Bladder Stone Formation Research Articles

Long-term outcome in bladder detrusorectomy augmentation.

Bladder augmentation in children can have significant benefits in terms of continence and social function. In an attempt to overcome the problems associated with using foreign mucosa in the urinary tract, techniques to increase to bladder volume and improve compliance by resecting the detrusor muscle alone have been described. Here we describe our experience using an omental-backed detrusorectomy augmentation and examine possible reasons for a poor outcome observed in some patients in the longer term. This was a retrospective review covering an eight-year period with a minimum follow-up of 2 years. Pre- and post-operative urodynamics were performed in every case. 11 patients were included in the study. There were 7 male and 4 female patients with a median age of 10 years (range 4 - 16). The underlying pathology in 6 patients was myelodysplasia and in the remaining cases there was one each of ano-rectal malformation with neuropathic bladder, Guillain-Barré syndrome, a myopathy of unknown cause, transverse myelitis and one case of a non-neuropathic neuropathic bladder. Detrusorectomy provided a modest increase in bladder capacity (median 26 %) and decrease in maximum bladder pressure (median 12 %). Long-term follow-up has revealed treatment failure in 6 patients, resulting in revision augmentation surgery in 3 (with surgery planned in a further 2), and one patient developing end-stage renal failure. Notable complications were bladder stone formation in 4 patients and troublesome lower abdominal pain related to bladder drainage in 2. There appeared to be no correlation between initial diagnosis, age at operation, pre-operative urodynamics, peri- or post-operative factors, and long-term outcome. In our series, omental-backed detrusorectomy for a neuropathic bladder in children resulted in a poor outcome in 55 % of cases. We were unable to identify factors that would allow this result to be predicted pre-operatively.

Bladder Management and Risk of Bladder Stone Formation in Spinal Cord Injured Patients

We determined by statistical analysis whether method of management is associated with risk of bladder stone formation in spinal cord injured patients. A retrospective cohort study was performed of 457 patients admitted to Stoke Mandeville Hospital Spinal Injuries Center between 1985 and 1990 with more than 6 months of followup. Analysis included Cox regression and Poisson regression. Relative to those patients treated with intermittent self-catheterization, the hazard ratio was 10.5 (p <0.0005, 95% confidence interval 4.0-27.5) for patients with suprapubic catheters and it was 12.8 (p <0.0005, 95% confidence interval 5.1-31.9) for those with indwelling urethral catheters. The absolute annual risk of stone formation in patients with a catheter was 4% compared with 0.2% for those on intermittent self-catheterization. However, having formed a stone, the risk of forming a subsequent stone quadrupled to 16% per year. Bladder stones were no more likely to form in patients with suprapubic catheters compared to those with indwelling urethral catheters (hazard ratio 1.2, p = 0.6). In spinal cord injured patients long-term catheterization is associated with a substantial increased risk of bladder stone formation. This increased risk occurs independently of age, sex and injury level. Degree of injury (complete or incomplete) was considered in the model. Catheter type (suprapubic or urethral) did not change this risk significantly if at all.

The Gastrostomy Button as a Catheterizable Urinary Stoma: A Pilot Study

We assessed the impact of the gastrostomy button used as a catheterizable urinary stoma on the infection, encrustation and erosion rates, and quality of life in a series of 19 patients. Patients were selected as candidates for the button based on multichannel urodynamic studies that confirmed an areflexic neurogenic bladder. At study enrollment each patient completed a quality of life questionnaire based on a visual analog scale. If the patient had a preexisting indwelling suprapubic tube, it was replaced with a button. If no preexisting suprapubic tube was present, one was inserted. The button was then inserted approximately 1 month later after an adequate tract was established. For 1 year the patient underwent cystoscopy with urine culture every 2 months for a total of 6 times. Symptomatic infections were treated but asymptomatic colonization was not. A quality of life questionnaire was completed at each visit. Of the 19 patients 10 had failure, necessitating button removal. These failures were due to an excessive suprapubic distance from skin to bladder, which prevented adequate button fit. All patients in whom the button remained showed significant improvements in quality of life. The colonization rate was 100% but the rate of symptomatic infections was low. The incidence of bladder stones was zero and the rate of encrustation was low. When used as a catheterizable stoma to treat areflexic neurogenic bladder, a gastrostomy button is a safe, effective option for these patients. The rate of symptomatic infections is low, the risk of bladder stone formation is minimal and erosion was not observed in properly sized button insertions. The current limiting factor is the length of the button compared with the patient suprapubic measurement (length from skin to bladder). Each patient reported that quality of life with the button was significantly better than prior to button placement.

