was declared by
tion is able to develop in the absence of infravesical obstruction. the authors.

In conclusion, almost all reports of giant bladder stones published Financial Disclosure: The authors declared that this study has
so far are stones that formed secondary to preoperative situations, received no financial support.
such as infravesical obstruction, neurogenic bladder or foreign
bodies. We think that this case is striking because of the finding References
that a giant infected stone can develop in the bladder without any
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as a different clinical presentation than small bladder stones, boy. Urol Res 2012;40:273-4.
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Assistant Professor Turan Yıldız, Sakarya University in Medical with attendant renal dysfunction. Nihon Hinyokika Gakkai Zasshi
School, Departmant of Pediatric Surgery Sakarya, Turkey. 1994;85:1777-80.