The lecture has been given on Mar. 30th, 2011 by Dr. Ali Kamal.

1. Definition
• A primary bladder stone is one that develops in sterile urine; it often originates in a kidney
and passes down the ureter to the bladder, where it enlarges.
• A secondary bladder stone occurs in the presence of infection, bladder outflow
obstruction, impaired bladder emptying or a foreign body such as nonabsorbable sutures,
metal staples or catheter fragments.
Composition and cystoscopic appearance
• Oxalate calculus is a primary calculus that grows slowly. Usually, it is of moderate size and
is solitary. Its surface is uneven (mulberry type); sometimes it bristles with spines .Although
calcium oxalate is white; the stone is usually dark brown or black because of the
incorporation of blood pigment on to it.
• Uric acid and urate calculi are round or oval, fairly smooth, and vary in color from pale
yellow to light brown: they may be single or multiple. They may occur in patients with gout,
but are also found in patients with ileostomies or with bladder outflow obstruction.
• Cystine calculus occurs only in the presence of cystinuria and is radio-opaque owing to its
high sulphur content.
• Triple phosphate calculus is composed of ammonium, magnesium and calcium
phosphates, and occurs in urine infected with urea-splitting organisms. It tends to grow
rapidly. In some instances, it occurs on a nucleus of one of the foregoing types of calculus;
much more rarely on a foreign body. In others, the nucleus is composed of desquamated
epithelium and bacteria. It is dirty white in color and of chalky consistency.
A bladder stone is usually free to move in the bladder. It gravitates to the lowest part of the
bladder which is the outflow when the patient is erect or sitting. In the recumbent position
(and at cystoscopy) the stone occupies a position behind the interureteric ridge..
Clinical features
Males are eight times more often affected than females
Symptoms
• It may be asymptomatic
• Frequency is the earliest symptom.

2. • There may be a sensation of incomplete bladder emptying.
• Pain (Strangury) is most often found in patients with a spiculated oxalate calculus. It
usually occurs at the end of micturition and is referred to the tip of the penis or to the
labia majora, more rarely to the perineum or suprapubic region.
• Haematuria
• Interruption of the urinary stream is due to the stone blocking the internal meatus and
may develop into acute retention of urine
• Symptoms of urinary infection
Examination
• Rectal or vaginal examination is usually normal; occasionally a large calculus is
palpable in the female.
• Examination of the urine usually reveals microscopic haematuria, pus or crystals
typical of the calculus.
• Radiography — in most patients, the stone is visible on a plain X-ray .If the stone is
radiolucent, a filling defect may be visualised on IVU.
• Cystoscopy is essential and most stones nowadays can be dealt with endoscopically.
Treatment
Litholapaxy
The blind litho trite is a satisfactory instrument for the treatment of a large, hard stone. Other
devices include the stone punch which is useful to crush small fragments further so that they
can be evacuated with an Ellik evacuator.
Contraindications to per urethral litholopaxy
• •Urethral:
o A urethral stricture that cannot be dilated sufficiently
o When the patient is below 10 years of age
• •Bladder:A contracted bladder
• •Stone characteristics:A very large stone

3. Technique; the patient should receive appropriate antibiotics treatment before operation.
The major advantage of the blind lithotrite is that, because of its solidity and strength, harder
stones can be crushed than is the case with the optical instrument. A cystoscopic lithotrite,
stone punch or stone loop enables the stone or stone fragments to be seized under vision. To
carry out litholapaxy, the bladder is filled with about 200—300 ml of saline and the instrument
is introduced with its obturator in place so that its closed jaws point downwards. After
irrigation of the bladder and insertion of the telescope, the stone is seen. The distal blade is
hooked over the centre of the stone and grasped. After withdrawing the telescope slightly to
prevent damage to the optics, the screw is turned slowly, breaking the stone. Large fragments
are crushed into small ones by repeating the manoeuvre. With the jaws closed the lithotrite is
rotated so that the jaws point upwards, and after removing the telescope and allowing the
saline and stone fragments to escape, the instrument is withdrawn. The use of an Ellik
evacuator is necessary to ensure complete removal of all stone fragments.
Mechanohydraulic lithotripsy
The lithoclast generates energy by purely mechanical means using a steel ball which is fired in
a closed chamber at the proximal end of the endoscopic probe. Also, an energy source is
generated between paired or concentric electrodes. With repeated discharges, the stone is
broken into small pieces. The probes come in two or three sizes and it is sensible to use the
largest (9 F) for bladder calculi. The patient is cystoscoped and the probe placed close to the
stone, but away from the end of the telescope, and fired.
Evacuation of the fragments; Fluid (200 ml) is introduced into the bladder. The evacuator, filled
with solution, is fitted on to the sheath. The bulb is compressed slowly and then permitted to
expand. The returning solution carries with it fragments of stone which sink into the glass
receptacle. Alternate compression of the bulb and aspiration is continued until no further
fragments -fall. The beak of the cannula is turned to the left and to the right, and suction is
applied in these situations. After checking that no fragments are left in the bladder, a Foley
catheter is introduced and left in Situ for 24 hours.
Suprapubic lithotomy
Percutaneous suprapubic litholapaxy
Extracorporeal shock wave lithotripsy (ESWL)
Removal of a retained Foley catheter
This is not an uncommon problem and is usually caused by the channel which connects the
balloon to the side arm becoming blocked, usually at the very distant end. The best way of
dealing with this problem is to further inflate the balloon with 20 ml of water and then burst the

