Authored by Mukesh C Arya*
Abstract
Introduction: Urethral calculi constitutes about 1-2% of all calculi in developing countries. Such calculi are more common in males in comparison to females owing to their longer urethra. Herein, we present a series of 264 such calculi.
Material and methods: This is a retrospective study of 264 cases of urethral calculi from July 2013 and February 2019. Detailed history, physical and local examination (palpation of penile urethra and perineum including Digital rectal /Per Vaginal examination) was done. Investigations included urine analysis, culture and sensitivity, ultrasonography (USG) whole abdomen with the perineal region and X-ray pelvis. A retrograde urethrogram was performed if associated urethral pathology was suspected. Cystourethroscopy confirmed the diagnosis in all cases. Patients were analysed about their age, sex, presentation, anatomical site of stone at the time of presentation, and their subsequent management. Composition of urethral calculi was studied using Fourier transform infrared spectroscopy (FTIR).
Results: A total of 264 patients with urethral calculi were analysed (250 males and 14 female). Most common age group was 21-40 years (46.8%). 203 (81.2%) of the calculi in the male patients were in the posterior urethra, 25 (10%) were in the penile/ bulbar urethra and 22(8.8%) in the fossa navicularis. The most common presenting symptom was dribbling & dysuria (70.45%). Radiological studies (X-ray pelvis and USG) showed stone in 85% of cases; Cystourethroscopy was diagnostic and discovered the stone in 15 % of additional cases. Size of stones varied from 1.2 to 2.5 cm. Most of the patients i.e. 190 (71.96 %) were treated with pushback cystolithotripsy (CLT).
Conclusion: Most urethral calculi in patients in developing countries originate from upper tract in contrast to the previous misconception that they originate in the bladder. Management of the urethral calculi varied according to the site, size and associated urethral pathology.
Keywords: Urethral calculus; anterior urethral calculi; pushback cystolithotripsy
Abbreviations: Cystolithotripsy (CLT); Ultrasonography (USG); Fourier transform infrared spectroscopy (FTIR)
Introduction
Urethral calculi are common in developing countries. There are only a few studies that have been conducted so far on these subsets of patients with very limited literature from developing countries. Urethral calculi are divided into primary which forms in urethra and secondary, which migrates from upper urinary tract. Primary urethral calculi are usually small and multiple, and secondary migratory calculi are usually large. Small calculus is commonly found in the anterior urethra and larger calculi usually occur in the posterior urethra. Primary urethral stones are generally composed of magnesium ammonium phosphate (struvite) or uric acid. Calcium oxalate and cystine stones originate from kidney. The causes of secondary stones are stricture, infection, and/or inflammation or within a poorly drained communicating cavity, with an obstruction, stagnation, acting as the predisposing factor.
Secondary or migratory stones are usually more common mainly comprising of calcium oxalate or citrate. Migratory stones are most often encountered in association with urethral stricture disease or other forms of urethral obstruction .The main symptoms are dribbling, dysuria, acute urinary retention, frequency, haematuria, interruption of the urinary stream, or a history of spontaneous passage of stone (such patients were excluded in our study). Retrograde manipulation into the urinary bladder followed by litholopaxy or lithotripsy is a suitable procedure for small urethral calculi. Anterior urethral calculi can be removed under local anaesthesia via endoscopy or ventral meatotomy.
Patients and Methods
This is a retrospective study of 264 patients presenting with urethral calculi from July 2013 and February 2019. A detailed urological history was taken along with physical and local examination including palpation of the urethra and digital rectal examination (DRE). Complete blood counts (CBC), serum biochemistry including serum urea and creatinine serum calcium, serum uric acid, serum parathyroid hormone (PTH), urine calcium creatinine ratio, urine analysis, urine culture and sensitivity, ultrasonography whole abdomen with perineal/scrotal region and x-ray pelvis were done. Intravenous urography (IVU) was done in cases with upper urinary tract calculi. A retrograde urethrogram was performed if associated urethral pathology was suspected. Cystourethroscopy was performed in all cases and confirmed the diagnosis. MRI (magnetic resonance imaging) was done in one female to depict relevant anatomy of the urethral diverticulum and associated stone. Urethral calculi were analysed about age, sex, presentation, the anatomical site at presentation, associated diseases, and management. Finally, the stone analysis was done using Fourier transform infrared spectroscopy (FTIR) to study the composition of urethral calculi.
