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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 156-158

Hanging vesical stone in post-transplant recipient – delayed and unusual complication


Department of Urology, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India

Date of Submission14-Sep-2019
Date of Acceptance28-Mar-2020
Date of Web Publication06-Jul-2020

Correspondence Address:
Dr. Venkat Arjun Gite
Swastik Building No. 4, House No. 6, Ist Floor, Grant Medical College and Sir JJ Hospital, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_48_19

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  Abstract 


Vesical stone formation is very rare in posttransplant recipients. We describe a patient who developed hanging vesical stone more than 10 years after receiving a transplant near the ureteroneocystostomy site on polypropylene suture, treated by cystolithotripsy using the removal of suture material with cystoscopic scissors. The use of nonabsorbable suture leads to very late formation of stones over it. Hence, it should be avoided.

Keywords: Kidney transplant, lithotripsy, nonabsorbable suture, urinary tract infection, vesical stone


How to cite this article:
Agrawal M, Gite VA, Sane M, Sengol J. Hanging vesical stone in post-transplant recipient – delayed and unusual complication. Indian J Transplant 2020;14:156-8

How to cite this URL:
Agrawal M, Gite VA, Sane M, Sengol J. Hanging vesical stone in post-transplant recipient – delayed and unusual complication. Indian J Transplant [serial online] 2020 [cited 2020 Aug 5];14:156-8. Available from: http://www.ijtonline.in/text.asp?2020/14/2/156/289042




  Introduction Top


The occurrence of urinary calculi following renal transplantation is an uncommon phenomenon, <150 cases are reported in the literature, and the formation of vesical stone is even rarer.[1],[2] We describe a patient who had recurrent urinary tract infection (UTI) (two attacks in recent past), > 10 years later to transplant, found to have hanging vesical stone over polypropylene suture near the ureteroneocystostomy site.


  Case Report Top


A 47-year-old male presented with mixed lower urinary tract symptoms with prior history of two episodes of UTI over the past 2 years, which got resolved with culture-specific antibiotics. Ten years before the presentation he underwent live related donor kidney transplantation for end-stage renal disease. Exact details of surgery were not known. His clinical examination was normal. His urine microscopy showed 6–8 pus cells per high power field. Urine culture showed no growth. The rest of the hematological and biochemical profiles (liver function tests, kidney function tests, serum calcium, phosphorus, uric acid, and lipid profile) were within the normal range. Ultrasonography was suggestive of vesical stone of size 2.5 cm [Figure 1], and X-ray kidney ureter and bladder (KUB) showed vertically oriented radio-opaque density in the nondependent area of the bony pelvis [Figure 2]. He underwent cystoscopy, which revealed single vesical stone hanging from the right anterolateral wall of the urinary bladder near ureteroneocystostomy site attached through blue colored suture material [Figure 3]. Cystolithotripsy was done using pneumatic lithotripter. All stone fragments were removed by evacuator. Cystoscopic scissors were used to cut the suture thread and was completely removed. Suture material was nonabsorbable polypropylene. Stone was sent for the stone analysis. Per urethral catheter was removed after 48 h. The patient's postoperative recovery was uneventful. The patient was discharged on the postoperative day 3. On the stone composition of stone was mainly amorphous carbonated calcium phosphate (50%). He was stone free at the end of 6 months follow-up and his graft function has been stable till date.
Figure 1: Ultrasonography of pelvis showing vesical calculus

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Figure 2: X-ray kidney ureter and bladder showing vertically oriented radio-opaque density in the nondependent area of the bony pelvis

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Figure 3: Cystoscopic view showing stone around the nonabsorbable suture material hanging from the bladder wall

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  Discussion Top


As a result of the growing number of renal transplants and increase in graft survival, it has led to an increase in reporting of complications, one of which is urinary calculi.[3] Most commonly, calculi are seen in the kidney.[4] Vesical stone either migrate from the kidney and stay inside the bladder due to the bladder outlet obstruction or they from in situ due to the presence of the foreign body.[5] The bladder is the most common site for foreign body calculus followed by the kidney, urethra, and ureter.[4] Bladder calculi may form over absorbable or nonabsorbable suture material.[2] Suture act as a nidus for stone formation, which increases the chance of UTI and infective stone formation. Susceptibility of stone formation depends on the time of exposure of suture with urine; hence, nonabsorbable sutures have the greatest chance to act as a nidus for stone formation.[2],[6] In a retrospective study by Kim et al. of 849 patients, 15 (1.8%) patients had urinary stones which were diagnosed 3–109 months after transplant with a mean duration of 17.8 months. In their study, 11 were vesical stones of 15.[2] Our patient presented 120 months after transplant surgery.