4. balloon percutaneously using a spinal needle under ultrasound screening. The instillation of
fluid such as ether to dissolve the balloon is not recommended because fragments of balloon
may be left behind. However the balloon is burst, it is important to subsequently cystoscope
the patient to ensure that any fragments are removed before they can form a foreign body
calculus.
Foreign bodies in the bladder
The commonest foreign body is a fragment of catheter balloon
Complications of a foreign body in the bladder
i. Lower urinary tract infection
ii. Perforation of the bladder wall
iii. Bladder stone
Treatment
A small foreign body can usually be removed per urethram by means of an operating
cystoscope. Occasionally, a suprapubic approach using the Percutaneous insertion of a
cystoscope is needed.
Diverticulum of the bladder
The normal intravesical pressure during voiding is about 35—50 cmH2O. Pressures as great
as 150 cmH2O may be reached by a hypertrophied bladder endeavouring to force urine past
an obstruction. This pressure causes the mucous lining between the inner layer of
hypertrophied muscle bundles to protrude, so forming multiple saccules. If one or more, but
usually one, saccule is forced through the whole thickness of the bladder wall, it becomes a
diverticulum. Congenital diverticula are due to developmental defect.
Etiology of diverticulum
• Congenital diverticulum — This is rare. It may be situated in the mid line
anterosuperiorly and represent the unobliterated vesical end of the urachus. It empties
with the bladder and is symptomless. Others in the usual situation on the base of the

5. bladder can occur without obstruction, and may require excision because of the risk of
chronic infection or stone formation in a young adult
• Pulsion diverticulum — the usual causative obstructive lesion is bladder outflow
obstruction
Complications
1. Recurrent urinary infection; Squamous cell metaplasia and leucoplakia are
infrequent complications.
2. Bladder stone
3. Hydronephrosis and hydroureter
4. Neoplasm
Clinical features
An uninfected diverticulum of the bladder usually causes no symptoms. The patient is nearly
always male (95 per cent) and over 50 years of age.
There are no pathognomonic symptoms; they are those of lower urinary tract obstruction,
recurrent urinary infection and pyelonephritis. Haematuria (due to infection, stone or tumour)
is a symptom in about 30 per cent.
Diagnosis;
1. Cystoscopy
2. Intravenous urography
3. Retrograde cystography
4. Ultrasonography
Indications for operation
Operation is only necessary for the treatment of complications
Preoperative treatment
When the urine is infected, suitable preoperative antibiotic treatment is given. In the presence
of gross sepsis and retention of urine, it is necessary to resort to an indwelling urethral
catheter for a period.

6. Combined intravesical and extravesical diverticulectomy
This is the standard operation. Cystoscopy is performed, a ureteric stent is passed up the
ureter on the affected side.The anterior bladder wall is exposed through a suprapubic
incision, the peritoneum is displaced upwards and the side of the bladder bearing the
diverticulum is cleared from surrounding structures until the pouch is identified. The bladder is
then incised in the mid-line and the diverticulum is packed with a strip of gauze. Usually the
neck of the diverticulum can be separated from the ureter and when the pouch is free it is
severed from its attachment to the bladder with a diathermy knife. The resulting defect is
closed in two layers. A suprapubic catheter is left in place and an extravesical drain is
inserted.
Traction diverticulum (syn. hernia of the bladder)
A portion of the bladder protruding through the inguinal or femoral hernial orifice occurs in 1.5
per cent of such herniae treated by operation.
Urinary fistulae
• Congenital urinary fistula
 Ectopia vesicae;
 from a patent
 in association with imperforate anus
• Traumatic urinary fistula
Vesicovaginal fistula
Etiology
• Obstetrics — the usual cause is protracted or neglected labour;
• Gynaecological — the operations chiefly causing this complication are total hysterectomy
and anterior colporrhaphy;
• Radiotherapy
• Direct neoplastic infiltration.

