INTRAVESICAL AND INTRAVAGINAL STONE FORMATION SEVERAL YEARS AFTER

HYSTERECTOMY : A CASE REPORT

Ahmad Agila, Aninditho Dimas Kurniawana

a
Urology Department, Hasan Sadikin Hospital, Universitas Padjajaran Bandung, Indonesia

ABSTRACT

Introduction: In developing counties, Vesico-vaginal fistula (VVF) results following obstetric

trauma or iatrgenic post-surgical hysterectomy. Large calculus is associated with VVF is relatively
rare, with the risk factor are presence of foreign body, urinary tract infection, and pronged duration of
disease. Most bladder stones can be found among patients who are bedridden, use urethral catheter,
bladder outlet obstruction, infection, and other similar characteristic. Stone formation can also be
precipitated due to suture material within the bladder cavity. We report a case intravesical and
intravaginal stone formation in 37 year old woman.
Case Presentation: A 37-year-old, gravida 2, para 2 woman with history of hysterectomy
occurs three years ago. Intermittent small amounts of watery vaginal discharge developed 1,5 years
after the operation. She sought medical aid for these symptoms at the gynecological department, but
without resolution A physical examination revealed mild tenderness over the suprapubic area and no
evidence of uterine prolapse. Urinalysis showed 15 – 18 white blood cells per high power field, and
positive Trichomonas in the urine. Cystography computed tomography scan with contras confirmed a
fistula vesicovagina which connect posterosuperior wall of vesicaurinaria with anterosuperior wall of
vagina with vesicolithiasis, size 15 x 26 x 14mm and two vaginal stone with size of 7x12x17mm and
4x4x5mm. A grayish stone was identified supratrigon with size of 30x12mm. Two vaginal stone were
also identified alongside with size of 20x 8mm and 4x4mm, both were grayish.
Conclusion: A hanging intravesical calculus on the trigone of the urinary bladder is rare. It
usually hints that the bladder stone encrusts sutures or devices. The complication can be prevented by
the routine use of absorbable material in sutures outside the urinary bladder, no use of any suture
through the urinary bladder and cystoscopic double checking.

Keywords: Vesicolithiasis, Suture, Hanging calculous, Vesico-vaginal fistula

INTRODUCTION

In developing countries, Vesico-vaginal fistula (VVF) results following obstetric trauma or

iatrogenic post-surgical hysterectomy. 1 Large calculus is associated with VVF is relatively rare, with

the risk factor are presence of foreign body, urinary tract infection, and prolonged duration of disease. 2

In about 7% of VVF case we can identify stone radiologically. 3 Most bladder stones can be found
among patients who are bedridden, use urethral catheter, bladder outlet obstruction, infection, and
other similar characteristic. 4 Several investigator have reported that intrauterine contraceptive device

migrate through the wall of urinary bladder and the serve as a nidus of intravesical stone formation. 5, 6

Stone formation can also be precipitated due to suture material within the bladder cavity. 7 We report a
case intravesical and intravaginal stone formation in 37 year old woman.

CASE PRESENTATION

A 37-year-old, gravida 2, para 2 woman was referred to our urogynecology clinic because of
long standing dysuria, urinary frequency and urgency for the previous 1 years, with unsuccessful
antibiotic drug treatment. She had had an abdominal hysterectomy due to uterine adhesive during her
2ndchild delivery, which cause tonus become weak, occurs three years ago. Intermittent small amounts
of watery vaginal discharge developed 1,5 years after the operation. She sought medical aid for these
symptoms at the gynecological department, but without resolution

Clinical examination shows the patient is fully conscious. Vital signs 120/70mmHg, pulse
78x/min, respiration 21x/min, temperature 37 oC, not anemic conjunctiva and sclera no jaundice. On
the patient’s chest, the shape and motion are symmetrical, the right vesicular sound is the same as the
left, there are no rhonchi and there is no wheezing. The patient's abdomen was normal. A physical
examination revealed mild tenderness over the suprapubic area and no evidence of uterine prolapse.
 Laboratory test results demonstrated Hb14.2g/dl, white blood counts of 6600/µL, ureum of
23,9mg/dL, blood creatinine of 0,73 mg/dL. Urinalysis showed 15 – 18 white blood cells per high
power field, and positive Trichomonas in the urine.