Continent Urinary Diversion and the Exstrophy-Epispadias Complex

The use of continent urinary reservoirs has gained wide acceptance, particularly in urinary reconstruction in children with a small capacity or neuropathic bladder. When augmentation cystoplasty is combined with clean intermittent catheterization, patients are often able to achieve continence with low intravesical filling pressures and renal preservation. Often this approach requires fashioning a continent cutaneous stoma, which remains the most challenging aspect of continent urinary reservoirs. We analyzed our experience with continent diversion in patients with exstrophy-epispadias to determine complications and long-term results. We performed a retrospective database review of 704 cases of exstrophy-epispadias. Medical records were then used to identify those patients who had undergone creation of a continent urinary reservoir. Charts were reviewed to determine initial diagnosis, augmentation technique, continence mechanism, age, preoperative and postoperative bladder capacity, continence status and complications. Of the 91 patients identified (68 male, 23 female) who had undergone continent urinary diversion classic bladder exstrophy was present in 80, cloacal exstrophy in 8, complete male epispadias in 2 and female epispadias in 1. The most common techniques for augmentation and continent diversion were ileocystoplasty (41 patients [45%]) and sigmoid cystoplasty (30 [33%]), respectively. Appendix was used in 67 patients (74%) and variants of the Mitrofanoff procedure using segments of tapered ileum or ureter were used to create a continent stoma in 10 (11%). Bladder neck transection was performed in 59 patients (65%). Mean age at augmentation and continent diversion was 8 years (range 2 to 25), with a mean preoperative bladder capacity of 77 cc (15 to 220). Mean followup was 6 years (range 6 months to 12 years). Of the 91 patients 85 (93%) were continent with clean intermittent catheterization per stoma. Of these 85 patients 13 required anticholinergics and alpha-agonists to achieve continence. Six patients (7%) were incontinent after the procedure. Analysis of bladder capacity measurements after augmentation and continent diversion revealed that mean postoperative volume and mean volume increase were 404 cc (range 250 to 640) and 524%, respectively. The most common complications were bladder stone formation (24 patients [26%]) and stomal stenosis (21 [23%]). Bladder stones recurred in 9 patients and stomal stenosis in 3. Other less common complications were vesicourethral fistula (3 patients) and a small bladder perforation (2). Augmentation and continent diversion procedures can increase the functional capacity of the small contracted noncompliant exstrophic bladder, and allow the vast majority of patients to achieve continence and preserve renal function. Bladder calculi and stomal stenosis pose the most significant long-term complications in these patients.

Bladder Stones Following Sci In The Sprague-Dawley Rat

Objective: To develop a spinal cord injury (SCI) animal model for the study of bladder stones and compare this model with a non-SCI animal model.Methods: Small pieces of catheters were implanted into the bladders of Sprague-Dawley rats as a nidus for bladder stone formation. Three weeks later, the rats underwent an SCI surgery (SCI transection or sham SCI). Control rats had SCI surgery, but no catheters were implanted into their bladders.Main Outcome Measures: Bladder stone number, weight, and composition were determined in two groups of SCI and sham SCI animals: Group A (recent spinal shock: 2 weeks post-SCI/sham SCI surgery) and Group B(out of spinal shock: 3 weeks to 3 months post-SCI/sham SCI surgery). AX2 test was used to compare the incidence of bladder stones in SCI vs sham SCI animals. AStudent t test was used to compare the weight of bladder stones in the 2 groups.Results: Group A(recent spinal shock): Of the 20 SCI rats, 8 (40%) had stones. None of the sham SCI rats with implanted catheters (n = 5) had stones (0%). Group B(out of spinal shock): All 6 of the SCI rats with implanted catheters had stones (100%). Of the 10 sham SCI animals with implanted catheters, 3 (30%) had stones. Stones were more common in the SCI rats than in the sham SCI rats (X2., = 4.9, P < 0.05). The mean weight of the bladder stones in SCI rats (42.2 ± 16.3 mg) was greater than that in sham SCI rats (5.4 ± 1.5 mg) (P < 0.01). Group C (controls: SCI surgery, but no catheter implanted): At 3 weeks post-SCI, control rats had no stones (n = 7); control rats at 3 months post-SCI also had no stones (n = 9). Stone composition in the 3 sham SCI animals was calcium apatite (90%) and calcium oxylate (10%). In the 14 SCI rats, 10 had struvite stones (1 00%), 1 had struvite (70%) and carbonate apatite (30%) stones, 1 had brushite (100)% stones, and 2 had carbonate apatite (>90%) stones.Conclusion: Bladder stones occurred earlier and more frequently and attained a larger size in SCI rats with catheters compared with sham SCI rats with catheters. There were no stones in SCI rats without catheter implants, even at 3-month follow-up. The bladder stone composition in SCI rats was similar to that in humans with SCI. The Sprague-Dawley rat model appears to be an excellent animal model for the study of bladder stones following SCI.J Spinal Cord Med. 2003;26:65-68