Klein and Goldman reviewed records of 312 patients who underwent a renal transplant, out of which in 196 patients ureteroneocystostomy was done with nonabsorbable polypropylene suture and formation of vesical stone were there in 7 of those 196 patients (3.6%). In their review, none of 116 patients developed vesical stone where absorbable polydioxanone suture was used for ureteroneocystostomy.[4] In our case, polypropylene suture was used, which led to the delayed formation of the stone.

Presentation of vesical stone in posttransplant patients varies from incidental detection to symptomatic UTI or hematuria.[1] In our case, the patient had two attacks of UTI before the presentation which were treated by culture-specific antibiotics.

To determine stone location and size, ultrasonography, and X-ray KUB are the most useful, easily available, and inexpensive diagnostic tools. However, noncontrast computed tomography is an excellent, although expensive, and modality to detect stones.[2] On ultrasound or X-ray KUB, vesical stone usually appears in a dependent position, transversely lying, mobile on any change in position. Nonmobility is suggestive of hanging stone, as in our case.[5]

In our case, the patient did not have any complications at the time or following transplant surgery and the occurrence of the vesical stone more than 10 years later could not be attributed to any medical or surgical cause except polypropylene suture material used for ureteroneocystostomy which acted as a nidus for stone formation. Successful endoscopic treatment of vesical stone on nonabsorbable suture material using cystolitholapexy and electrohydraulic lithotripsy have been reported.[4] In our case, we used pneumatic lithotripsy for fragmentation and cystoscopic scissors for suture removal, which was the cause for the formation of the stone. Klein et al. found that on cystoscopic evaluation, all patients showed calculus firmly attached to the bladder wall near ureteroneocystostomy as seen in our case also.[4] Stones in posttransplant patients usually consist of calcium oxalate, but there are high rates of struvite stones.[7] In our case, the stone was composed of mainly amorphous carbonated calcium phosphate (50%).

In the study by Klein et al., of 7 cases with vesical stones, no patient had recurrent UTI or calculus formation in follow-up period of 12 months.[4] In our case, at the end of 6 months follow-up, the patient was asymptomatic, and his graft function was stable.


  Conclusion Top


Delayed occurrence of vesical stone should be suspected if a patient presents with recurrent UTI and with a history of nonabsorbable suture material used for ureteroneocystostomy. As prevention is better than cure, one should avoid the use of nonabsorbable suture material for ureteroneocystostomy anastomosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chawla NS, Sajiv CT, Pawar B, Bansal V and Mammen KJ. Vesical calculus in a post renal transplant patient – A short case report. Indian J Nephrol 2003;13:41-2.  Back to cited text no. 1
  [Full text]  
2.
Kim H, Cheigh JS, Ham HW. Urinary stones following renal transplantation. Korean J Intern Med 2001;16:118-22.  Back to cited text no. 2
    
3.
Lipke M, Schulsinger D, Sheynkin Y, Frischer Z, Waltzer W. Endoscopic treatment of bladder calculi in post-renal transplant patients: A 10-year experience. J Endourol 2004;18:787-90.  Back to cited text no. 3
    
4.
Klein FA, Goldman MH. Vesical calculus: An unusual complication of renal transplantation. Clin Transplant 1997;11:110-2.  Back to cited text no. 4
    
5.
Carson WF, Hutcheson JC, Bechtold R, Dyer RB. Hanging bladder stone. Appl Radiol 2004;33:40-1.  Back to cited text no. 5
    
6.
D'Silva M, Gittes RF, Wolf P, Pirenne J, Munger K, Pascual J, et al. Rat kidney transplantation update with special reference to vesical calculi. Microsurgery 1990;11:169-76.  Back to cited text no. 6
    
7.
Norlén BJ, Hellström M, Nisa M, Robertson WG. Uric acid stone formation in a patient after kidney transplantation–metabolic and therapeutic considerations. Scand J Urol Nephrol 1995;29:335-7.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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