A Forgotten Double-J Ureteric Stent as the Core of a Bladder Stone: A Case Report and Literature Review.

BACKGROUND Double-J (D-J) ureteric stents are widely applied in urological operations as they play a vital role in maintaining postoperative functionality of the patient's urinary system and thereby accelerating recovery. D-J stent encrustation may occur due to prolonged retention and lead to secondary complications. We report the case of a forgotten D-J stent that gradually formed into a bladder stone. CASE REPORT A 54-year-old man was referred to the Urology Department due to intermittent hematuria, left flank pain, and lower urinary tract symptoms that persisted for 2 weeks. His history was significant for undergoing left ureterolithotripsy followed by the implantation of an ipsilateral D-J stents 2 years ago in a local hospital. The patient did not follow-up regularly or actively seek medical attention for his urinary tract symptoms. Computed tomographic urography revealed a hyperdense tubular object protruding from the left distal ureter to the bladder. The patient underwent cystolithotripsy, left ureteric stent removal, and left ureteroscopy to clear away the bladder stone and its D-J stent core. CONCLUSIONS Formation of bladder stones secondary to prolonged indwelling D-J stent and its encrustation is not uncommon in developing countries where the level of public education is low. Prompt D-J stent removal can prevent complications associated with its retention and avoid unnecessary secondary procedures. Endoscopic urologic procedures are safe and feasible management options, and doctor-to-patient communication is vital for a better prognosis.

Thulium fiber laser cystolithotripsy under local anesthesia: A day care procedure.

INTRODUCTION: Bladder stones account for 5% of all urolithiasis. Patients present with LUTS or acute urinary retention. Thus, warranting an early intervention. Minimally invasive approach with laser lithotripsy is the present gold standard to treat bladder stones. AIMS AND OBJECTIVES: To evaluate the outcomes of TFL (60 W) for bladder stones performed under local anesthesia as a day-care procedure. MATERIALS AND METHODS: This was a retrospective single-center study conducted after obtaining IRB approval. Study period was between June 2021 and June 2022 were included. All patients were operated under local anesthesia as a day care procedure. The procedure was carried out using an 18 Fr laser sheath and calculus dusted using TFL energy (15-30 W). Parameters including operative time in minutes, complications were recorded. Patients were encouraged oral and normal voiding in the immediate post-op period. RESULTS: A total of 47 patients with bladder stones presented during this period. Of these, 30 underwent laser lithotripsy (TFL) for bladder calculi. The clinical presentation of patients was LUTS in 28 (93%) and 5 (16%) patients had AUR. The average size of the stone in this series was 15 ± 2.8 mm. The mean duration of laser lithotripsy was 15 ± 5.4 min. Energy to dust the stone was variable with mean LASER energy of 18.23 ± 10 W. All patients tolerated the procedure well and none required conversion to conventional anesthesia. One patient failed to void in the post-op period. 100% clearance rate was documented in all patients. CONCLUSION: Thulium fiber laser for transurethral cystolithotripsy of bladder stones under local anesthesia is a feasible technique with minimal morbidity and good outcome.

Frequency Of Stone Clearance After Transurethral Fragmentation Of Large Urinary Bladder Calculi Using Pneumatic Swiss Lithoclast.

BACKGROUND: Vesical calculi refer to stones in the urinary bladder. The causes of bladder stones include bladder outlet obstruction, neurogenic voiding dysfunction, infection, or foreign bodies. Very rarely, these vesical calculi may reach very large sizes and the largest dimension can sometimes reach 13 centimetres. METHODS: This descriptive cross-sectional study was conducted from 1ST May 2019 to 31st October, 2019 at Institute of Kidney Diseases, Urology Department, Hayatabad Peshawar. 164 patients with vesical stone were included in study. Ultrasound-KUB was used for diagnosis of vesical stone and after informed consent, and they underwent transurethral nephroscopic lithotripsy via the pneumatic Swiss Lithoclast. RESULTS: Frequency of stone clearance was 96.34%. No statistically significant association of stone clearance was observed with age, gender, number of stones or max dimension of largest stone in the bladder (p>0.05). CONCLUSIONS: Transurethral nephroscopic pneumatic lithotripsy via pneumatic Swiss Lithoclast is safe and effective procedure for treatment of large vesical stones. However, this being the first such study in adults, more data is needed to confirm these findings.