Renal stones in the tropics.

Urolithiasis is a problem that is generally increasing in the tropics as it is in most Western countries. There are 2 main types of the disorder-bladder stones in children, a form of the disorder that disappeared from Europe in the late 19th and early 20th centuries, and upper urinary tract stones in adults. The former has been decreasing in most countries in the so-called endemic bladder stone belt with gradual improvements in levels of nutrition. However, as living standards increase, particularly in the urban areas of the more affluent developing countries, so the incidence of upper urinary tract stones in adults is increasing. The types of stones formed depend mainly on the composition of urine, which, in turn, reflects the type of diet consumed in the countries concerned. The main factor that leads to the formation of bladder stones in children is a nutritionally poor diet that is low in animal protein, calcium, and phosphate, but high in cereal and is acidogenic. This leads to the formation of urine with a relatively high content of ammonium and urate ions and consequently to the formation of ammonium acid urate crystals and stones. In countries where there is also a high intake of oxalate from local leaves and vegetables, urinary oxalate is increased and, as a result, the ammonium acid urate stones often contain calcium oxalate as well. The stone problem in the tropics is compounded by low urine volumes resulting in some areas from poor drinking water, which causes chronic diarrhea, and in others from the hot climate and fluid losses through the skin. As nutrition improves in these countries, the formation of bladder stones gives way to upper urinary tract stones consisting of calcium oxalate, often mixed with calcium phosphate or uric acid, such as are formed in most Western countries.

Pancreas after kidney transplantation.

After three decades of controversy surrounding the therapeutic validity of pancreas transplantation, the procedure has become accepted as the preferred treatment for patients with insulin-dependent diabetes mellitus (IDDM) and advanced diabetic nephropathy with end-stage renal disease (ESRD) and for

RABBIT MUSCLE AND URETHRAL IN SITU BIOCOMPATIBILITY PROPERTIES OF THE SELF-REINFORCED L-LACTIDE-GLYCOLIC ACID COPOLYMER 80: 20 SPIRAL STENT

A new type of self-reinforced L-lactide-glycolic acid copolymer, molar ratio 80:20, stent was developed. We evaluated the tissue biocompatibility properties of the new material. Rods made of self-reinforced L-lactide-glycolic acid copolymer were inserted into rabbit dorsal muscles and rods of latex or polyvinylchloride and silicone served as positive and negative controls, respectively. Urethral stents of self-reinforced L-lactide-glycolic acid copolymer and steel were inserted in situ via cystoscopy into the rabbit prostatic urethra. The animals were sacrificed after 2 weeks, 1, 2 and 3 months, respectively. In situ histological analysis was done. Tissue reactions around the implantation types were analyzed histologically and scored semiquantitatively. In addition, macroscopic analysis was done of the urethral in situ stents. In rabbit muscle implantation test tissue reaction to the self-reinforced L-lactide-glycolic acid copolymer stent resembled that of negative control silicone. Less than moderate chronic inflammatory changes gradually subsided after 2 weeks. Foreign materials in the tissue and the reaction to these materials began to disappear after 1 month and at 3 months were completely absent. All rabbits fitted with the stent voided normally postoperatively. Self-reinforced L-lactide-glycolic acid copolymer stents were soft, partially fragmented and easily disintegrated when touched at 2 months, and were almost completely degraded at 3 months. The material did not encroach into the urethral wall macroscopically or microscopically. No calcification on the self-reinforced L-lactide-glycolic acid copolymer stents or bladder stone formation was seen. The new self-reinforced L-lactide-glycolic acid copolymer 80:20 material is safe, highly biocompatible and suited for future clinical use. It is most appropriate for preventing postoperative urinary retention after most minimally invasive thermal treatments for benign prostatic hyperplasia.