Results
1. Age and sex: A total of 264 patients with urethral calculi were analysed (250 male and 14 female). Male to female ratio was 17.8: 1. Age ranged from 6 months to 86 years (Figure 1).
The maximum number of patient (46.6%) was in the 21-40 years of age group. Mean age was 52.7 years.
2. Presenting complaints: Most common presenting symptom was dribbling &dysuria (70.45 %) followed by penile& perineal pain (43.18%), decreased urinary stream & intermittency (36.36%), retention of urine and hematuria (12.87% each), fever (3.78%) and purulent discharge (2.27%) in these patients (Table 1).
Out of these, 81 stones (30.68%). were palpable; one female (age 31years) had procidentia with a palpable stone in the prolapsed bladder. Twenty-nine (10.98%) had associated diseases of the lower urinary tract, the commonest being urethral stricture (15 patients). Seventy-four patients (28.03%) had a prior history of urolithiasis or surgery for the same (Table 2).
Associated upper urinary tract calculi were found in 30 cases. Out of which, 2 were in the bladder, 20 in kidney and 18 in ureter (Table: 3).
All-female patients and 7.57% of male patients presented with retention of urine (ROU). In these patients, catheterisation was done; while in 28 cases where the attempt of catheterisation was unsuccessful suprapubic catheterisation (SPC) was done.
4. Urine culture: In only 18 cases, urine culture was positive. Majority of them (15) were positive for E. coli, two for klebsiella and one showed growth of pseudomonas.
5. Management: One hundred fifty-one cases were operated under local anaesthesia, followed by 90 in spinal and 23 in general anaesthesia. Most of the patients i.e. 190 (71.96 %) were treated with pushback cystolithotripsy (CLT), 15 patients (5.68%) were treated with endoscopic retrieval, 12 patients (4.54%) were treated with meatotomy with the retrieval of stone. Larger stones impacted at meatus should be treated with meatotomy to prevent stricture. Holmium laser lithotripsy was done in nine patients of the pediatric age group using 6-7.5 F ureteroscope. Seven patients (2.64%) with urethral calculi and associated urethral strictures underwent visual internal urethrotomy or endoscopic dilatation initially; the stones were then pushed into the bladder and CLT was done. In the remaining eight patients (3.03%) urethrolithotomy & BMG onlay urethroplasty was done. Percutaneous cystolithotripsy (PCCL) done in 2 cases, perineal urethrostomy done in 1 case, CLT and bladder neck incision (BNI) done in 6 cases. Foley’s catheter was placed for 3-5 days after VIU/meatotomy, 3 weeks for onlay urethroplasty and for 2 weeks after diverticulectomy. Suprapubic cystolithotomy (SPCL) was done in 2 patients with neurogenic bladder and one patient with Exstrophy; these patients were put on CIC. One female had a diverticular stone which was treated with diverticulectomy and another female patient had associated uterine prolapse in whom sacral colpopexy was done (Table 4).
These patients were followed at 6 weeks and 3 months with symptomatology, uroflowmetry to detect stricture due to stone or transurethral surgery. Seven patients developed stricture in the bulbar urethra which was managed successfully with VIU. Twelve patients developed symptomatic urinary tract infection which was treated by culture-sensitive antibiotics.
6. Stone analysis: Stone analysis was performed in 100 cases using FTIR of which mostly (85 cases) were mixed stone with calcium oxalate monohydrate as a primary component, calcium phosphate in 10, struvite in 3 and uric acid stone in 2 patients (Table 5).
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