Bladder stones can be primary, when there is no obstruction, or secondary, when there is. In the industrial world, primary bladder stones were once common in adults and children, but have now almost disappeared. A few secondary stones are seen in adults with urinary obstruction. Primary stones are however still common at all ages in a ''stone belt' which includes North Africa, the Near and Middle East, Pakistan, India, Burma, Thailand, Vietnam, Laos, Kampuchea, southern China, and Indonesia; mostly, but not only, in the poor.
If you are not in the stone belt, and you do find a bladder stone in an adult, be sure to exclude distal obstruction. If you remove a stone from his bladder, and there is obstruction, a fistula may form and refuse to heal.
Most bladder stones in adults cause no pain, or slight pain in the perineum, or, if a stone is big, a ''bumping feeling' as the stone moves about.
The operation to remove a bladder stone in an adult is similar to that for the first stage of a Freyer's prostatectomy, and the open suprapubic cystostomy described in Section 23.7. The exact way in which you close the bladder is not important, you can use continuous, or interrupted, sutures, of plain or chromic catgut. There is no need to oppose the mucosa precisely, nor is it now considered important to avoid penetrating the mucosa with stitches. But be sure to: (1) Keep the bladder empty with an indwelling suprapubic or urethral catheter. (2) Drain the retropubic space, so that blood and urine cannot accumulate.
When you have removed a bladder stone it does not usually recur, so the strict measures for preventing the recurrence of stones in the upper urinary tract are less necessary in the bladder.
Fig. 23-20 DETAILS OF THE PFANNENSTEIL INCISION. A, the incision. The inferior epigastric arteries lie at the ends of the incision on the deep surface of the rectus muscles. B, reflecting the anterior layer of the rectus sheath. C, the rectus muscles have been parted and you are preparing to enter the abdomen. Alternatively, you can cut them transversely little by little, until you reach the epigastric vessels on the deep surface. From ''Hamilton Bailey's Emergency Surgery', edited by HAF Dudley, (John Wright). With the kind permission of Hugh Dudley.
BLADDER STONES [s8]IN ADULTS X-RAYS confirm the diagnosis, because bladder stones in an adult are usually radio-opaque. Other retropubic calcifications include: (1) Calcification of the bladder wall due to bilharzia (very common in endemic areas and gives no trouble). If necessary, confirm this by showing that the shadow is a different size when the bladdder is full and empty. (2) Calcification in a uterine fibroid. (3) A calcified mesenteric lymph node.
DIAGNOSIS. If this is in doubt, pass a sound, and feel it grating against the stone (the classical way of diagnosing one).
ANAESTHESIA. (1) Local infiltration of the skin, subcutaneous tissues, and muscle layers of the abdominal wall will produce enough anesthesia for short operations. If he is debilitated, this is the method of choice. (2) If the operation is a long one, or you need muscle relaxation, use general anaesthesia, or a low subarachnoid (A 7.6).
PREPARATION. If his bladder is going to be difficult to find, consider inserting a urethral catheter and filling it with fluid; you can use the same catheter for postoperative drainage. A steep Trendelenburg position will make exposure easier.
A PFANNENSTEIL INCISION (23-20) makes it easier to keep low, and avoid opening his peritoneum, as it passes from his abdominal wall to his bladder.
Incise his skin and subcutaneous tissue transversely. Either: (1) part his rectus muscles to expose his peritoneum in the midline. Or, (2) cut his rectus muscles transversely in line with the skin incision, little by little, until you see the inferior epigastric vessels in the deep surface laterally. This will give you better exposure, and you will be less likely to incise the peritoneal reflection over his bladder in error, which may spread infection into his peritoneum.
Alternatively, make a paramedian incision.
Find the reflection of his peritoneum and displace this upwards. Grasp his bladder with stay sutures on either side of the midline, or with two Allis' forceps, holding the entire thickness of its wall. Make a vertical incision in his bladder, unless you want to remove a large stone[md]then make a transverse one. You can suture a transverse incision more easily, but it will bleed more than a vertical one. Suck away his urine as it gushes out.
Put your finger into his bladder to feel if the stone is lying free, or is impacted in a diverticulum. Feel for a tumour or other pathology. Remove any free stones with your fingers, a scoop, or lithotomy forceps.
CAUTION ! Repeatedly wash out his bladder before you close it. If you leave any stony fragments, they will act as the nuclei for the formation of more stones.
Close his bladder in two layers with continuous or interrupted 2/0 catgut or ''Dexon'.
Most surgeons rely on a urethral Foley catheter to provide drainage, and don't feel that a suprapubic one is necessary; it does however allow the patient to have a trial of voiding. Be sure to drain his retropubic space; bring the drain out through a stab wound.
POSTOPERATIVELY, remove his retropubic drain after 48 hours. Leave the Foley catheter in place for 8[nd]10 days, to keep his bladder collapsed while it heals. Take a specimen of urine for culture a day or two before you take it out.
DIFFICULTIES [s7]WITH BLADDER STONES IN ADULTS If he develops a FISTULA, which is not uncommon, it will probably be the result of some obstruction to his urethra. Leave his urethral catheter in long enough for his fistula to heal.