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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 103-106

An unusual coexistence of vesicourethral collar stud and bulbar urethral diverticular calculi


1 Department of Surgery, Federal Medical Center, Nguru, Yobe State, Nigeria
2 Department of Surgery, Aminu Kano Teaching Hospital/Bayero University, Kano, Katsina State, Nigeria
3 Department of Surgery, Federal Medical Center, Katsina, Katsina State, Nigeria

Date of Web Publication29-Oct-2018

Correspondence Address:
Dr. B M Abubakar
Department of Surgery, Federal Medical Center, Nguru, Yobe State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_19_17

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  Abstract 


Urolithiasis is a common urological condition and an important affliction of the urinary tract; however, urethral calculi account for a small fraction of stones in the entire urinary tract. The dual occurrence of a vesicourethral collar stud calculus and a bulbar urethral diverticula calculus is exceptionally rare. We report the case of a 50-year-old man who presented with lower urinary tract symptoms that culminated into acute urine retention, which was relieved by suprapubic cystostomy after a failed attempt at urethral catheterization. His pelvic X-ray revealed vesicourethral collar stud and bulbar urethral calculi. There was no urethral stricture on retrograde urethrogram. The patient underwent cystolithotomy, urethrolithotomy, diverticulectomy, and urethroplasty. He was treated for suprapubic surgical site infection during the postoperative period. His voiding remained normal on removal of urethral catheter and he had no lower urinary tract symptoms at the last follow-up. Collar stud vesicourethral calculus coexisting with bulbar urethral diverticular calculus is rare. Appropriate patient work-up followed by cystolithotomy, urethrolithotomy, diverticulectomy with urethroplasty alleviates lower urinary tract symptoms.

Keywords: Collar stud stone, prostatic urethral stone, urethral diverticular stone, vesicourethral stone


How to cite this article:
Abubakar B M, Abubakar A, Isah M J, Ogunyele T T. An unusual coexistence of vesicourethral collar stud and bulbar urethral diverticular calculi. Arch Int Surg 2017;7:103-6

How to cite this URL:
Abubakar B M, Abubakar A, Isah M J, Ogunyele T T. An unusual coexistence of vesicourethral collar stud and bulbar urethral diverticular calculi. Arch Int Surg [serial online] 2017 [cited 2020 Jul 12];7:103-6. Available from: http://www.archintsurg.org/text.asp?2017/7/3/103/244402




  Introduction Top


Urolithiasis occupies the third position among the most prevailing uropathological conditions.[1] Primary urethral calculi are rare entities, however, most migrate from the urinary bladder and upper urinary tract. Most urethral stones in men present as prostatic or bulbar urethral calculi. The few reported cases are either exclusively vesicourethral[1],[2],[3],[4],[5] or distinctly anterior urethral calculi.[6] The dual occurrence of collar stud vesicourethral calculus with a separate bulbar urethral diverticula calculus is exceptionally unusual. Till date only 10 cases have been reported in literature. We present the case of a 50-year-old man with vesicourethral calculus and an added bulbar urethral diverticula calculus that was managed with a gratifying outcome.

We obtained an informed consent from the patient to report this unusual presentation of urolithiasis.


  Case Report Top


The patient was a 50-year-old man farmer who presented with lower urinary tract symptoms of 6 years duration. He had progressive urinary frequency, nocturia, poor urinary stream, interrupted stream, and feeling of incomplete bladder emptying. These climaxed into acute urine retention 1 month prior to presentation to us, which was relieved by suprapubic cystostomy (SPC) after a failed attempt at urethral catheterization. No upper urinary tract symptoms and no other comorbidity were noted.

He was not pale, afebrile, and had no pedal edema. His vital signs were normal. He had SPC catheter in-situ draining clear urine. There was hard urethral induration around the bulbar region. Digital rectal examination (DRE) revealed a stony hard prostatic mass, with prominent lateral sulci and obliterated median groove.

Urine microscopy revealed 4–6 pus cells per high power field; culture yielded  Escherichia More Details coli sensitive to ciprofloxacin among other antibiotics.

