Abstract
Giant bladder stones are an uncommon entity in modern urological practice that developed secondary to longstanding bladder outlet obstruction, chronic infection, or neurogenic dysfunction. A 37-year-old male presented with a long-standing history of lower urinary tract symptoms. A non-contrast computed tomography scan revealed a giant intravesical calculus. The patient underwent open cystolithotomy and the stone weighing 1200 g was successfully extracted. The postoperative course was uneventful with a full recovery after 1 month. Comprehensive evaluation with laboratory testing, imaging, and cystoscopy is essential for accurate assessment and operative planning of giant bladder stones. Management should be individualized. Open vesicolithotomy remains a dependable and definitive approach, especially when complete clearance in a single session is required or endoscopic resources are limited. While minimally invasive techniques represent the standard for most bladder stone patients, vesicolithotomy remains an indispensable option in the armamentarium of giant bladder stone management.
Introduction
Urinary bladder calculi are an uncommon form of urolithiasis, accounting for ~5% of urinary tract stones, and are more frequently observed in adults with underlying lower urinary tract dysfunction [1, 2]. According to European Association of Urology guidelines, bladder outlet obstruction is one of the most important etiological factors in adult bladder stone formation, as secondary formation of bladder stone [2]. Additional risk factors, including prior pelvic radiotherapy, reconstructive bladder surgery, urethral stricture disease, schistosomiasis, and anatomical abnormalities such as bladder diverticula, all of which predispose patients to stone formation by altering normal urinary dynamics [2]. We report a rare case of a giant vesical calculus managed surgically at our institution. Giant bladder stones are infrequently encountered in modern urological practice, and their management remains challenging due to associated comorbidities and stone burden. To our knowledge, the largest bladder stone documented in Indonesia was in Maluku by Salim et al. [3]. This report describes the largest bladder stone documented in Indonesia to date, offering a rare clinical presentation that highlights persistent gaps in early detection, access to urologic care, and disease progression in resource-variable settings. This case report has been prepared in accordance with the SCARE guidelines to ensure standardized and transparent reporting [4].
Case report
A 37-year-old male presented with a long-standing history of lower urinary tract symptoms, including severe dysuria, urinary urgency, increased frequency, and suprapubic discomfort, which had progressively developed over approximately 10 years. During the early course of his illness, the patient self-medicated with over-the-counter remedies, resulting in intermittent symptom relief and postponement of formal medical evaluation. Over the past few months, however, his symptoms markedly intensified, and conservative measures no longer provided benefit, leading him to seek hospital care.
On physical examination, a firm, palpable mass was noted in the suprapubic region. Laboratory investigations were largely unremarkable, with a mildly elevated serum creatinine level of 1.32 mg/dl (reference range: 0.67–1.17 mg/dl). Urinalysis showed no evidence of active infection. A non-contrast computed tomography (CT) scan of the kidneys, ureters, and bladder revealed a giant intravesical calculus measuring 13.4 × 10.6 × 10.4 cm with a density of ~1131 Hounsfield units (Fig. 1).
Non-contrast urography CT showing large vesical calculus (13.4 × 10.6 × 10.4 cm).
The patient subsequently underwent open cystolithotomy via a midline incision. A single large bladder stone weighing ~1200 g was successfully extracted (Fig. 2). The postoperative course was uneventful. A surgical drain was placed intraoperatively and removed after 2 days with a minimal output. The patient was discharged on postoperative Day three, with the urethral catheter maintained for a total duration of 14 days. Stone composition analysis could not be performed due to resource limitations. At the 1-month follow-up visit, the patient was clinically well and had achieved complete functional recovery. He was able to void spontaneously without difficulty and reported no residual lower urinary tract symptoms. There were no complaints of urinary incontinence, hesitancy, or obstructive voiding.
Large bladder stone weighing 1200 g.
Discussion
Bladder stone disease represents a distinct subset of urolithiasis with marked geographic variation, remaining disproportionately prevalent in parts of Asia compared with Western countries. Epidemiological studies indicate that while the Asia prevalence of urinary stone disease ranges from 1% to 15%. Urinary stones account for a higher proportion of cases in South and Southeast Asia, including Indonesia, particularly in rural and low-resource settings [5]. Historically, endemic vesical calculi in children have been reported in Indonesia and neighboring countries, largely linked to malnutrition and chronic dehydration, whereas contemporary adult cases are more frequently secondary in nature as a consequence of bladder outlet obstruction [2, 6].
Giant bladder stone are most often the consequence of prolonged, neglected and untreated lower urinary tract symptoms. In addition to patient-related delays, limited access to adequate healthcare services can substantially contribute to disease progression and late presentation [2, 7]. These stones usually enlarge gradually over many years and commonly manifest with lower urinary tract symptoms such as dysuria, urinary urgency, increased frequency, suprapubic discomfort, and, in some cases, hematuria. Although giant bladder stones are most frequently encountered as single formations, multiple calculi have been reported in ~25%–30% of cases [7].
Urinalysis and urine culture are essential to identify hematuria and coexisting infection, while ultrasonography provides a readily available and non-invasive initial diagnostic modality, particularly in children and resource-limited settings [2, 8]. Plain kidney–ureter–bladder radiography can detect radiopaque stones, whereas non-contrast computed tomography offers the highest sensitivity and specificity and is valuable for pre-operative planning [8, 9]. Cystoscopy remains the definitive diagnostic tool, allowing direct visualization and simultaneous intervention when indicated [2, 10].
The management of bladder stones has evolved substantially over recent decades, shifting from predominantly open surgical approaches toward minimally invasive endoscopic techniques as first-line therapy in most patients [2]. Current treatment selection is primarily determined by stone size, stone burden, patient anatomy, availability of expertise, and the presence of underlying etiological factors such as bladder outlet obstruction or infection [11]. As a result, transurethral cystolitholapaxy, percutaneous cystolithotripsy, extracorporeal shock wave lithotripsy, and open vesicolithotomy are all established modalities, each with distinct advantages and limitations [11].
Open vesicolithotomy remains a highly effective and definitive treatment option for large or giant bladder stones, particularly when stone size exceeds the practical limits of endoscopic fragmentation [7, 11]. The principal advantage of vesicolithotomy lies in its ability to achieve complete stone removal in a single procedure, independent of stone hardness or volume, thereby minimizing operative time and the risk of residual fragments [12]. This approach is especially valuable in resource-limited settings or in patients with concomitant pathology requiring open correction, such as large bladder diverticula or complex bladder outlet obstruction. Although open surgery is associated with longer hospitalization and convalescence, its high stone-free rates and procedural reliability justify its continued role in selected cases involving massive stone burden [11, 13].
Conclusion
While minimally invasive techniques represent the standard for most bladder stone patients, vesicolithotomy remains an indispensable option in the armamentarium of giant bladder stone management, particularly for large and complex stones where endoscopic methods may be suboptimal.
Conflicts of interest
None declared.
Funding
None declared.