Advantages and risks of ileovesicostomy for the management of neuropathic bladder

Objectives. To evaluate the efficacy and complications of ileovesicostomy in patients with neurogenic bladder dysfunction. Methods. Fifteen consecutive neurologically impaired patients (8 from multiple sclerosis, 4 from spinal cord injury, 3 from other causes) with complications of previous bladder management underwent ileovesicostomy. There were 10 women and 5 men. All patients were either poor candidates for or refused continent urinary diversion or bladder augmentation cystoplasty. Results. At a mean follow-up of 23.2 months, 14 of 15 patients had low-pressure urine drainage through their ileovesicostomy. Four women with documented preoperative detrusor hyperreflexia had postoperative intermittent mild urge incontinence per native urethra. They did not require any further treatment, except for oral anticholinergic drugs (oxybutynin and tolterodine). Because of persistent severe urge incontinence, 1 woman required conversion of her ileovesicostomy to an ileal conduit with concurrent cystectomy. The ileovesicostomy of another myelodysplastic man who had four failed artificial urinary sphincters in the past was also converted to an ileal conduit because of persistent urethroperineal fistula despite perineal urethral closure. Renal function was preserved in all patients. Long-term complications were stomal stenosis in 2 patients, bladder and kidney stone formation in 5, and symptomatic urinary tract infections in 3. Conclusions. Ileovesicostomy can be safely performed in neurologically impaired women and men. Severe preoperative detrusor hyperreflexia with urge incontinence appears to be a risk factor for persistent urge incontinence postoperatively in women. Continued routine urologic surveillance for infection and stones is mandatory. Ileovesicostomy is a versatile procedure for neurologically impaired patients, because it can be converted to a conventional ileal conduit if necessary. In addition, in cases of neural recovery, the ileal “chimney” can be excised and the patient’s original lower urinary tract would be preserved.

Orthotopic ileal neobladder in male patients: functional outcomes of 66 cases.

Orthotopic urinary diversion has become the preferred form of bladder reconstruction after cystectomy. We report on our experience with 66 male patients undergoing this procedure from November 1990 to February 1998. A neobladder was constructed using an ileal segment with a Hautmann type bladder. Complications were assessed and subdivided into early and late types. Voiding function was evaluated in terms of voiding pattern and continence. Median follow up was 19.5 (range 3.5-87.7) months. There was one (1.5%) perioperative death. The most frequent pouch-related and unrelated early complications were persistent urine leak (7.6%) and prolonged ileus (16.7%), respectively, the majority of cases of which were managed conservatively. Analysis of late complications revealed 6.2% ureteroileal stenosis and 1.5% urethrointestinal stenosis rates, but no case of bladder stone formation. Of the 61 patients in whom voiding function was evaluable, 95.1% achieved excellent daytime continence, while only 67.2% had night-time continence. With regard to posture at voiding, 23 (37.7%) voided in a sitting position. Three of the patients (4.9%) were unable to void and required regular intermittent catheterization. An orthotopic neobladder can be constructed with acceptable morbidity and excellent functional results. We believe that orthotopic urinary diversion offers an attractive alternative to a bladder substitute when cystectomy is required.

Reconstruction of the urinary bladder by auto-augmentation, enterocystoplasty, and composite enterocystoplasty.

