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Table of Contents
Year : 2019  |  Volume : 30  |  Issue : 2  |  Page : 53-57

Bladder calculi in Taiwan

Department of Urology, China Medical University Hospital, Taichung, Taiwan

Date of Submission10-Apr-2018
Date of Decision18-Dec-2018
Date of Acceptance01-Feb-2019
Date of Web Publication28-Mar-2019

Correspondence Address:
Wen-Chi Chen
Department of Urology, China Medical University Hospital, No. 2 Yuh-Der Road, North District, Taichung
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_142_18

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In Taiwan, the reported admission rate for bladder calculi was 7.5% of all patients with urolithiasis. The admission rate for bladder calculi was 12.9/100,000 in 2010, with elderly males constituting 91.8% of these patients. Pediatric bladder calculi are rare in Taiwan with a reported prevalence of only 0.047%. There are four possible causes of secondary bladder calculi, namely bladder outlet obstruction (BOO), neurogenic bladder, intravesical foreign bodies, and renal transplant. The biggest reported bladder stone in Taiwan was approximately 7 cm × 4.8 cm in size, with a weight of 320 g. Several pathogenic factors contribute to the formation of bladder calculi, including intravesical foreign bodies, BOO, neurogenic bladder, and metabolic abnormalities. Contemporary treatment of bladder calculi includes endoscopic cystolithotripsy or cystolitholapaxy with laser or LithoClast lithotripters. Some studies from Taiwan have reported that bladder calculi may increase the risk of cancer. An association between bladder calculi and chronic kidney disease has been reported in serial reports. In conclusion, most bladder calculi can be treated by endoscopic surgery and attention to associated comorbidities is warranted.

Keywords: Bladder calculi, bladder outlet obstruction, chronic kidney disease, cystolithotripsy

How to cite this article:
Laih CY, Chang CH, Chen WC. Bladder calculi in Taiwan. Urol Sci 2019;30:53-7

How to cite this URL:
Laih CY, Chang CH, Chen WC. Bladder calculi in Taiwan. Urol Sci [serial online] 2019 [cited 2020 Aug 6];30:53-7. Available from: http://www.e-urol-sci.com/text.asp?2019/30/2/53/255160

  Introduction Top

Technological advancement has resulted in the availability of new technology and instruments, including minimally invasive and noninvasive procedures for urolithiasis. However, urolithiasis still remains one of the most common painful diseases in the world. Urinary calculi can be broadly divided into two types, namely upper urinary tract calculi and lower urinary tract calculi. Bladder calculi are the most common lower urinary tract calculi. Bladder calculi account for 5% of urolithiasis and usually result from the diet, foreign bodies, bladder outlet obstruction (BOO), or urinary tract infection.[1] Bladder calculi can be classified into the following two types: primary bladder calculi and secondary bladder calculi.[2] Primary bladder calculi are more common in children exposed to low-protein or low-phosphate diets. Primary bladder calculi have a low recurrence rate following completion of treatment. Huang et al. reported that the prevalence of pediatric urolithiasis in Taiwan was only 0.047% in 2005.[3] The following four causes may lead to secondary bladder calculi formation: (i) BOO, (ii) intravesical foreign bodies, (iii) neurogenic bladder and spinal cord injury (SCI), and (iv) renal transplant.[2] This review mainly focuses on secondary bladder calculi, with a focus on cases from Taiwan.

  Epidemiology Top

Although many studies have provided epidemiological evidence, most have focused on upper urinary tract calculi, especially renal stones. The risk of stone formation in the United States has been reported to be over 12% in men and over 6% in women.[4] For renal stones, the lifetime prevalence ranges from 1% to 15%. Furthermore, prevalence also varies according to age, sex, race, and geographical distribution.[5] Only a few studies have focused on the epidemiology of bladder stones because these account for only a small proportion of urolithiasis cases in Taiwan. Lee et al. conducted a nationwide survey to investigate the prevalence of upper urinary calculi in Taiwan. They concluded that 9.6% of the population (14.5% of males and 4.3% of females) experienced stones at least once during their lifetime.[6] Yu et al. conducted a cross-sectional study using data from the National Health Insurance Research Database. Taiwan had a population of 23,140,940 in 2010, of which a total of 40,027 patients were admitted to a hospital because of urolithiasis (at a ratio of 173/100,000 people). Among these 40,027 patients, 76.4% patients were admitted for ureteral stones (n = 30,577); 15.8% patients, for renal stones (n = 6,307); and 7.5% patients, for bladder stones (n = 2,987).[7] The admission prevalence for bladder stones was 12.9/100,000. The average age of inpatients admitted for bladder stones was higher than the average age of all inpatients admitted for urolithiasis at other locations (66.2 ± 14.1 years vs. 52.1 ± 14.2 years). Among the patients admitted for bladder stones, 91.8% (n = 2741) were male patients and only 8.2% (n = 246) were female patients. Prostatic hyperplasia and a neurogenic bladder resulting from long-term catheterization were causative factors for bladder stones in elderly males.[7] The statistical results also revealed that the highest admission rate for bladder stones occurred between July and August and most cases were reported from Northern Taiwan (n = 1,190, 39.8%). About 26% (n = 777) of patients were treated at a medical center; 53.8% (n = 1,607) of patients, at a regional hospital; and 20.2% (n = 603) of patients, at a local hospital.[7] Given the insufficient data regarding bladder stones in the pediatric population, Ni et al. conducted a retrospective study on urolithiasis in children over a period of 11 years at the National Taiwan University Hospital.[8] The study included only 14 patients with urolithiasis aged between 1 and 16 years, with a male-to-female ratio of 5:2. There were four male and three female pediatric patients with bladder stones, and no sex predominance was observed among the pediatric patients.