Cystography computed tomography scan with contras done in Cahya Kawaluyan Hospital,
04-12-2019, confirmed a vesicovaginal fistula which connect posterosuperior wall of vesicaurinaria
with anterosuperior wall of vagina with vesicolithiasis, size 15 x 26 x 14mm and two vaginal stone
with size of 7x12x17mm and 4x4x5mm (Fig 1).

Figure 1. Cystography CT Scan with contrast, Cahya Kawaluyan Hospital, 04-12-2019

After a careful discussion about the treatment, we are planned to do three step surgeries. First
step is Cystoscopy which revealed vesicovaginal fistula (Fig 2).
 Figure 2. vesicovaginal fistula during cystoscopy

Next step, after careful discussion about further planning, the patient opted open vaginal identification.
In this operation, the intravaginal which adherence with the fistula site was dissected (Fig 3).

Figure 3. Vaginal identification

Final step was transvesical approach to identify the stones and release them. A grayish stone was
identified supratrigon with size of 30x12mm. Two vaginal stone were also identified alongside with
size of 20x 8mm and 4x4mm, both were grayish (Fig 4).
 Figure 4 Vesical stone and vaginal stones

DISCUSSION
Vesico-vaginal fistula can be resulted following obstetric trauma or post-surgical. 1, 8 Risk for
calculous formation in VVF are presence of foreign body, urinary tract infection, and prolonged
duration of disease.2 The stone were found about 7% of VF case evaluated radiologically. 3 Study

conducted byBouya et al implies 7 cases of VVF with large stone disease among 89 patient. 9 Six of

which developed following caesarean sections and seven were following obstructed labour. 10
 A hanging intravesical stone on the dome of urinary bladder is rare. Theoretically children
have a potential risk of intravesical stone formation in adult life if they undergo reconstructive
procedure such as exstrophy repair. The incidence of intrauterine device migrating to adjacent organ is
between 1 – 3%. Synthetic and non-absorbable suture material were encrusted by bladder stone. The
underlying mechanism would be that the suture penetrated through the dome of urinary and then
caused the deposition of calcium salts. 8 Some urological and non-urological surgeries with proximity
to bladder have been reported to have such a complication. Non-urologocal surgeries are mostly
incontinence surgeries including Marshall-Marchetti-Krantz operation, Burch colposuspension,
laparoscopic colposuspension, and an even tension free vaginal tape procedure which mostly use non-
absorbable material.7
Animal studies have well depicted that the most important property of suture material leading
to bladder stone formation is their non-absorbability. 11 Either the technique or replacement of suture

material into the bladder cavity is the reason of iatrogenic suture within the bladder. 7, 8, 12 The suture
material can act as a nidus for aggregation of crystal and form stone around it, which reported in some
urological and non-urological surgery with proximity to bladder. 7
A patient with an intravesical stone usually presents with lower urinary tract symptom such as
pain, urgency, and or intermittency on voiding. 13 Abdominal radiography may reveal intravesical

stone, along with ultrasound evaluation. 7 Vesical stone usually accumulate in the bottom of the
urinary bladder because of gravitation. A hanging intravesical stone supratrigon is rare. It implies that
the patient has undergone procedure in the neighborhood region such as hysterectomy or placement of
intrauterine device. 8
Intravesical stone formation induced by surgical procedures outside the urinary bladder seems
to be rare.2 Though the complocation can be prevented by taking several steps. First use exclusive

absorbable suture material such as poliglecaprine polyglactin, and polydiaxonone. 14 Next is carefully
avoid needle and suture through the whole layer of urinary bladder. Last is the use of cystoscopy to
check the urinary bladder. 8

CONCLUSION
A hanging intravesical calculus on the trigone of the urinary bladder is rare. It usually hints
that the bladder stone encrusts sutures or devices. The complication can be prevented by the routine
use of absorbable material in sutures outside the urinary bladder, no use of any suture through the
urinary bladder and cystoscopic double checking.
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