Giant prostatic calculus in patient treated with perineal prostatotomy: case report

Introduction

Urolithiasis (kidney stone) is a common condition that often leads patients to urgent or emergency care services. Urinary calculi are generally found in the kidneys, ureters, or bladder. Urethral calculi are uncommon and can result from the migration of a calculus in the upper urinary tract or vesicle or may be primary of the urethra. Prostatic calculi are a rarity. Urethral calculi are associated with anatomic abnormalities of the urethra, such as stenoses and diverticula (1), and account for up to 0.3% of all urinary calculi (2).

Prostatic calculi are found with or without benign hyperplasia of the prostate and may be associated with adenocarcinoma. These calculi contain proteins, cholesterol, citrates, and inorganic salts, especially calcium phosphate and magnesium phosphate (3), and commonly occur in the form of micro-calculi.

This paper reports the case of a patient with a giant prostatic calculus treated by perineal prostatotomy. We present the following case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-23-115/rc).

Case presentation

A 34-year-old male was admitted to the emergency service of a university hospital reporting dysuria and pain in the hypogastrium with a 4-day history. The patient reported that the pain sometimes irradiated to the left flank, accompanied by micturition effort, a weak urinary stream, pollakiuria, and urine output with a crystal appearance. The patient reported taking ciprofloxacin every 12 hours for 2 days with no improvement in the condition. The clinical history revealed urinary difficulty since 10 years of age, renal lithiasis and surgery of the urethra, but the patient was unable to state what procedure had been performed.

The physical examination revealed that the patient was afebrile, anicteric, acyanotic, rosy, hydrated, conscious and oriented. The abdomen was flat, flaccid, with hydroaeric noises and pain upon palpation of the hypogastrium. Laboratory exams revealed an absence of urinary infection.

During the investigation, the patient developed acute urinary retention. Attempts at catheterization with a Foley catheter, Nelaton catheter and guide wire were unsuccessful. Due to the report of a previous history of urethral surgery, the patient presented a stenous urethra, increasing the difficulty in managing the case. So, the patient was sent to the surgical ward for endoscope-guided catheterization with a ureteroscope due to its smaller caliber. A large calculous mass was found in the posterior region of the urethra. Due to its size and position, the mass was considered to be vesical calculus. It was not possible, due to the stenosis found, through previous surgical manipulation, to displace the stone. Considering the possibility of the stone being located in the urinary bladder, close to the bladder neck, cystostomy was planned for the removal of the calculus. Upon performing the procedure, the supposed vesical calculus was not encountered. Thus, only urinary drainage was performed by cystotomy, resolving acute urinary retention.

In the postoperative period, the patient was submitted to radiological investigation. Pelvic computed tomography revealed a voluminous calculus with slightly lobulated contours in the intravesical topography in the interior of the prostatic urethra measuring approximately 4.3 cm × 4.1 cm × 2.7 cm (Figure 1). Urethrocystography revealed a prostatic calculus and the tapered passage of contrast through the prostatic urethra (Figure 2).

Figure 1 Pelvic computed tomography revealed a voluminous calculus with slightly lobulated contours in the intravesical topography in the interior of the prostatic urethra measuring approximately 4.3 cm × 4.1 cm × 2.7 cm.

Figure 2 Urethrocystography revealed a prostatic calculus and the tapered passage of contrast through the prostatic urethra.

After the diagnosis, the rectal examination confirmed the presence of a hardened calculous mass in the prostatic topography. Considering the complementary evaluation of the patient, perineal prostatotomy was planned.

The patient was positioned in advanced lithotomy with the lower legs flexed on the thighs, thighs on the abdomen and abdomen flexed on the thorax so that the perineum was parallel to the floor. During the surgical procedure, a urethral probe was inserted until reaching the calculus and a rectal probe was inserted for handing and protection of the rectum. The perineal incision was performed in the shape of an inverted “V” to gain access to the prostate (Figure 3A,3B).

Figure 3 Surgical view. (A) Inverted V-shaped incision; (B) prostatic capsule open for removal of calculus. At the tip of the arrow, you can see the encrusted calculus.

Prostatotomy was performed longitudinally in the prostatic capsule for the removal of the calculus after its release by dissection, the calculus was adhered to the mucosa. No significant bleeding requiring hemostasis occurred. With the removal of the calculus, a Foley catheter with a balloon was placed in the space for hemostatic control. The suturing of the prostatic capsule was performed with absorbable 3-0 multifilament thread.