Urinary incontinence resulting from congenital abnormalities of the urinary bladder and its nerve supply is a serious disability with a major impact on the quality of life of affected children and adolescents. Current clinical management centres on enterocysto-plasty, the reconstruction or enlargement of the bladder with segments of bowel.1,2 The use of bowel gives rise to significant complications, including mucus production, formation of bladder stones, metabolic disturbances, growth retardation and probably an increased long-term risk of malignancy.3 The use of stomach overcomes some of the problems associated with small and large intestine4 but carries the risk of complications such as haema-turia/dysuria syndrome and metabolic alkalosis.5,6 The complications and undesirable consequences of enterocystoplasty can be attributed to major differences in the properties of the epithelial linings of the intestine and bladder respectively. Intestinal epithelium is involved in mucus secretion, digestion and absorption of nutrients, electrolytes and water. It is therefore poorly adapted to replace the normal urothelial lining of the bladder which serves as a flexible but watertight impermeable barrier to urine.

Longterm effects of endoscopic sphincterotomy on gall bladder motility.

Some of patients with an intact gall bladder develop acute cholecystitis or have gall bladder stone formation after endoscopic sphincterotomy. Endoscopic sphincterotomy may affect gall bladder motility. To prospectively evaluate longterm effect of endoscopic sphincterotomy on gall bladder motility. Thirty two patients with an intact gall bladder (15 with and 17 without gall bladder stones) who underwent endoscopic sphincterotomy for choledocholithiasis. Gall bladder function was examined before and at from seven days to five years after sphincterotomy. Gall bladder volume, at fasting and after caerulein administration, was determined by ultrasonography. After endoscopic sphincterotomy, the enlarged orifice remained patent during a five year follow up period. One patient with gall bladder stones subsequently developed acute cholecystitis, the remaining being asymptomatic. In the patients before sphincterotomy, particularly in those with gall bladder stones, the gall bladder showed larger fasting volume and lower caerulein stimulated maximum contraction than normal controls. Throughout five years after sphincterotomy, fasting volume of the gall bladder decreased and its maximum contraction increased, regardless of gall bladder stones; significantly different from the values before sphincterotomy (p < 0.05). Endoscopic sphincterotomy decreases fasting volume of the gall bladder and increases its contraction ability for a long period. These changes may rather decrease the risk of future acute cholecystitis or gall stone formation.

Bladder stone formation on a swallowed knife blade and spontaneous passage through a vesicovaginal ñstula

Bladder stone formation on a swallowed knife blade and spontaneous passage through a vesicovaginal ñstula

Long-term Indwelling intraurethral catheters in elderly patients with prostatic obstruction. What are the true indications?

From July 1990 to September 1992, 32 elderly male patients with benign prostatic hypertrophy complaining of chronic urinary retention were treated with polyurethane intraurethral catheters (IUC). All of them were unfit for prostatic surgery due to several complications. Indwelling lUCs were left for more than 6 months in 20 (62.5%) patients, and the longest period was 1 year and 11 months. Indwelling lUCs could not be used in patients who had undergone previous operations for prostatic hypertrophy. Comparing urodynamic study findings prior to and after insertion of the IUC results in patients with an overactive or normal bladder were significantly better than those in patients with an underactive bladder (p&lt;0.05, chi-square test). Nine patients were urine continent, and 2 of those patients in whom an indwelling IUC could be left for more than 6 months, complained of mild urinary incontinence. Urinary tract infection disappeared in 7 patients, and improved in 11 of the 20 patients. IUC placement was successful for more than 6 months without exchange in 7 of the 20 patients. Bladder stone formation was found in one patient and was the only complication in these 20 patients. In conclusion, IUC placement can be successful for more than 6 months in patients without underactive bladder or previous prostatic operation.

Curative radiotherapy following chemotherapy for invasive bladder carcinoma (a preliminary report)

Twenty-five patients with invasive transitional cell carcinoma of the bladder (Stage T 2, T 3, T 4) received combined modality therapy using four cycles of methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) chemotherapy followed by surgery or radiation therapy (RT). Sixteen patients had complete (N = 8) or partial (N = 8) response to MVAC. Curative RT was delivered to 11 responders with T 2 or T 3 disease and to 2 patients with T 4 disease. All 11 with T 2 and T 3 disease are currently alive, 7 with normal bladder function. The two with T 4 disease are dead of disease. Three patients required salvage cystectomy for local recurrence and one patient had cystectomy for bladder stones. Follow-up ranged from 11 to 50 months with a median of 31 months. No late chemo-radiotherapy treatment-related complications to the intestines or in bladder function (other than one bladder stone formation) occurred. These preliminary results are encouraging and warrant further evaluation of this innovative approach in treating invasive carcinoma of the bladder. T 2 and T 3 patients with a complete or partial response to MVAC may be excellent candidates for a bladder-sparing treatment.