Plain pelvic X-ray [Figure 1] showed vesicourethral collar stud calculus with additional bulbar urethral calculus. Retrograde urethrogram [Figure 2] affirmed the collar stud vesicourethral and bulbar urethral diverticular calculi. Other investigations were within normal limit.
Figure 1: Plain pelvic X ray showing vesicourethral and bulurethral stone

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Figure 2: Retrograde urethrogram, showing Bulbar Urethral diverticular and vesicourethral stone

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The patient had cystolithotomy, urethrolithotomy, urethral diverticulectomy, and urethroplasty through suprapubic and midline perineal incision. Intraoperative findings were thickened bladder wall, impacted collar stud vesicourethral, and bulbar urethral diverticula calculi [Figure 3] and [Figure 4]. No associated urethral stricture was noted. [Figure 5] shows the varied extracted calculi.
Figure 3: Cystolithotomy

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Figure 4: Calculi within the bulbar urethral diverticulum

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Figure 5: Extracted calculi

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The patient was treated for superficial suprapubic surgical site infection. His voiding has remained normal since the removal of the silicon urethral catheter and no UTI at the 6-month postoperative follow-up.


  Discussion Top


The prevalence of urolithiasis among common uropathologic conditions is only exceeded by UTI and lesions of the prostate.[1] Urethral calculi accounts for only 0.3% the entire urolithiasis.[7] Prostatic or urethral diverticula calculi are rare, and less than 10 cases of urethral diverticula plus prostatic calculi occurring simultaneously have been reported in the literature. Urethral calculi have a bimodal age of presentation, with spiked incidences in early childhood and fourth decade of life.[8] Notwithstanding that our patient was 50 years old, we presumed he had congenital urethral diverticulum, which often manifests after 25 years of age, often times with complications such as calculus or recurrent UTI.[9] Congenital anterior urethral diverticulum in males is in contrast from the urethral diverticula in females which are commonly acquired traits.

Urethral calculus is autochthonous or primary when it arises de novo in the urethra and migrating or secondary if descended from the bladder or upper urinary tracts. Calculi that arise de novo in the urethra do so mainly by inspissation of stone elements on a urethral foreign body or the stasis of urine in urethral diverticula.[10] Our patient probably had an initial asymptomatic congenital bulbar urethral diverticulum with subsequent calculi development.

Urethral calculi in the prostatic urethra are on the whole proximal to the narrow membranous portion. They are often small in size; however, isolated giant prostatic stones have been reported.[10],[11],[12],[13],[14] The index patient is exceptional as he presented with paired vesicourethral and urethral diverticula stones.

Young in 1934 classified primary urethral calculi into four groups.[15] Group I are the prostatic urethral calculi occurring concurrently with prostatitis. Group II are calculi existing with benign prostatic hyperplasia. Group III are calculi that mimic carcinoma. Group IV are calculi in the pair of prostatic urethra plus the urinary tract. The index case belonged to Young's group IV.

In a different categorization, Joly[16] portioned stones in the posterior urethra into three classes. Categories “a” are vesicourethral calculi that lie partly in the posterior urethra and to some degree in the bladder, and hence, lie straddling the internal sphincter, which is the reason for the calculus unique configuration. Category “b” are urethral calculi confined to the urethra. Class “c” are urethroprostatic calculi that lie to some degree in the prior cavity in the prostate gland. Index patient has category “a” Joly's classification.

The clinical presentation of patients with urethral calculi depends on its etiopathogenesis plus its position along the urethra. Patients with isolated primary urethral calculi as well as diverticula calculi often present with insidious symptoms. In migratory calculi, the presentation is most often with acute symptoms occasioned by impaction. Index patient had gross hematuria, urinary retention, and painful micturition from impaction.

Urinary tract infection is frequent in these patients and could be culpable for acute presentation for all categories of calculi. Against early reports that 60% of urethral calculi were radiolucent, waxing facts was that most of the urethral calculi are radiopaque (98–100%), and hence, can be visualized in plain radiographs,[8] as in this patient.

Treatment depends on the size, position, as well as associated urethral lesion. For small distal urethral stones, instillation of 2% lignocaine jelly along with milking out may be possible, albeit occasionally traumatic and not always encouraged.[8],[17] The small calculi can also be pushed into bladder accompanied by transurethral or suprapubic cystolitholapaxy or lithotripsy.

Large collar stud vesicourethral calculus is removable through vesical approach as in the index patient. Other modes of managing impacted giant prostatic urethral stone reported are radical prostatectomy, open retropubic prostatolithotomy, and endoscopic lithotripsy. Impacted bulbar diverticular calculi were removed by diverticulectomy; this with prospective urethroplasty was achieved through the perineal approach in our patient.

