Vesicolithotomy for Acute Intestinal Obstruction

Abstract

A 57-year-old man was referred with lower urinary tract symptoms, suprapubic discomfort and recent alteration in bowel habits. He had been involved in a motor vehicle accident 20 years previously, sustaining a fracture of the right femur, which was internally fixed. He did not sustain any lower urinary or spinal injuries. Clinical examination revealed an otherwise healthy individual with normal abdominal and focused neurological findings. He was not uremic. Further investigation confirmed a giant bladder stone measuring 14 12.5 cm with bilateral mild hydronephrosis on ultrasonography. Cystoscopy confirmed absence of bladder outflow obstruction. Vesicolithotomy was elected. However, acute large bowel obstruction developed, characterized by progressive abdominal distention and absolute constipation with hyperactive bowel sounds. On digital rectal examination the large stone was found to be compressing the rectal lumen with no evidence of impacted feces. Erect and supine abdominal x-rays confirmed acute large bowel obstruction (fig. 1). “Drip and suction” with antibiotics administered for 24 hours were futile as the abdominal distention worsened and nasogastric aspiration increased. Emergency extraperitoneal vesicolithotomy was performed through a lower midline incision. Wrigley’s forceps (used for forceps delivery) were used to extract the stone (fig. 2). This maneuver relieved the bowel obstruction and subsequent recovery was uneventful. Postoperative colonoscopy excluded any organic lesion in the colon. Urodynamics confirmed an atonic bladder.