  Pathogenesis Top

Campbell-Walsh Urology and Douenias et al. proposed four possible causes of secondary bladder calculi, among which BOO was the most common predisposing factor, present in 45%–79% of all patients diagnosed with bladder calculi.[2],[9] In female patients, BOO is generally associated with urethral kinking due to cystocele or pelvic organ prolapse, whereas in men, BOO has been associated with benign prostatic hyperplasia.[2] Childs et al. advocated that the pathogenesis of bladder calculi is likely complex with multiple contributing lithogenic factors, including metabolic abnormalities and not only urinary stasis.[10] Patients with BOO and benign prostatic hyperplasia were more likely to have a history of renal stone disease, low urinary pH, low urinary magnesium, and increased urinary uric acid supersaturation in the prospective analysis.[10] In Taiwan, some studies have reported a relationship between bladder stones and urinary stasis or BOO. Chuang et al. reported a case of an 89-year-old male patient with a 7 cm × 4.8 cm giant stratified lamellate stone occupying almost the entire urinary bladder, which resulted in bilateral hydronephrosis and acute renal injury.[11] Lai and Kuo reported a case of a 69-year-old male patient who developed acute renal failure as a result of a huge triangular bladder calculus weighing around 320 g.[12] The case of a 41-year-old male patient who experienced acute urine retention and bladder stones due to two giant urinary bladder diverticula secondary to BOO was reported by Chia-Yu Chang et al.[13]

The composition of bladder stones varies with geography and ethnicity and includes calcium oxalate, calcium phosphate, cystine, struvite (calcium-magnesium-ammonium phosphate), and uric acid. Moreover, stones are usually solitary, although multiple stones may exist in 25%–30% of patients according to the study by Sarica et al.[14] Lu et al. reported a case involving a total of 1050 bladder stones.[15]

Intravesical foreign bodies are also a common cause of bladder stone, most of which occur as a result of iatrogenic interventions. Many studies in Taiwan have investigated the correlation between intravesical foreign bodies and bladder stones. Lu et al. reported the case of a 54-year-old female patient, who developed intravesical calculus from nonabsorbable sutures used during a surgical hysterectomy performed 14 years previously.[16] A similar case was reported in which a 35-year-old female patient developed bladder stones from nonabsorbable sutures used during a cesarean section 8 years prior.[17] Juan et al. reported the case of a 20-year-old male patient who had a history of SCI with paraplegia, which necessitated the use of a long-term Foley indwelling catheter. The bladder stone was induced by a fragment of a ruptured Foley balloon.[18] Su et al. also reported the case of a 77-year-old man with a bladder stone, who had undergone ventral hernia repair with a mesh 5 years prior. The hernial repair resulted in surgical complications, and the mesh migrated into the urinary bladder, resulting in the formation of an enterovesical fistula. He was treated by segmental resection of the ileum, stone removal, and cystography.[19] Chuang et al. reported a case of a 31-year-old patient with bladder diverticulocutaneous fistula and a giant stone as a complication of pelvic fracture.[20] Ke et al. reported the case of a 25-year-old man with neurogenic bladder secondary to SCI with bladder stones induced by a hair nidus probably due to a permanent cystostomy performed 4 years previously.[21] Tsai et al. reported the case of a 62-year-old man with stones encrusted over a forgotten old double-J stent, which had been placed 24 months after ureterorenoscopic lithotripsy. Cystolithotripsy and ureterorenoscopic lithotripsy with a holmium laser were performed to remove the stones and the double-J stent.[22] For the forgotten double-J stent, Yeh et al. proposed a new treatment technique using silk-loop-assisted ureterorenoscopic lithotripsy in Taiwan.[23] Therefore, treatment associated with intravesical foreign bodies may be causative of bladder stones.