IUCD as bladder stone.

Intrauterine Contraceptive Devices (IUCDs) are commonly used in low to middle-income countries. IUCD migration into the adjacent organs, especially bladder, is exceptionally rare, though important to exclude. A 55-year-old para three post-menopausal female with history of recurrent urinary tract infections presented with lower urinary tract symptoms. Urine examination was indicative of Eschericia coli infection. Pelvic radiograph revealed an intravesical calculus having a T-shaped extension. Cystoscopy confirmed a bladder stone encasing an encrusted IUCD. Cystolithotripsy was performed, fragmenting the calculus which was then removed along with the IUCD in toto. IUCDs require regular evaluation to confirm their correct position. Gynecologists must properly counsel the patient so that the incidence of forgotten IUCDs can be minimized. Urologists need to be aware of these cases so that gynecological history is kept in mind while evaluating females with urinary symptoms. Serious complications such as intravesical migration are extremely rare but possible.

Assess the safety and effectiveness of a novel approach during transurethral pneumatic cystolithotripsy in large urinary bladder stone: quasi-clinical trial.

To assess the safety and efficacy of using continuous irrigation-modified hysteroscopy during transurethral pneumatic cystolithotripsy for large bladder calculi. A prospective study was carried out from May 2016 until March 2020. All patients with solitary or multiple bladder stones > 2.5 cm were subjected to Transurethral pneumatic cystolithotripsy using a modified continuous irrigation hysteroscopy, the stone fragments were removed by Ellik Evacuator, the safety and effectiveness of the procedures were evaluated, stone-free rate (SFR), stone recurrence and stricture urethra disease during follow-up. 55 patients with a mean age of 57.36 (22-82) years were included, the male: female ratio was 4:1, single stone in 74.5% and the mean stone size was 52 mm. Lithotripsy time and an operative time were (20.39 ± 3.06 and 32.00 ± 3.57) minutes, respectively. Mean hospital stay was 10 ± 3.6 h. This endoscopic technique succeeded with a 100% SFR. During the 22 months of follow-up, no urethral stricture or stone recurrence was documented. The mean visual analog pain score (VAS) was 4.2 ± 2.1 and 1.4 ± 0.6, respectively, during and after the operation. The use of the modified hysteroscopy sheath during transurethral pneumatic cystolithotripsy is safe and effective for the management of large urinary bladder stones, an alternative to holmium laser in developing countries when laser equipment is unavailable. Comparable to other transurethral maneuvers, with a decrease in the risk of urethral stricture disease due to the small caliber of the device, as there is no urethral dilatation is required.

Neglected double-J stent with giant bladder stone: a case report.

Double-J (DJ) stents have been widely utilized in urological practice. They are commonly used to relieve ureteral obstruction. Serious complications may occur when stents are left in place for long periods of time. In the present paper, we report a patient with a neglected DJ stent that had been inserted for five years after uterus-tumor surgery and led to a bladder stone. We report a case of a female who presented a bladder stone with a right DJ stent in the pelvic cavity. The stone was evident in radiological examination in an incidental finding. The treatment was transurethral cystolithotripsy. This case reminds us of the necessity of providing enough information and appropriate knowledge pertaining to the insertion of a ureteral stent. Transurethral cystolithotripsy is one of the treatment methods and can be suggested as a definitive method in consideration that it is a clinically effective and safe intervention.

A prospective evaluation of high- and low-power holmium laser settings for transurethral lithotripsy in the management of adults with large bladder calculi.