In the absence of bleeding on the first postoperative day, the balloon of the Foley catheter was repositioned to the interior of the bladder. On the second day, the patient was asymptomatic and had clear urine. The patient was discharged. Upon return for outpatient follow-up after 21 days, the patient was in a good general state, with the maintenance of clear urine and no complaints. The urethral tube was removed for the evaluation of the urinary pattern. During assisted micturition, the urinary stream was strong. The cystostomy tube was maintained for reasons of precaution. The patient returned after 7 days with a good urinary pattern and the cystotomy tube was removed. The patient is currently asymptomatic and in outpatient follow-up. The stone was calcium oxalate, confirmed after laboratory evaluation, and probably formed secondary to urinary stasis.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Urethral calculi are normally found in the prostatic urethra at a narrow point near the membranous urethra. Stones less than 5 mm generally pass through the urethra spontaneously, whereas passage is much more difficult for those larger than 10 mm (4). Giant calculi are rarely diagnosed (1).

The literature offers few studies on this condition and its resolution in the emergency room poses a challenge. In a systematic review, Bello et al. reported calculi measuring 7 cm × 6.5 cm × 6 cm (2) and Kaczmarek et al. reported calculi measuring 7.5 cm × 6.5 cm, demonstrating considerable variation in terms of size and shape (4). Prabhuswamy et al. reported a vesico-prostatic urethral calculus measuring 10.2 cm × 3.5 cm × 4.5 cm, which was removed using a transvesical approach (5).

Although urethral calculi may be completely asymptomatic, the clinical manifestations can progress with perineal or penile pain, an increase in urinary frequency, micturition urgency, diminished urinary stream, dripping, urethral discharge, and hematuria (1). Thus, the diagnosis is based on the clinical history and complementary methods.

In urgent cases, treatment is based on the control of pain and unblocking of the urinary tract with an indwelling catheter or cystostomy, if needed, as performed in the initial procedure of the present case.

Definitive treatment depends on the size and location of the calculus. When located in the posterior urethra, the stone can be moved back into the bladder for subsequent fragmentation using electrohydraulic lithotripsy or laser, for which the success rate is 66% to 86% (5). If fragmentation is not successful, open cystolithotomy is necessary (6).

The literature on prostatic calculi is scarce. The diagnosis is generally performed when one or several firm areas produce a sensation of crepitus upon palpation, but the radiological exam is more useful than the rectal examination, since rigid hardening in the prostate may not be diagnosed as calculus unless there is radiological evidence, because it may be a case of carcinoma (3). In the present case, the age of the patient and previous history of surgery in the urethra excluded the need for a rectal examination in the emergency phase.

Most cases of prostatic calculi are microscopic, generally associated with chronic prostatitis and benign hyperplasia of the prostate and are removed by transurethral resection of the prostate. In the case described here, however, the only viable option was open surgery through the retropubic or perineal route, the latter of which was chosen considering the shorter hospital stay and lower rate of postoperative complications.

In cases of patients with urinary retention treated at an emergency service, the following diagnostic hypotheses should be investigated: benign hyperplasia of the prostate, urethral stenosis, prostatic urethral calculus and prostatic calculus. In the present case, the patient had a giant calculus in the prostate, which is rarely seen in the literature. Large urethral stones are rarely diagnosed. In the literature, a limited number of cases have been described, which typically led to clinical dilemmas. In most of those situations, typical minimally invasive endoscopic treatment, such as forceps or basket extraction or endoscopic push-back with lithotripsy, is not possible. In general, open surgery is recommended, but some exceptions have been described (4).

Conclusions

Several techniques can be used, including less invasive techniques, such as endourology, laser stone fragmentation and endoscopic removal, however, the case was conducted in a Public Hospital, linked to the Sistema Único de Saúde (SUS), which does not have all the required technologies. In addition, the patient had a stenosed urethra, which would also be another factor complicating the endoscopic approach. Therefore, in this case, the perineal route proved to be the best therapeutic option.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-23-115/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-23-115/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-23-115/coif). L.C.F.S. serves as an unpaid Urology Editor and F.N.F.J. serves as an unpaid Urology Section Head of AME Case Reports from December 2022 to January 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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