Wei and Lu et al. also reported cases of intravesical migration of an intrauterine device with stone formation in Taiwan.[24],[25] Yu et al. proposed three types of intravesical Hem-o-Lok clip (HOLC) migration after laparoscopic radical prostatectomy. The incidence of intravesical HOLC migration has been reported to be 0.8% (6/750).[26] Intravesical migrations have been classified into three types: (i) Type I migration resulting in obstructive lower urinary tract symptoms 2–8 months after prostatectomy; (ii) Type II migration leading to stone formation, gross hematuria, or bladder spasm; and (iii) Type III migration, resulting in spontaneous expulsion of HOLC a few weeks after surgery.[26] Chen et al. reported a case series of three male patients with stones within the Kock pouch occurring 14–23 months after operation.[27] Electrohydraulic lithotripsy was used for the treatment of stones. In addition, Yeh et al. reported a rare case of a 42-year-old male patient with ureteral fibroepithelial polyps that prolapsed into the bladder cavity and were suspended with a bladder stone.[28]

In cases of neurogenic bladder and SCI, the risk of bladder stone formation peaked 3 months after the initial injury, and the 5-year cumulative incidence rate of an initial bladder stone varied from 8% to 29% from 1973 to 1996 according to the report by Chen et al.[29] Ord et al. claimed that the absolute annual risk of stone formation in patients with a catheter was 4% compared with 0.2% for those on intermittent self-catheterization.[30] Moreover, suprapubic catheters were associated with a decreased risk of occurrence of bladder stones compared with indwelling urethral catheters. In Taiwan, Chen et al. conducted a study on 40 consecutive adults with SCI who underwent enterocystoplasty and found that long-term complications, including urinary incontinence, were observed in 4 (10%) patients; reservoir calculi, in 13 (32.5%); and new-onset upper tract stones, in 9 (22.5%) patients.[31] Therefore, the occurrence of bladder stones is more frequent in patients with SCI and following long-term Foley indwelling when compared to that in the general population.

The occurrence of bladder calculi in renal transplant patients is very rare. Only a few case reports have been published, and in most reports, stone formation was induced by nonabsorbable suture material or surgical clips.[2] Neither data nor reports on this topic have been published in Taiwan.

Regarding the role of metabolic factors in the occurrence of urinary tract calculi, most studies have focused on the role of metabolic factors in the occurrence of upper urinary tract calculi and have seldom discussed their role in the occurrence of lower urinary tract calculi. Jou et al. analyzed the composition of stone matrix proteins present in a bladder uric acid stone (BUAS) by mass spectrometry[32] and concluded that the inflammatory process and lipid metabolism might play a role in BUAS formation.

Chou et al. conducted a study on the characteristics of patients presenting with ammonium acid urate (AAU) urolithiasis in Taiwan.[33] Among a total of 3457 patients with urolithiasis, only 25 (0.7%) presented with AAU stones. Among these 25 patients, 44% were male and 56% were female patients. AAU stones were frequently observed in the bladder (44%), and patients with AAU stones were most likely to have significant comorbidities such as chronic kidney disease (CKD), urinary tract infections, irritable bowel syndrome, gout, and even urothelial carcinoma. Li et al. compared the clinical characteristics of uric acid urolithiasis of upper urinary tract urolithiasis and bladder stones.[34] The authors collected data from 77 stone patients over a period of 3 years. Calculi were located in the upper urinary tract in 55 (71.4%) patients and were located in the bladder in 22 (28.6%) patients. Of these, 72.7% of patients were overweight or obese. In the bladder stone group, the incidence of benign prostate hyperplasia was significantly higher, and the incidence of diabetes mellitus and serum uric acid and creatinine levels were significantly lower than in the upper urinary tract group. The authors concluded that local factors were more important than systemic factors in the formation of BUASs. The cause of this association was unlikely to be influenced by metabolic derangements accompanying the metabolic syndrome.