PURPOSE: To prospectively investigate the efficacy and safety of high-power (100 W) vs low-power (20 W) laser settings for transurethral laser lithotripsy in the management large vesical calculi (> 4 cm). METHODS: All patients with vesical calculi > 4 cm in the maximum dimension and scheduled for transurethral holmium laser lithotripsy were invited to participate in the study. Every alternate patient was treated with either the low- or high-power laser settings. We used a continuous irrigation resectoscope with laser bridge or a laser working element (Karl Storz) for laser lithotripsy of bladder stones. We compared the operative time, intra-operative/post-operative complications (up to 1 year), and stone-free rates between the treatment groups using IBM SPSS Statistics 24 software. Comparisons between treatment groups for continuous variables were assessed using the Welch test, while categorical variables were compared with either the Chi-square or Fisher's exact test. A p value < 0.05 was considered statistically significant. RESULTS: Twenty patients with ten in each cohort were recruited. Preoperative data and mean bladder stone size were comparable in both groups. The duration of surgery was significantly reduced from 70.80 ± 25.28 min in low-power cohort to 40.90 ± 15.01 min in the high-power group (p = 0.005). There were no significant intra-operative complications in either group. All patients were stone-free following the procedure. CONCLUSION: High-power laser setting of up to 100 W results in a significant reduction in duration of surgery without any increase in the complication rate for treatment of large bladder stones.

Application of Percutaneous Holmium Laser Lithotripsy in the Treatment of Bladder Calculi with Lower Urinary Tract Obstruction or Pelvic Joint Disease.

OBJECTIVE: The aim was to summarize the experience of percutaneous holmium laser lithotripsy in the treatment of bladder calculi with lower urinary tract obstruction or pelvic joint disease in our hospital, explore its efficacy and safety, and improve the minimally invasive surgical technique for bladder calculi. METHODS: The clinical data of 61 patients with bladder calculi combined with lower urinary tract obstructive diseases, including urethral stricture, benign prostatic hyperplasia, and bladder neck contracture or pelvic joint diseases in our hospital from 2017 to 2019 were retrospectively analyzed. All patients with bladder stones measuring 1.5-9 cm were placed in supine or lithotomy position. B-scan was conducted to locate the puncture above the pubic symphysis, establishing a 16-30 Fr bladder channel, and Lumenis holmium laser lithotripsy was subsequently performed through a Li Xun Nephroscope. The crushed stones were flushed out through the percutaneous bladder channel or taken out with foreign body forceps. After surgery, the cystostomy tube was indwelled for 3 days. RESULTS: All the 61 cases were operated successfully with an average lithotripsy time of 25 min, and there was no conversion to open surgery. Postoperative reexamination showed neither residual calculi nor complications such as severe infection, massive hemorrhage, and intestinal injury. CONCLUSION: Percutaneous holmium laser lithotripsy is an improved minimally invasive surgical technique for the treatment of bladder calculi with the advantages of clear surgical field, high stone removal efficiency, less trauma, low-pressure bladder perfusion, and low incidence of accessory injury and infection. For patients with lower urinary tract obstructive disease resulting in obstruction of transurethral surgery and patients with pelvic joint disease resulting in difficult lithotomy position placement, this procedure is more advantageous than transurethral surgery. It is also suitable for bladder calculus with a long diameter >5 cm or multiple calculi.

Laser-guided real-time automatic target identification for endoscopic stone lithotripsy: a two-arm in vivo porcine comparison study.

