In some parts of Asia, smooth stones, up to 5 cm in diameter, form in the bladders of underprivileged children (mainly boys). Even an infant may suffer from them. In India a third of all urinary problems in childhood are caused by bladder stones. Why they form is far from clear, because the kidneys of these children show no special tendency to form them. When you have removed a bladder stone, it is unlikely to recur.
A child's mother will say that he cries every time he passes urine, and pulls at his penis as he tries to relieve his pain. Frequency and strangury make his life unbearable; sometimes he passes blood. Other symptoms include: interruption of the stream, frequency, dysuria, and suprapubic pain.
There are few physical signs. His bladder may be distended, and his foreskin red and swollen from being pulled on. You may be able to feel the stone when you examine him rectally. It is likely to be made of urates, but it will probably contain enough calcium for you to see it on an X-ray.
Removing a stone from the bladder of a child is not too difficult. When you have done so, there is no need to drain his bladder with a catheter, either suprapubically or through his urethra[md]if you have sutured it securely.
ASHVIN (3 years) had repeated urinary infections which had been treated with antibiotics on many occasions, but his symptoms always returned. He then saw another doctor, who remembered that repeated urinary infections in children should always be investigated, so he X-rayed Ashvin's bladder and was surprised to see a large stone. At operation, the stone was difficult to remove, and appeared to be lying in a diverticulum. Afterwards he had no more urinary infections. LESSON Don't forget the possibility of stones in children, especially if you are in a high-stone area.
CHILDREN'S BLADDER STONES ANAESTHESIA. Give the child a general anaesthetic (A 18.3). A relaxant is helpful. Ketamine, tracheal intubation, and relaxants (A 8.5).
PREPARATION. As soon as he is asleep, prepare his lower abdominal wall, thighs and genitalia, and drape him. If you are new to this kind of surgery, distend his bladder with water before you start, so that you can find it more easily. Pass a small plain catheter; then, using a 20 or 50 ml syringe, inject 100 to 200 ml of water into his bladder, depending on his size.
INCISION. Make a midline skin incision, starting at his symphysis pubis and extending up to a point 5 cm below his umbilicus. Reflect the skin flaps 1 cm on either side.
Divide his linea alba strictly in the midline, without entering his peritoneal cavity. Keeping his umbilicus in view to help you stay in the midline, make a vertical incision through the whitish aponeurotic fibres of his linea alba. Continue the incision down to his symphysis pubis, where you will meet his pyramidalis muscle on each side. With a sponge on a holder, gently push his rectus muscles laterally, so that you can see his posterior rectus sheath. Insert a small self-retaining retractor to keep his rectus muscles apart.
Feel for his distended bladder: it should be easily palpable as it rises out of his pelvis. Using a sponge, or your index finger, gently break down the thin layer of his posterior rectus sheath, and open his retropubic space. At the same time displace his peritoneum, so that you don't enter his peritoneal cavity. You should now be able to feel and see his distended bladder.
Insert stay sutures, and apply a haemostat on each side of the midline at the most easily accessible part of his bladder. This will prevent it slipping away. Get the sucker ready. Then with a scalpel, or cutting diathermy, make a 2 cm incision in the bladder wall, between the two stay sutures. Water will squirt out.
With your index finger, feel through the hole in his bladder for the stone. Remove it with stone forceps or a sponge-holder. If the hole is not big enough, enlarge it. Having removed one stone, feel again to make sure that he has not got another one.
Close his bladder carefully with continuous 3/0 chromic catgut or ''Dexon' on an atraumatic needle. Include all layers, and make the bites not more than 5 mm apart. The longer the incision, the more care you need in closing it.
CAUTION ! Make a small stab incision just beside the wound and insert a small soft rubber drain down to the suture line. Dont't forget to do this. Even if you think you have closed his bladder securely, it may still leak. If urine extravasates, it may cause a serious cellulitis.
Sew up his linea alba with 2/0 catgut. Make sure that you have controlled all bleeding, and then close his skin. If you think that his bladder may leak, or if you have had to make a large incision, insert a Foley catheter and connect this to a bedside drainage bottle for 4 to 5 days. Otherwise, don't insert one. Some surgeons always insert a small suprapubic catheter and use it for a trial of voiding.
POSTOPERATIVELY, he will probably pass urine without difficulty later that day. If urine leaks through the suprapubic drain, insert a urethral catheter, and leave it there for a few days. Otherwise, remove his suprapubic drain after 3 to 4 days. He is unlikely to get another stone, but his siblings may.
Fig. 23-21 CLOSING THE BLADDER IN TWO LAYERS. This is the standard way of closing the bladder in adults. In a child you can usually use a single layer. A, and B, use continuous or interrupted plain or chromic 2/0 or 3/0 catgut sutures on an atraumatic round-bodied needle. Don't use non-absorbable sutures because they may be the focus of stone formation. C, if his bladder is very thin and weak, close it with figure of eight sutures like this. After Blandy J, ''Operative Urology', Figs. 8.10 and 8.11. Blackwell Scientific Publications, with kind permission.