  Bladder Stones and Cancer Top

Various studies have investigated the relationship between bladder stones and bladder cancer. Some authors believe that bladder stones may be the result of necrotic areas of tissue or encrustation of a bladder tumor after transurethral resection of the latter.[35] Conversely, some authors believe that the chronic irritation of the bladder mucosa caused by stones may induce chronic inflammation, resulting in bladder cancer.[36] In Taiwan, Chung et al. conducted a case-control study that included 2086 patients who had received an initial diagnosis of bladder cancer and 10,430 randomly selected controls without bladder cancer to examine the association between bladder cancer and prior bladder calculus using a population-based dataset. A bladder calculus was found in 71 (3.4%) cases of bladder cancer, whereas only 105 (1.1%) cases of bladder calculi were detected in the control group. The odds ratio (OR) of a previous diagnosis of bladder calculi for the cases was 3.45 (95% confidence interval [CI] = 2.39–4.99) compared to that in controls.[36] This study emphasized that patients with bladder cancer had a relatively high incidence of bladder stones.[36] Regarding the risk of urinary tract cancer (UTC) in patients with bladder calculi, Lin et al. performed a nationwide cohort study to investigate the risk of bladder cancer in patients with a history of urolithiasis and to determine whether intervention for calculi attenuated the risk of subsequent UTC in Taiwan.[37] The authors concluded that urolithiasis increases the risk of subsequent UTC, especially upper UTC. Furthermore, Chung et al. also conducted another population-based study to address the relationship of urinary calculi with prostate cancer.[38] The authors concluded that patients with prostate cancer also had a higher possibility of having urinary calculi, especially bladder stones.

  Treatment Top

Various treatment modalities are available for the management of bladder stones. The treatment modalities can be broadly divided into two types: (i) nonsurgical management and (ii) surgical management. However, due to the low efficiency of nonsurgical methods, surgical management is the treatment of choice. In addition, the underlying conditions contributing to the formation of bladder calculus should also be treated. Open cystolithotomy was previously the gold standard before the introduction of endoscopic technology for the treatment of bladder stones. However, it is associated with the need for prolonged catheterization, increased length of hospital stay, and poor cosmesis.[39] In Taiwan, only 5% of inpatients with urolithiasis underwent open surgery for lithotomy.[7] Transurethral cystolitholapaxy and lithotripsy have now become the gold standards for the treatment of bladder stones. Most published studies have used a holmium laser, electrohydraulic lithotripter, and LithoClast technology for the treatment of all types of bladder stones in both the adult and pediatric populations.[8] Shock wave lithotripsy has also been used for the treatment of bladder stones in some countries; however, it is rarely used in Taiwan. According to the statistical data of Yu et al., shock wave lithotripsy has not been performed in any case for the treatment of bladder stones in Taiwan. Overall, 65.8% of bladder stone cases were treated using endoscopic manipulation and 34.2% cases were treated using an open surgical approach in 2010, despite the preference for endoscopic lithotripsy in recent years.[7]

  Prevention Top

The prevention of bladder stones requires close attention toward the amelioration of metabolic status, similar to the management policy employed in the prevention of upper urinary tract calculi, and should be directed toward improving BOO, neurogenic bladder, and lessening intravesical foreign bodies. Appropriate metabolic adjustment is highly effective in preventing urolithiasis in both the upper and lower urinary tract. However, some comorbidities that are related to bladder stone in Taiwan have been proposed. Keller et al. conducted a population-based study to investigate the association of CKD with prior kidney calculus, ureter calculus, and bladder calculus in Taiwan.[40] The OR of prior urinary calculi was 1.91 (95% CI: 1.81–2.01, P < 0.001); whereas for kidney calculus, the OR was 2.10 (95% CI: 1.95–2.27), for ureter calculus, the OR was 1.68 (95% CI: 1.51–1.85), and for bladder calculus, the OR was 1.49 (95% CI: 1.13–1.98). The authors concluded that there was an association between CKD and urinary calculi regardless of stone location. Moreover, the authors also conducted two additional studies using the same population-based dataset. In the first study, they investigated the association between bladder pain syndrome/interstitial cystitis and urinary calculi, with results indicating that there was a high correlation.[41] The second study investigated the association between osteoporosis and urinary calculi, and the results revealed a high correlation between the conditions.[42] Therefore, close attention should be paid to these comorbidities and efforts should be made to control the comorbid conditions to prevent the recurrence of bladder stones.

  Conclusion Top

Bladder calculi are one of the oldest known human diseases. Due to technological advancements, many new minimally invasive surgical procedures have become available for the treatment of bladder calculi and Taiwan is no exception to such advanced treatment options. This review includes nearly all published studies from Taiwan available in the Medline database, including case reports, research articles, and nationwide prevalence studies related to bladder calculi since 1989 to date. This article provides detailed information covering all aspects of bladder calculi, including recent advances in the management of the condition.

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