INTRODUCTION AND OBJECTIVE: Thermal injuries associated with Holmium laser lithotripsy of the urinary tract are an underestimated problem in stone therapy. Surgical precision relies exclusively on visual target identification when applying laser energy for stone disintegration. This study evaluates a laser system that enables target identification automatically during bladder stone lithotripsy, URS, and PCNL in a porcine animal model. METHODS: Holmium laser lithotripsy was performed on two domestic pigs by an experienced endourology surgeon in vivo. Human stone fragments (4-6 mm) were inserted in both ureters, renal pelvises, and bladders. Ho:YAG laser lithotripsy was conducted as a two-arm comparison study, evaluating the target identification system against common lithotripsy. We assessed the ureters' lesions according to PULS and the other locations descriptively. Post-mortem nephroureterectomy and cystectomy specimens were examined by a pathologist. RESULTS: The sufficient disintegration of stone samples was achieved in both setups. Endoscopic examination revealed numerous lesions in the urinary tract after the commercial Holmium laser system. The extent of lesions with the feedback system was semi-quantitatively and qualitatively lower. The energy applied was significantly less, with a mean reduction of more than 30% (URS 27.1%, PCNL 52.2%, bladder stone lithotripsy 17.1%). Pathology examination revealed only superficial lesions in both animals. There was no evidence of organ perforation in either study arm. CONCLUSIONS: Our study provides proof-of-concept for a laser system enabling automatic real-time target identification during lithotripsy on human urinary stones. Further studies in humans are necessary, and to objectively quantify this new system's advantages, investigations involving a large number of cases are mandatory.

Urinary bladder stone due to retained indwelling ureteral stent: A case report.

RATIONALE: The indwelling ureteral stents is a common procedure in routine urological practice. The double-J (D-J) stent is the most common type of stents used and is indicated mainly for short-term urinary drainage and prevention of obstruction and infection. However, prolonged indwelling stents may result in disastrous complications, such as hematuria, infection, encrustation, and stone formation. In this context, the persistence of stent in situ might play a key role as a nidus in deposition of urinary sediment, then forming calculus. Although the encrustation may become more serious as time goes on, large bladder stones are relatively rare. However, the serious encrustation and giant stone may complicate or exacerbate the conditions in turn. PATIENT CONCERNS: A 45-year-old female patient who underwent right ureteral stent placement after open ureterolithotomy 6 years ago complained of dysuria, urinary frequency, and urgency over 2 months. DIAGNOSIS: The kidney ureter bladder (KUB) x-ray showed the presence of a giant stone in the bladder and an entire D-J stent. The computed tomography (CT) urography scans revealed normal left kidney, right hydronephrosis, and an encrusted D-J stent with the significant stone, diameter 4.2 cm with a CT value of 1211.0 ±â€Š221.6 HU, on the vesical coil. On the basis of these auxiliary examinations, the case was diagnosed as cystolith and prolonged-indwelling stents. INTERVENTIONS: Pneumatic ballistic lithotripsy was used for crushing the bladder calculi followed by the successful extraction of intact D-J ureteral stent. OUTCOMES: No residual stone was detected on postoperative KUB x-ray and CT urography scans. Patient recovered well and was discharged 10 days after surgery. Semi-annual ultrasound examination was suggested to monitor the effect of therapy. LESSONS: This case reminds us that it is crucial to take various measures to avoid the forgotten ureteral stent and its unfortunate late complication.

[Urolithiasis in a pet rat (Rattus norvegicus)]. / Urolithiais bei einer Heimtier-Ratte (Rattus norvegicus).

Uroliths are uncommon findings in rats. This report describes a case of a neutered male rat with dysuria due to an infectious cystitis as well as an urolith of the urinary bladder consisting of struvite and whewellit. Following cystotomy as well as treatment with antibiotics and analgetics the rat recovered rapidly.

A consecutive series of patients undergoing trans-urethral cystolithotripsy with ballistic lithotripsy by a tertiary referral center for neurogenic bladder.

Background and aim of the work Patients with neurogenic bladder (NB) have an increased risk of developing bladder stones due to bladder catheter, incomplete bladder emptying, recurrent urinary tract infections, and immobilization. In these patients, minimally invasive treatments are usually adopted, as noninvasive extracorporeal shockwave lithotripsy is limited by the risk of not clearing all stone fragments, and open surgery is usually discouraged. The aim of our study was to present our experience with trans-urethral cystolithotripsy (TUCL) in patients treated by a tertiary referral center for NB. Methods We retrospectively collected pre-, intra- and post-operative data from our patients, who underwent TUCL from October 2013 to October 2019. The procedure was performed with a 24 Fr cystoscope and a ballistic lithotripter. Lapaxy was performed with Ellik bladder evacuator. All procedures were performed by two expert surgeons. Stone-free rate (SFR) was defined as the percentage of patients with absence of residual fragments > 2 mm in diameter. Results We performed consecutively 90 TUCLs in 75 patients during the selected period. SFR was 94.1%. Intra- and post-operative complications occurred in one (1.1%) patient. Our statistical analysis outlined the SFR was affected in a statistically significant way by sex, NB etiology, stone cumulative diameter, and operative time. Conclusion Our series proved the safety and efficacy of TUCL with ballistic lithotripsy in NB patients. Further multicenter randomized controlled trials are mandatory to validate definitively TUCL as the gold standard therapy for bladder urolithiasis in NB patients, and to identify risk factors limiting the SFR.

