成功治療一名跨性別男性合併7公分毛髮核心相關尿道結石與左側2公分腎結石-病例報告

李宗翰¹、許程皓¹、陳人傑^1,2、黃逸修^1,2

¹臺北榮民總醫院 泌尿部；²國立陽明交通大學醫學院泌尿學科及書田泌尿科學研究中心

Successful Treatment of a 7-cm Hair-nidus–associated Urethral Calculus and a 2-cm Left Renal Stone in a Transgender Man: A Case Report

Tsung-Han Li¹, Chen-Hao Hsu ¹, Jen-Chieh Chen^1,2, Eric Yi-Hsiu Huang^1,2

¹Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan

²Department of Urology, College of Medicine and Shu-Tien Urological Science Research Center
National Yang Ming Chiao Tung University, Taipei, Taiwan

Introduction: We report a transgender man who underwent phalloplasty more than 30 years ago and presented with a 7-cm hair-nidus–associated urethral calculus and a 2-cm left renal stone.

Case Presentation: A 59-year-old transgender man visited our urology outpatient clinic because of acute urinary retention caused by two small meatal stones. His past history was significant for female-to-male sex reassignment surgery with phalloplasty about 30 years earlier. Cystoscopy under local anesthesia was arranged; however, a neomeatal stricture of the neophallus was identified, with the meatal opening measuring approximately 10 Fr.. A Ureteroscope was used, revealing two yellowish stones in the distal urethra. One was removed with a Kelly clamp, while the other passed spontaneously during urination. Subsequent abdominal sonography for urolithiasis follow-up revealed a 2-cm renal stone in lower calyx of left kidney. The patient also complained of left flank soreness. After discussion of treatment options, left retrograde intrarenal surgery (RIRS) was arranged. During surgery, a 7-cm hair-nidus–associated urethral calculus was found, completely obstructing the bladder outlet. The calculus was located within the neophallus, and therefore was not detected on preoperative abdominal ultrasonography or plain X-ray of the kidney, ureter, and bladder (KUB) imaging. The surgery was halted because the urethral stone was too large for endoscopic management. Additionally, the meatal stricture only allowed passage of the ureteroscope, making irrigation of the stone during URS laser extremely difficult. Even if complete stone clearance were achievable, the acute angle of the neophallus prevented our access to the bladder. Furthermore, if pubic hair is not removed, future stone formation may occur.

A few weeks later, an open urethrolithotomy was performed in collaboration with a plastic surgeon. An incision was made along the lower margin of the neophallus wound to access the stone; the stone was completely removed, and local flap manipulation was performed. The neophallus urethra was anastomosed to the perineal skin using 3-0 nylon. Intraoperative ultrasound was employed to avoid injury to the flap vessels. This procedure not only allowed complete removal of the urethral stone but also provided a better angle for subsequent endoscopic access to the bladder. A 16 Fr. Foley catheter was placed for better wound healing. After the patient’s wound had healed and the nylon sutures were removed, a left retrograde intrarenal surgery (RIRS) was arranged. During the operation, the urethral lumen could be identified, and a semi-rigid ureteroscope was successfully advanced into the bladder with the assistance of a floppy tip guidewire. After a 10/12-Fr suction ureteral access sheath (S-UAS) was inserted smoothly into the ureter, flexible ureteroscopy revealed a stone located in the lower pole of the left kidney. Stone fragmentation and removal were achieved using laser lithotripsy and S-UAS. Complete stone clearance was achieved, and a 6 Fr. double-J ureteral stent with a retrieval string was placed uneventfully. The postoperative course was smooth, and the patient was discharged on postoperative day (POD) 1. The double-J ureteral stent was removed on POD 7. The patient subsequently underwent hair removal procedures in the plastic surgery department.

Discussion: This case provides several important considerations for the management of urinary tract stones in transgender men. First, preoperative evaluation with abdominal ultrasonography and plain X-ray of the KUB alone may fail to detect stones located entirely within the neourethra. Therefore, clinicians should maintain a high index of suspicion when managing such patients. In selected cases, additional imaging modalities, such as computed tomography (CT), may be considered to improve diagnostic accuracy.

Second, anatomical factors, including neomeatal stricture and the acute angulation of the neophallus, may hinder successful access to the bladder using cystoscopy or ureteroscopy. In the present case, the presence of a large urethral stone necessitated open urethrolithotomy. Subsequent local flap manipulation not only enabled complete removal of the urethral stone but also facilitated improved endoscopic access to the bladder. However, in patients without concomitant urethral stones, retrograde access to the bladder and upper urinary tract may remain challenging. In such situations, management strategies should be individualized, with multidisciplinary discussion involving urologists and plastic surgeons.

Finally, the invention of suction ureteral access sheaths has improved immediate stone clearance during retrograde intrarenal surgery (RIRS). These innovations enhance surgical outcomes and the overall quality of patient care.

Conclusions: Careful surgical planning and familiarity with reconstructive anatomy are essential to achieve safe and effective stone treatment in managemen of stone disease in transgender men, a unique population.