Giant Vesical Calculus with Adenocarcinoma of the Bladder: A Rare Association

Abstract

Background: A giant vesical calculus is one weighing >100 g. A long-standing vesical calculus can be associated with squamous cell carcinoma of bladder.

Case Presentation: In this study, we report an unusual association of giant vesical calculus (weight 570 g) with adenocarcinoma of urinary bladder in a young man. We could find only two such cases in the literature.

Conclusion: Rarity of the association of giant vesical calculus and adenocarcinoma of the bladder and their management issues warrant this presentation.

Introduction and Background

Bladder calculi account for 5% of urinary calculi. Bladder stones >100 g come under the category of giant vesical calculus. In India, the largest vesical calculus reported to date is of 743 g. A vesical calculus can be found with squamous cell carcinoma of urinary bladder. In this study, we report a unique case of giant vesical calculus (weight 570 g) found with adenocarcinoma bladder in a young man. We found two such cases reported earlier.

Presentation of Case

A 27-year-old unmarried male farmer presented to us with dysuria, poor urinary stream from past 3 months. He had no history of ureteral colic, lithuria, hematuria, urinary incontinence, recurrent urinary tract infections, catheterization or urologic instrumentation, bleeding per rectum, or altered bowel habits. We found a firm nontender lump in hypogastric area on abdominal examination. Digital rectal examination revealed induration just above the prostate. On investigations, hemoglobin was 11.4 g/dL. Renal function test, serum uric acid, and chest X-ray were normal. With a provisional diagnosis of bladder stone, plain kidney, ureter, and bladder radiograph showed a huge radio-opaque shadow in the pelvis (Fig. 1).

FIG. 1.

Kidney, ureter, and bladder radiograph revealing a huge laminated vesical calculus.

Abdominal ultrasonography confirmed finding the large solitary vesical calculus with evidence of bilateral moderate hydroureteronephrosis. Intravenous pyelogram revealed bilateral hydroureteronephrosis with normal excreting kidneys. Preoperative cystoscopy showed the normal urethra and large bladder stone precluding proper observation of the bladder. We did suprapubic cystolithotomy by open approach. A 10 × 8 × 4 cm hard calculus adherent to bladder mucosa was removed (Fig. 2).

FIG. 2.

Extracted specimen of stone with weight 570 g.

A 2 × 3 cm polypoidal mass was arising from right posterolateral wall of bladder, which was excised. Histopathology report confirmed moderately differentiated adenocarcinoma without involvement of muscularis propria (Fig. 3). Stone was of mixed type containing magnesium ammonium phosphate hexahydrate, calcium oxalate monohydrate, and xanthine (Fourier transform infrared spectroscopy method). He was counseled regarding radical cystectomy, but he denied. Later CT scan revealed no mass in the abdomen. Patient was evaluated for other primary sites of adenocarcinoma by carcinoembryonic antigen test, upper and lower gastrointestinal endoscopy, and prostate-specific antigen tests, which came out to be within normal limits. At follow-up cystoscopy at 1 month we resected the scar tissue that showed no malignancy. Patient is alive at 18 months without any recurrence with regular follow-up visits.

FIG. 3.

Adenocarcinoma with glandular pattern, stratification, pleomorphism, hyperchromatic nuclei (vertical arrow), and invasion into stroma (horizontal arrow) suggestive of moderately differentiated adenocarcinoma.

Discussion and Literature Review

Bladder stones vary in size, shape, and numbers. Till now, the largest urinary bladder stone weighing 6294 g was reported in a bladder diverticulum in 1953. They are much less common in women as compared with men (about 95%) because of the lower incidence of urinary obstruction in women.

Giant bladder calculi are commonly associated with bladder outlet obstruction, benign prostatic hyperplasia, bladder diverticulum and urethral strictures in men, or genital prolapse in women. Prolonged catheterization, chronic and recurrent urinary tract infection, neurogenic bladder, and foreign body are other causes. It is thought that a giant vesical calculus develops because of progressive layer-wise deposition of calcified matrix over either a single renal and ureteral calculus or over the nidus of the infected material. Infections may play a major role in stone crystallization but may not be the initiating factor in its formation.

Geography and ethnicity contributes to the variation in the composition of stones. Magnesium ammonium phosphate hexahydrate in outer core, calcium oxalate monohydrate in middle, and xanthine in inner core formed most of the composition of the laminated bladder stone in our patient. Giant vesical calculi are mainly of mixed composition. They are rarely asymptomatic at the time of discovery. The most common presentations of giant vesical calculus are recurrent urinary tract infection, hematuria generally terminal and retention of urine. Such patients may also present with frequency, intermittency, urgency, dysuria, decreased force of the urinary stream, incontinence, and lower abdominal pain aggravated by brisk movement. Complications may include bilateral hydronephrosis, sepsis, acute renal failure, and rarely perforation. In our patient probably poverty, illiteracy, and negligence lead to delay in the diagnosis and large vesical calculus.

Adenocarcinoma of the urinary bladder contributes only for 0.5% to 2.0% of malignant bladder tumors. They can be primary or caused by metastasis from other organs especially colon, prostate, endometrium, cervix, stomach, appendix, lung, or breast. They can also be classified under urachal or nonurachal. Its association with exstrophy bladder and schistosomiasis are well known. In this case there were no symptoms suggestive of its distant origin and gastrointestinal endoscopies were normal.

Gupta et al. found a concomitant adenocarcinoma of bladder contrary to squamous cell carcinoma of bladder with calculus.¹ This association was also reported by Tanaka et al. in a 83-year-old man with history of gross hematuria.² Bladder tumor was diagnosed by cystoscopy and calculus and tumor were removed transurethrally. In contrast, our patient of young age complained of only dysuria without hematuria. Kumar et al. reported a case of incidentally detected primary signet ring cell adenocarcinoma of the bladder with vesical calculi during cystolithotomy as in our case.³ Fein et al. found an unusual case of bladder calculi enveloped by cystitis glandularis.⁴ As our patient was young, nonsmoker, and without any positive family history of malignancy, we speculate that chronic inflammation by large bladder stone caused glandular metaplasia and adenocarcinoma. It was intraoperative surprise as preoperative ultrasonography could not detect it. Large stone size precluded proper cystoscopy. Preoperative CT scan could have detected the mass but was not indicated.

In case of preoperative diagnosis of coexistent pathology, endoscopic management would be the treatment of choice. Even bladder stones ≥5 cm have been effectively treated with holmium laser. Most of the adenocarcinoma bladder at presentation have muscle invasion. Similar to other variants radical cystectomy would have been the preferred first-line treatment.

Conclusion

Bladder adenocarcinoma is rarely associated with calculus disease. We could search only two such case reports. Preoperative cystoscopy or CT abdomen may help in the diagnosis of hidden bladder malignancy associated with large vesical calculus. This dual pathology should be managed endoscopically. Radical cystectomy is the preferred mode of management for adenocarcinoma of bladder.

Patient's Consent

We took written informed consent from patient.

Abbreviation Used

CT

computed tomography

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Kumar L, Arya MC (2020) Giant vesical calculus with adenocarcinoma of the bladder: a rare association, Journal of Endourology Case Reports 6:2, 83–85, DOI: 10.1089/cren.2019.0140.