7. Clinical features
There is leakage of urine from the vagina and as a consequence excoriation of the vulva
occurs. Digital examination of the vagina may reveal a localised thickening on its anterior
wall, or in the vault in the case of posthysterectomy fistula. On inserting a vaginal speculum,
urine will be seen escaping from an opening in the anterior vaginal wall.
Differential diagnosis between a ureterovaginal and vesicovaginal fistula can be made if a
swab is placed in the vagina and a solution of methylene blue is injected through the urethra;
the vaginal swab becomes coloured blue if a vesico-vaginal fistula is present. With the advent
of good, portable X-ray image intensifiers, a cystoscopy and bilateral retrograde ureterograms
provide a more reliable demonstration of the anatomy. An IVU should be performed to
exclude a coincidental ureterovaginal fistula.
Treatment
Just occasionally, conservative management of a vesicovaginal fistula following
hysterectomy by urethral bladder drainage is successful. Usually, operative treatment is
required. The low fistula (subtrigonal) is best repaired per vaginam. The fistula is exposed
with dissection of the edges which are freshened. The bladder is then closed using
absorbable sutures and the vagina subsequently closed with a separate layer. A urethral
catheter should be left in situ for at least 10 days. For the higher (supratrigonal) fistula, a
transvaginal approach can be extremely difficult. These patients should always be
cystoscoped prior to a repair procedure and bilateral ureterograms performed as occasionally
one of the ureters is also involved. For the high fistula, a suprapubic approach is the best
method in most hands. The Pfannenstiel incision should be re opened, the bladder should be
dissected free from the peritoneum and bisected posteriorly in the midline down to the level of
the fistula. The bladder is then separated from the vagina and, occasionally, careful
dissection from the rectum is also required. The vagina is then closed with a heavy catgut
suture and omentum brought down to lie between the closed vagina and the bladder
anteriorly. This is lightly sutured in place and the bladder then closed. A urethral and
suprapubic catheter should be left in situ for 10—14 days.
For the patient with a ureterovaginal fistula, an extraperitoneal approach to the ureter via the
previous Pfannenstiel incision is made.
Fistula from renal pelvis to skin or gut
Tuberculosis of a kidney may result in caseation and a chronic sinus leading to duodenum,
colon or skin in the iliac fossa or lumbar triangle. Similarly, a pyonephrosis may
spontaneously discharge into the gut or on to the skin. Cases of duodenal ulcer involving the

8. pelvis of the right kidney and Crohn’s disease involving either renal pelvis or ureter, or cases
of xanthogranulomatous pyelonephritis may cause fistulae.
Fistulae arising as a result of infection
The commonest cause is diverticulitis of the colon. They may also follow Crohn’s disease,
appendix abscess or pelvis sepsis in association with acute salpingitis, or may be the result of
surgery and radiotherapy within the pelvis.
Cases due to carcinoma
By the time a fistula between the bowel and the bladder has developed the tumour is usually
locally advanced, but may be operable.
Urethral fistulae
These occur as the result of infection above a stricture producing a para urethral abscess
which ruptures into the urethra, allowing extravasation to occur suddenly into the scrotum and
perineum. Urine and infection extend into the upper 2.5 cm of thigh and lower abdominal wall.
Widespread cellulitis and tissue necrosis (which may lead to Fournier’s gangrene) may occur
unless drainage of urine is achieved by suprapubic cystostomy, and the tissue planes are
freely drained by inguinal and scrotal incisions.
Neoplastic fistulae
Primary bladder tumours very rarely fungate through the abdominal wall unless an open
cystotomy has been performed without further treatment, such as low dose irradiation being
performed to cut down the risk of wound implantation.. Involvement of the bladder by tumours
of cervix, uterus, colon and rectum can produce fistulae, as may lymphosarcoma of the small
gut. Carcinoma of the prostate rarely produces a rectal fistula. Treatment is palliative .