Case 1: Male, 47 years old, admitted in July 2007 with the complaints of “urinary frequency, urgency, painful urination with fever for one month”. 20 years of recurrent urinary tract infections. 20 years of history of “foreign body in the bladder (broken urinary catheter)”. After a week of anti-inflammatory treatment, a cystotomy was performed to retrieve the stone, which was located in the lower part of the bladder and had heavy adhesions to the bladder mucosa, making it difficult to retrieve the stone, which weighed 320 g. On the second day after surgery, a hematoma appeared in the incision, and on the fourth day, a hematoma removal was performed. The fistula was healed 38 days after surgery. Chronic inflammation of the bladder mucosa was biopsied.
Case 2: Male, 53 years old, was admitted to the hospital in July 2008 with the chief complaint of “recurrent urinary frequency and urgency for 20 years, aggravated for half a month”. He had been diagnosed with “urinary tract infection” in several hospitals. On examination, a mass was palpated on the pubic bone and a hard object could be found on the prostate with unclear borders, CT examination showed severe hydronephrosis in both kidneys and a bladder stone of 10cm×9cm×9cm.
Case 3: Male, 78 years old, was admitted to the hospital in February 2009 with the chief complaint of “lower abdominal pain, urinary frequency and difficulty in urination for 30 years, aggravated for 3 months”. He was admitted to the hospital in February 2009 with the complaints of “lower abdominal pain, frequent urination and dyspareunia for 30 years, aggravated for 3 months”. After treatment with indwelling urinary catheter and anti-inflammatory therapy, renal function could not be improved, so cystotomy was performed under basic plus local anesthesia, and stones were seen at the top of the bladder, size 13cm×10cm×8cm, weighing 250g. Postoperatively, renal function returned to normal. The BPH was not further diagnosed for economic reasons. Follow-up lower urinary tract symptoms were more severe.
Discussion The incidence of bladder stones has decreased significantly, and the common causes are malnutrition, lower urinary tract obstruction, bladder foreign body, infection, metabolic disease, and parasites. In our group, case 1 was due to bladder foreign body, case 2 was infection, and case 3 was lower urinary tract obstruction. Most of the bladder stones are single, but 25%-30% are multiple, and the size of stones varies greatly, from small ones such as gravel to large ones of more than a kilogram. In our three cases, all stones were single, with an average weight of 323.33 g. Because of stone stimulation, the bladder mucosa often shows chronic inflammatory changes, and long-term infection can lead to peri-cystitis, and long-term stone stimulation can cause mucosal carcinogenesis. There are reports of bladder stones combined with bladder phosphor carcinoma. Two cases in this group showed chronic inflammatory changes in the bladder mucosa, including one case of peri-cystitis, and case 3 showed squamous epithelial metaplasia and moderate atypical hyperplasia of the bladder mucosa, which should be examined by cystoscopy regularly.
The main symptoms of bladder stones are urinary pain, dysuria and hematuria, etc. Larger stones and longer duration of disease may lead to back pain, oliguria and anemia when renal function is impaired. Liu Kun Chong et al. reported a case of a 20-year-old male civilian worker with a huge bladder stone causing acute renal failure, and renal function was restored to normal after cystotomy and lithotomy. Two cases in this group had mainly bladder irritation symptoms, one case had mainly urination disorder, and two cases showed renal function impairment. Based on the symptoms, signs and KUB examination, bladder stones can often be clearly diagnosed. In this group of patients, the IVU examination failed because of the pain in the lower abdomen due to lap band compression, so CT examination was performed in all cases. The first two cases in this group had mainly bladder irritation symptoms, which were diagnosed as “urinary tract infection” in several hospitals, and the anti-inflammatory treatment was not effective, and the recurrent attacks were not examined further in time, so that the diagnosis was missed and treatment was delayed. Common treatments for bladder stones include transurethral lithotripsy for removal and suprapubic cystotomy for stone extraction, which should be accompanied by treatment of the cause. In this group, three cases were performed suprapubic cystotomy for huge stones. In case 1, the stone was embedded in the pelvis and the posterior pubic plexus was damaged during stone extraction, resulting in posterior pubic hematoma and secondary surgery. If the stone is large, the stone should not be removed by force to avoid damaging the posterior pubic plexus and causing hemorrhage, but the stone can be broken and removed in pieces during surgery. In case 1, the preoperative anti-inflammation was not sufficient and the urinary catheter was not left in place, the bladder wall was edematous and the healing was slow, resulting in the formation of bladder fistula.