Morphological lesions of the rat urinary tract induced by inoculation of mycoplasmas and other urinary tract pathogens.

The effects on the urinary tract after inoculation of Ureaplasma urealyticum into the rat bladder were evaluated and compared to that seen after Mycoplasma hominis, Escherichia coli and Proteus mirabilis inoculation. The inoculation of the urease-producing organisms P. mirabilis and U. urealyticum were associated with the formation of struvite bladder stones and predominantly hyperplastic lesions of the bladder. The P. mirabilis inoculated rats also displayed marked pyelonephritis. A similar but much less pronounced reaction also occurred in the kidneys of some of the U. urealyticum inoculated rats. P. mirabilis could frequently be recultured. In contrast, this was not possible with U. urealyticum, but the organism was detected by scanning electron microscopy 2 weeks after the inoculation. Inoculation of M. hominis was associated with a few mild lesions of the bladder, but inflammatory lesions were not present in the kidneys. The study confirms the potential of Ureaplasma to form struvite stones in rat urinary tract. It also demonstrates that it can induce inflammatory changes in both bladder and kidney of rats without concomitant stone formation.

Intestinal Absorption of Carbohydrates and Calcium: A Review

AbstractA review is given of recent publications on the absorption of carbohydrates especially in relation to calcium. Starch and sucrose are hydrolyzed in mammals by enzymes attached to the wall of the jejunum to glucose and fructose. These are rapidly absorbed via carrier mediated mechanisms in adjoining epithelial cells. Feeding relatively high levels of lactose, sugar alcohols or modified starches to rodents leads to enhanced calcium absorption in the ileum. This results in increased urinary calcium, which may lead to lesions of the kidneys and adrenals in rats or to the formation of bladder stones in mice. If not hydrolyzed to absorbable moieties in the small intestine, carbohydrates pass to the cecum where they are fermented by microbial flora. This fermentation leads to cecal enlargement, diarrhoea and a decrease in urinary pH. All these effects, mainly caused by substantially overfeeding the rodents with these carbohydrates, are of no significance to humans consuming a balanced diet.

Endemic bladder stones in Nepal.

Bladder stones account for a large proportion of surgical admissions in many developing countries. We report in detail the clinical features and risk factors of one such case, a 5 year old Nepali boy, and propose the theory that a low calcium intake, by causing hypocalciuria, predisposes to bladder stone formation.

An ecological study of infected urinary stone genesis in an animal model.

Direct molecular and morphological techniques of modern microbiology were used to monitor the sequential development of bacterial microcolonies and biofilms in a rat model of urinary infection and to demonstrate that the urease activity of the infecting organisms sets in course a series of reactions in which struvite and apatite crystals develop within the matrix of the enlarging bacterial aggregate. This forms multiple stone nidi on the uroepithelial surface upon which succeeding bacterial biofilms develop and with the incorporation of other urine components, such as urinary mucroproteins, establishes a matrix skeleton that becomes mineralised, thus allowing for the growth of the stone in concentric layers. To arrive at this hypothesis, we studied infection stone genesis using a newly developed model for infection-induced bladder stone formation in the rat. We examined in detail the sequential events in the evolving microbial ecology of progressive struvite calculogenesis, using conventional microbiological techniques, direct ultrastructural observation, newly developed ultrastructural cytochemical localisation techniques and immunological procedures for stabilisation of the biofilm glycocalix and stone matrix in the rat model. It was concluded that the organic glycocalix material secreted by the associated bacteria comprises a substantial and aetiologically important part of the infection stone calculogenesis and matrix production.

Tubed vesicostomy for tetraplegics.

The main advantage of our newly developed cystostomy method is that tetraplegic patients carrying indwelling urethral catheters can lead their daily lives free from a complicated bladder washing technique for preventing bladder stone formation. But under the present condition, this desirable state can only be achieved by patients who have bladder contractility and a urine volume of more than 2,000 ml per day. We recommend the use of small brushes to clean the inserting tubes.