Our patient was treated for suprapubic surgical site infection; subsequently, he did well with no lower urinary tract symptoms at follow-up.


  Conclusion Top


The coexistence of vesicourethral collar stud calculus with bulbar urethral diverticular calculus is exceptionally rare. Proper patient work-up followed by cystolithotomy, urethrolithotomy, diverticulectomy, and urethroplasty alleviates the debilitating lower urinary tract symptoms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prabhuswamy VK, Tiwari R, Krishnamoorthy R. A giant dumbbell shaped vesico-prostatic urethral calculus: A case report and review of literature. Case Rep Urol 2013;2013:167635.  Back to cited text no. 1
    
2.
Recasens Guinjuan JR, Flores Gonzalez JJ, Samso Pinol JM, Ribes Amoros Y, Massó Badia A. [Vesico-urethral lithiasis secondary to foreign body]. Actas Urol Esp 2002;26:136-8.  Back to cited text no. 2
    
3.
Yoneda K, Uchida M, Nakagawa Y, Kitamura K, Kawauchi A, Imaide Y, et al. [Vesico-prostatic calculi treated by microexplosion lithotripsy: A case report]. Hinyokika Kiyo 1990;36:161-3.  Back to cited text no. 3
    
4.
Hemal AK, Sharma SK. Giant vesico-prostatic and prostatic calculi. Trop Geogr Med 1989;41:164-6.  Back to cited text no. 4
    
5.
Presman D. Prostatic calculi, symptomatology and management. Proc Inst Med Chic 1953;19:329-30.  Back to cited text no. 5
    
6.
Zhou T, Chen G, Zhang W, Peng Y, Xiao L, Xu C, et al. Impacted anterior urethral calculus complicated by a stone-containing diverticulum in an elderly man: Outcome of transurethral lithotripsy without resection of the diverticulum. Int Braz J Urol 2013;39:754.  Back to cited text no. 6
    
7.
Aegukkatajit S. Reduction of urinary stone in children from north-eastern Thailand. J Med Assoc Thai 1999;82:1230-3.  Back to cited text no. 7
    
8.
Kamal BA, Anikwe RM, Darawani H, Hashish M, Taha SA. Urethral calculi: Presentation and management. BJU Int 2004;93:549-52.  Back to cited text no. 8
    
9.
Allen D, Mishra V, Pepper W, Shah S, Motiwala H. A single-center experience of symptomatic male urethral diverticula. Urology 2007;70:650-3.  Back to cited text no. 9
    
10.
Rivilla F, Luis A, Llanos D, Ruiz A. Giant urethral calculus in a 6-year-old girl. J Pediatr Urol 2008;4:469-71.  Back to cited text no. 10
    
11.
Demir O, Kefi A, Cahangirov A, Cihan A, Obuz F, Esen AA, et al. The giant calculus within the prostatic urethra. Urol Res 2011;39:319-21.  Back to cited text no. 11
    
12.
Bello A, Maitama HY, Mbibu NH, Kalayi GD, Ahmed A. Unusual giant prostatic urethral calculus. J Surg Tech Case Rep 2010;2:30-2.  Back to cited text no. 12
    
13.
Shanmugam TV, Dhanapal V, Rajaraman T, Chandrasekar CP, Balashanmugam KP. Giant urethral calculi. Hosp Med 2000;61:582.  Back to cited text no. 13
    
14.
Kaplan M, Atakan IH, Kaya E, Aktoz T, Inci O. Giant prostatic urethral calculus associated with urethrocutaneous fistula. Int J Urol 2006;13:643-4.  Back to cited text no. 14
    
15.
Young HH. Prostatic urethral calculi. J Urol 1934;32:660-709.  Back to cited text no. 15
    
16.
Barrett JC. Giant prostatic calculi. Br J Surg 1957;45:267-9.  Back to cited text no. 16
    
17.
Rodriguez Martinez JJ, Perez Garcia FJ, Martinez Gomez FJ, Regadera Sejas FJ, Fernández Gómez JM, San Martín Blanco A. [Multiple urethral lithiasis. Report of a case]. Arch Esp Urol 2000;53:384-7.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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