經尿道碎石手術治療K他命膀胱炎患者接受膀胱擴大成形術後併發之巨型結石

洪健哲、王世鋒

國泰綜合醫院 外科部 泌尿科

Transurethral cystolithotripsy of a huge bladder stone in the patient receiving bladder augmentation due to ketamine-induced cystitis: A case report and literature review

Chien-Che Hung, Shih-Feng Wang

Division of Urology, Department of Surgery, Cathay General Hospital, Taipei, Taiwan

Bladder augmentation can be a valuable life-changing operation for patients with bladder dysfunction. However, several associated complications require long-term management. One of the most common complications seen in these patients is bladder calculi formation. If bladder stones are left untreated, they can become extremely large.  Further symptoms of pain, urinary tract infections, or difficulty emptying the bladder may occur.

We present a case of a 43-year-old male with a medical history of hypertension who was also a ketamine abuser before. He initially came to our urological department for severe lower urinary tract symptoms of frequency, urgency, and hematuria. IVP exam revealed a contracted bladder with multiple outpouchings and calcification, which is strongly impressed with the diagnosis of neurogenic urinary bladder. Bladder augmentation with ileocystoplasty was performed in 2011. After the operation, mucus secretions were only occasionally produced with urine, but no further LUTS symptoms were complained of. He received routine check-ups at our outpatient clinic. Nonetheless, intermittent micturition pain with hematuria has become worse in the past two years. Thus, he came back to our outpatient apartment for further evaluation. Both KUB and CT demonstrated a 5cm spherical radiopaque stone with an annual ring-like texture. Transurethral cystolithotripsy was further arranged. The huge stone exploded piece by piece during the operation, just like crashing the roof tiles. Owing to the fact that there was no elasticity in his bladder, the water pressure was too low to drain out the urine. Furthermore, the stone fragments occasionally glued on the sticky intestine villi and could not be easily washed out. Therefore, the surgery is extremely time-consuming. However, he was discharged without sepsis or any discomfort afterward.

Bladder calculi are associated with multiple urological conditions, including bladder outlet obstruction, chronic bacteriuria, neurogenic bladder dysfunction, and long-term catheterization. The incidence of bladder calculi formation is almost 50% in patients with augmented bladders. Mucous retention in the bladder serves as a precursor for urinary tract infection. Chronic bacterial colonization may also increase the risk of struvite calculus. Thus, these patients with bladder stones should undertake techniques to prevent recurrence to reduce the morbidity of dealing with recurrent stone formation. Besides, these patients should be kept under regular surveillance to ensure early management if stone formation occurs. We herein present this peculiar and educational case to share our experience and management.