Cystolitholapaxy and laparoscopic sacrocolpopexy in a case of multiple urinary bladder calculi & vault prolapse.

Vesical calculi are more common in men than women. The prevalence in women is less than 2%. Multiple vesical calculi in chronic cases of utero vaginal prolapse or vault prolapse is rare. Urinary stasis, urethral kinking along with chronic infection are the probable predisposing factors for stone formation [2]. We report a case of 65 year old female, with mass per vagina since 10 years, who developed acute urinary retention due to impaction of vesical calculus at the external urethra meatus. Subsequently in a span of 12 h she passed 3 more vesical calculi. KUB X-ray failed to show any calculi but Computed Tomography(CT) Kidney Ureter Bladder (KUB) showed 2 vesical calculi. After cystolitholapaxy she underwent laparoscopic sacrocolpopexy for vault prolapse. In cases of chronic uterovaginal prolapse or vault prolapse X-Ray KUB should not miss the prolapsed part of the cystocele as calculi are present in the most redundant part. Chances of missing radiolucent uric acid calculi is high. In such cases CT KUB is essential.

[Multidisciplinary approach in urology. Laser technologies: faster, simpler, more efficient].

Laser technology has taken a place among the methods of treatment of various urological diseases. The new laser devices are being developed in addition to commonly used. Physicists of the russian NTO "IRE Polus" in collaboration with doctors from Sechenov University have developed a new generation laser device - thulium fiber laser. It has been actively used since 2017 for laser enucleation of prostate. Later the laser was used for treatment of bladder tumor, lithotripsy. The device has already managed to prove its efficacy in in-vitro experiments and clinical practice surpassing foreign analogues.

Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel.

CONTEXT: Bladder stones (BS) constitute 5% of urinary stones. Currently, there is no systematic review of their treatment. OBJECTIVE: To assess the efficacy (primary outcome: stone-free rate [SFR]) and morbidity of BS treatments. EVIDENCE ACQUISITION: This systematic review was conducted in accordance with the European Association of Urology Guidelines Office. Database searches (1970-2019) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and nonrandomised studies (NRSs) with ≥10 patients per group. Quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. EVIDENCE SYNTHESIS: A total of 2742 abstracts and 59 full-text articles were assessed, and 25 studies (2340 patients) were included. In adults, one RCT found a lower SFR following shock wave lithotripsy (SWL) than transurethral cystolithotripsy (TUCL; risk ratio 0.88, p=0.03; low QoE). Four RCTs compared TUCL versus percutaneous cystolithotripsy (PCCL): meta-analyses demonstrated no difference in SFR, but hospital stay (mean difference [MD] 0.82d, p<0.00001) and procedure duration (MD 9.83min, p<0.00001) favoured TUCL (moderate QoE). Four NRSs comparing open cystolithotomy (CL) versus TUCL or PCCL found no difference in SFR; hospital stay and procedure duration favoured endoscopic surgery (very low QoE). Four RCTs compared TUCL using a nephroscope versus a cystoscope: meta-analyses demonstrated no difference in SFR; procedure duration favoured the use of a nephroscope (MD 22.74min, p<0.00001; moderate QoE). In children, one NRS showed a lower SFR following SWL than TUCL or CL. Two NRSs comparing CL versus TUCL/PCCL found similar SFRs; catheterisation time and hospital stay favoured endoscopic treatments. One RCT comparing laser versus pneumatic TUCL found no difference in SFR. One large NRS comparing CL techniques found a shorter hospital stay after tubeless CL in selected cases; QoE was very low. CONCLUSIONS: Current available evidence indicates that TUCL is the intervention of choice for BSs in adults and children, where feasible. Further high-quality research on the topic is required. PATIENT SUMMARY: We examined the literature to determine the most effective and least harmful procedures for bladder stones in adults and children. The results suggest that endoscopic surgery is equally effective as open surgery. It is unclear whether stone size affects outcomes. Shock wave lithotripsy appears to be less effective. Endoscopic treatments appear to have shorter catheterisation time and convalescence compared with open surgery in adults and children. Transurethral surgery, where feasible, appears to have a shorter hospital stay than percutaneous surgery. Further research is required to clarify the efficacy of minimally invasive treatments for larger stones and in young children.

