International Journal of Surgery Case Reports 114 (2024) 109136

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International Journal of Surgery Case Reports

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Case report

Treatment of giant prostatic urethral stone with prostatolithotomy

case report
Yunus Erol Bozkurt a, *, Caner Buğra Akdeniz b, Bilali Habeş Gümüş c
a
Manisa Merkez Efendi State Hospital, Department of Urology, Manisa, Turkey
b
İzmir Foça State Hospital, Department of Urology, İzmir, Turkey
c
Manisa Celal Bayar University Faculty of Medicine, Department of Urology, Manisa, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The patient with prostatic urethral stones of the size mentioned in the case report is very rare, and
Urethral stone there is no standard surgical procedure for patients with giant stones in the prostatic urethra.
Giant stone Presentation of case: A 62-year-old male patient presented to the emergency department with complaints of
Prostate
dysuria and hematuria. Computed tomography showed a prostatic urethral stone measuring 78x48x56 mm.
Case report
Open prostatolithotomy was performed by extending the bladder incision towards the prostate capsule and the
stone was removed.
Discussion: Prostate stones can be classified into two types: true prostate stones, which form within the prostate's
tissues, and urethral stones, which develop in the prostatic urethra. Urethral stones can be primary (forming in
the urethra) or secondary (migrating from the upper urinary tract).
Conclusion: Treatment options vary based on stone size and patient history, with endoscopy recommended as the
primary approach. However, in cases with large stone burdens, open surgical methods may be preferred.

1. Introduction 2. Presentation of case

Giant calculi in the prostatic cavity are uncommon, the diversity
being those associated with chronic calculus prostatitis or small multiple
calculi. Prostatic parenchymal calculi are usually incidental findings on
computed tomography. They are asymptomatic and may be associated
with benign prostatic hyperplasia and prostate cancer [1] Male urethral
calculi is a rare clinical condition and is more common in Middle and Far
Eastern societies, depending on socio-economic status and dietary
habits. Most of these stones migrate from the bladder and upper urinary
tract. In the literature, stone sizes ranged from 10 to 60 mm in a case
series of 26 patients. [2] Various methods are used to treat urethral
stones. In the case series of 14 patients, urethroplasty was performed in 5
cases, surgical removal of the stone in 3 cases, retrograde manipulation
inside the bladder in 4 cases and electrohydraulic endourethral litho­
tripsy in 2 cases. [3] The global prevalence of urolithiasis and the ex­
istence of rare forms/types of urolithiasis in other parts of the urinary
tract, in addition to the typical renal or ureteral occurrence, must not be
forgotten. [11] We believe that this case report will guide the manage­
ment of giant prostatic urethral stones.
A 62-year-old male patient with no history of urological instru­
mentation or surgery was admitted to the emergency department with
only complaints of dysuria and hematuria, but he had no history of
fever, medication use for benign prostatic hyperplasia (BPH), acute
urinary retention or urinary outflow obstruction. The patient had no
family history of stones or prostate cancer. PSA measured 0.52 ng/ml.
Since he had a history of stone expulsion about 20 years ago, plain
abdominal radiography was performed first and then computed tomo­
graphic imaging was performed. As a result of imaging, a 78 × 48 × 56
mm prostatic urethral stone was detected (Fig. 1), but no dilatation in
the upper urinary tract was observed (Fig. 2). On physical examination,
the stone could be palpated in the perineal region, but no fistula tract
was seen on the skin in this area. A prostatolithotomy was planned for
the patient who was unable to undergo urethral catheterisation. An
approximately 8 cm suprapubic sagittal incision (midline incision) was
made and an open prostatolithotomy was initially performed. After
coagulation and transection of some of the dorsal veins on the prostate
capsule, the bladder incision was extended approximately 4 cm from the
prostate capsule. Adhesions of the visualised stone to the prostate tissue

* Corresponding author at: Department of Medicine, Section of Urology, Manisa Merkez Efendi State Hospital, 45030 Yunusemre, Manisa, Turkey.
E-mail address: yunusbozkurt88@hotmail.com (Y.E. Bozkurt).

https://doi.org/10.1016/j.ijscr.2023.109136
Received 13 November 2023; Received in revised form 3 December 2023; Accepted 5 December 2023
Available online 20 December 2023
2210-2612/© 2023 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
Y.E. Bozkurt et al.
were separated bimanually. The stone, grasped with an ovarian clamp,
was removed from the prostatic urethra using perineal pressure and the
bladder neck was sutured with 1–0 Vicryl. The extracted stone weighed
154 g (Fig. 3). A 22 French 3-way urethral catheter was placed in the
bladder, bleeding was controlled and finally a drainage catheter was
placed but no suprapubic catheter was used. There were no complica­
tions during or after the patient's 3-day hospital stay. Stone analysis
could not be performed because the patient's health insurance did not
cover it. Patient gave informed consent for publication. Our case was
presented in line with SCARE guidelines [10].
3. Discussion
There are two types of prostate stones: true prostate stones and
urethral stones. True prostate stones are those that develop in the acini
or tissues of the prostate and should not be confused with urethral stones
that develop in the prostatic urethra. Similarly, a stone in a diverticulum
Fig. 1. Preoperative tomographic imaging.
2
International Journal of Surgery Case Reports 114 (2024) 109136
or an abscess associated with the urethra should not be considered a true
prostate stone. Urethral stones are divided into primary and secondary:
primary stones are those that form de novo in the urethra, and secondary
stones are those that form in the upper urinary tract and migrate
downwards. According to the history of our patient, the stone fits the
definition of a secondary urethral stone [4]. The most common site of
urethral stone is the posterior urethra. Although endoscopic treatment is
recommended as the primary treatment in the literature, we preferred
the open surgical method due to the high stone burden and prolonged
operation time [5] Patients who remain asymptomatic for many years
despite increased stone burden become rare cases when recognised in
the late period, and whether to use the standard surgical procedure
depends on the surgeon's experience [6]. A case report by Krystian
Kaczmarek et al. presented a patient with a history of urethral surgery, a
7 cm prostatic urethral stone formed a perineal fistula, so the stone was
treated by perineal incision [7]. Similarly, in the case report by Mustafa
Kaplan et al., the stone was removed by perineal incision due to a
Y.E. Bozkurt et al. International Journal of Surgery Case Reports 114 (2024) 109136

urethrocutaneous fistula in a patient undergoing secondary catheter­ Informed consent for publication
isation for spinal cord trauma [8].
Imaging and pathology of the male urethra is uncommon, but urol­ All authors have permission.
ogists make extensive use of endoscopic imaging. Computed tomogra­
phy should not be neglected in patients with lower urinary tract Ethical approval
symptoms, a history of urinary stones, and a history of previous urinary
surgery [9]. The patient's informed consent to participate was obtained for the
case presentation. However, ethics committee approval was not
4. Conclusion obtained.

This case report highlights the successful management of a rare case Funding
of giant prostatic urethral stone through open surgical intervention,
demonstrating the importance of considering stone burden and indi­ None.
vidual patient characteristics when deciding on the surgical approach.
Author contribution

YEB: Conceptualization, Data curation, Resources, Supervision,

Fig. 2. Preoperative tomographic imaging.

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Y.E. Bozkurt et al. International Journal of Surgery Case Reports 114 (2024) 109136

Fig. 3. Post-operative view of prostatic urethral stone.

Validation, Visualization, Roles/Writing - original draft, and Writing - published article [and its supplementary information files].
review & editing.
CBA: Investigation, Methodology. References
BHG: Formal analysis, Project administration.
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