Analysis of Holmium Laser Enucleation of the Prostate in a High-Volume Center: The Impact of Concomitant Holmium Laser Cystolitholapaxy.

Purpose: To assess the influence of holmium laser cystolitholapaxy (HLC) concomitantly with holmium laser prostate enucleation (HoLEP) on patients with benign prostatic hyperplasia (BPH) presenting bladder calculi. Materials and Methods: We present a retrospective analysis of patients with BPH (with or without concomitant HLC) at three Spanish centers. Intraoperative variables (e.g., time and resected tissue), changes in functional parameters of the prostate, and frequency of complications (intraoperative, early postoperative, and at 12 months) in patients with and without HLC were compared. Results: The analysis included 963 patients aged 48 to 91 years, of which 54 (5.6%) underwent HLC to treat vesical lithiasis. Mean (range) prostate size (measured by transrectal ultrasound) was 79 (43-173) g and 91 (35-247) g for patients with and without concomitant HLC, respectively (p = 0.080). All bladder calculi were effectively removed. No significant differences were found regarding enucleation and morcellation times, but total operation time was significantly higher in patients with HLC: mean (standard deviation [SD]) of 78 (27) minutes vs 95 (41) minutes (p < 0.001). Three patients underwent conversion to open surgery because of bladder perforation, all of them from the group without HLC. Rates of intraoperative, early, and 12-month complications were similar in both groups. No significant differences in International Prostate Symptom Scale, maximum flow rate (Qmax), and mean flow were observed between groups 12 months after surgery. Conclusions: Simultaneous HoLEP and HLC increases the total operation time, but does not influence the risk of clinically relevant perioperative and postoperative complications.

Shock wave lithotripsy versus endoscopic cystolitholapaxy in the management of patients presenting with calcular acute urinary retention: a randomised controlled trial.

PURPOSE: Shock wave lithotripsy (SWL) in treatment of bladder and urethral stones was not precisely determined. The objective of this study is to compare the efficacy and safety of SWL versus visual cystolitholapaxy in the management of calcular acute urine retention. METHODS: From March 2015 to February 2017, a randomised controlled study was conducted on 100 patients for whom urethral catheter fixed for acute retention of urine due to urethral or vesical radio-opaque stone(s) ≤ 2 cm. Patients were randomised to either SWL group (n = 50) or visual cystolitholapaxy (endoscopy group) (n = 50). RESULTS: No statistically significant differences between the pre-operative parameters of both groups were found. The mean stone diameter was 12.2 ± 3 mm and 12.2 ± 3.2 mm in SWL and endoscopy groups, respectively (p value = 0.4). The overall success rates of SWL group were 94% (47 of 50 patients) and endoscopy group were 98% (49 of 50 patients). SWL failed in 3 patients (6%); these 3 patients underwent cystolitholapaxy and were rendered free of stones. Intra-operative and post-operative complications were comparable between both groups (p value = 0.5 and 1, respectively). One patient had bladder perforation in the endoscopy group and was managed conservatively. CONCLUSIONS: SWL mono-therapy is safe, non-invasive and as effective as visual cystolitholapaxy in management of patients presenting with acute urine retention by vesical or urethral stones 2 cm or less and could be useful for patients unwilling/unfit for general anaesthesia.

Bladder Stone in Pregnancy: A Case Report and Review of the Literature.

BACKGROUND Bladder stones are rare in pregnancy, and can be associated with adverse outcomes such as recurrent urinary tract infection and obstruction of labor. Management of bladder stones discovered in pregnancy has traditionally been done via open techniques such as cystolithotomy or with percutaneous removal. Our objective was to present a case of bladder stone in pregnancy and review prior reports on bladder stones and management in pregnancy. CASE REPORT A 28-year-old gravida 4 para 3 at 10 weeks gestation presented with dysuria, bladder spasm, weak urinary stream, and positional voiding. On first trimester ultrasound, a bladder stone (sized 3.7 cm) was identified and was confirmed by x-ray (KUB). Urology was consulted and removed the stone via cystolitholapaxy with holmium laser. Her symptoms subsequently resolved, and she went on to have an uncomplicated term spontaneous vaginal delivery. The removal of the stone enabled her to have a subsequent vaginal delivery without the potential for obstruction of labor. CONCLUSIONS Based on our review of the literature and this case report, laser cystolitholapaxy is a safe alternative to open surgery for the management of bladder stones in pregnancy. When discovered at the time of delivery, vaginal delivery is feasible if the stone is small or can be displaced. If encountered at time of cesarean delivery, then cystotomy with stone removal is recommended provided inflammation is not present.

Risk of ESRD and Mortality in Kidney and Bladder Stone Formers.

RATIONALE & OBJECTIVES: Kidney stones have been associated with increased risk for end-stage renal disease (ESRD). However, it is unclear whether there is also an increased risk for mortality and if these risks are uniform across clinically distinct categories of stone formers. STUDY DESIGN: Historical matched-cohort study. SETTING & PARTICIPANTS: Stone formers in Olmsted County, MN, between 1984 and 2012 identified using International Classification of Diseases, Ninth Revision codes. Age- and sex-matched individuals who had no codes for stones were the comparison group. PREDICTOR: Stone formers were placed into 5 mutually exclusive categories after review of medical charts: incident symptomatic kidney, recurrent symptomatic kidney, asymptomatic kidney, bladder only, and miscoded (no stone). OUTCOMES: ESRD, mortality, cardiovascular mortality, and cancer mortality. ANALYTICAL APPROACH: Cox proportional hazards models with adjustment for baseline comorbid conditions. RESULTS: Overall, 65 of 6,984 (0.93%) stone formers and 102 of 28,044 (0.36%) non-stone formers developed ESRD over a mean follow-up of 12.0 years. After adjusting for baseline hypertension, diabetes mellitus, dyslipidemia, gout, obesity, and chronic kidney disease, risk for ESRD was higher in recurrent symptomatic kidney (HR, 2.34; 95% CI, 1.08-5.07), asymptomatic kidney (HR, 3.94; 95% CI, 1.65-9.43), and miscoded (HR, 6.18; 95% CI, 2.25-16.93) stone formers, but not in incident symptomatic kidney or bladder stone formers. The adjusted risk for all-cause mortality was higher in asymptomatic kidney (HR, 1.40; 95% CI, 1.18-1.67) and bladder (HR, 1.37; 95% CI, 1.12-1.69) stone formers. Chart review of asymptomatic and miscoded stone formers suggested increased risk for adverse outcomes related to diagnoses including urinary tract infection, cancer, and musculoskeletal or gastrointestinal pain. CONCLUSIONS: The higher risk for ESRD in recurrent symptomatic compared with incident symptomatic kidney stone formers suggests that stone events are associated with kidney injury. The clinical indication for imaging in asymptomatic stone formers, the correct diagnosis in miscoded stone formers, and the cause of a bladder outlet obstruction in bladder stone formers may explain the higher risk for ESRD or death in these groups.