REVIEW ARTICLE

FOREIGN BODIES AND URINARY STONES

DAVID

L. DALTON,

JACK HUGHES, JAMES

M.D.

M.D.

F. GLENN,

M.D.

From the Division of Urology, Duke University Medical Center, Durham, North Carolina

ABSTRACT - Experimental and clinical aspects of calculogenesis about foreign bodies are reviewed. Factors such as infections, urine dilution, urinary pH, and suture materials are discussed from an investigative point of view. The various kinds of clinical foreign body stones reported are categorized according to the manner of introduction into the urinary tract and anatomic locations. ____

Review of urologic literature reveals a large number of extremely varied foreign bodies about which urinary stones have developed. The spectrum ranges from endogenous tissues as hair, calcified uterine fibromyomas, and gallstones to shell fragments, bullets, needles, catheter fragments, sutures, and others to be enumerated. Calculogenesis around such nidi is well documented and generally is regarded as an almost certain consequence. Anatomically, such stones have occurred in all portions of the urinary tract - kidney, ureters, bladder, urethra, and ileal conduit. Prior to discussing the clinical aspects offoreign body stones, a few comments regarding experimentally produced foreign body stones appear appropriate. Vermeulen et al. ’demonstrated that stones would form on suitable foreign bodies in the absence of infection or change of normal urinary pH. Foreign bodies included clay, lead, chalk, silk suture, zinc, paraffin, polythene, and porcelain. Metallic -nidi exhibited greatest propensity for stone formation. Analysis of stones revealed magnesium, ammonium, and phosphates primarily, with small amounts of calcium. The exact mechanism by which a foreign body produces a stone remains unknown. It may be that the surface of the foreign body serves as a point on which crystalloids precipitate; or the foreign body possibly changes the urine to an unstable solution.’ Urothelial reaction to the foreign body may also contribute to calculogenesis. 2

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Clinical Aspects Further experimental work centered on the influence of urine volume on foreign body stones3 Concentrations of magnesium and phosphorus were inversely related to urine volume. Chronic diuresis resulting in a fivefold increase in urine volume was found to prevent stone formation completely. Also demonstrated was consistent loss of weight in preformed stones during chronic diuresis. If man were to match this diuretic rate of laboratory rats, he would have to produce a urine volume greater than 15 L. a day. Important to emphasize is that infection with a urea-splitting organism always resulted in stone formation and/or an increase in stone size in spite of urine dilution to five times normal. 3 That infection is an important factor in the formation and growth of urinary stones appears to be clearly established.3-’ This is presumably due, at least in part, to the extreme alkalinity associated with such infections. It is of interest that infection of the urine with Salmonella enteritidis in the presence of foreign bodies inhibits stone formation without changing the urinary PH.~ The mechanism of this is unclear. The effect of urinary pH alone in the absence of infection has been studied.g Stone formation on sterile foreign bodies in animals whose diets were altered by the addition of sodium bicarbonate or ammonium chloride was negligible in the acidified group whose average urinary pH measured 5.7. Stone formation in the control and alkaline

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groups occurred without statistical significant difference. In another series of experiments relating to foreign bodies, Edwards, Garvey, and Boyce’ demonstrated that calcium phosphatemagnesium ammonium phosphate stones may be grown in dogs, but only if the foreign body is in contact with the urinary stream. Silk suture in bladder pouches separated from the urine did not form stones, while sutures in the bladder exposed to urine developed stones. Unrelated experiments have demonstrated that rough-surfaced foreign bodies give rise to more stones than do smooth foreign bodies.‘O Experimental urolithiasis on suture material should be considered since the incidence of postoperative stone recurrence is high (69 per cent in nephrolithotomy, 56 per cent in pyelolithotomy, 55 per cent in ureterolithotomy) according to one source. l1 Yudofsky and ScotP employed in vitro and in vivo experimental systems to observe and analyze stone formation on various suture material. Both nonabsorbable polyfilament (silk, Teflon-coated Dacron, mersilene, cotton) and absorbable gut-type sutures were shown to initiate and support urinary stones. Crystallization was initiated in or supported by crevices and imperfections on suture surfaces or fissures between surgical knots. Experimentally, 2-O chromic suture became covered with urinary stones before it could be absorbed by the tissues. A monofilament Teflon suture neither initiated nor supported urinary lithiasis as long as its surface remained intact. Others have documented that Teflon disks readily develop stones in the presence of a urea-splitting organism but not in sterile urine. 7 Similar experiments with Silastic or silicone rubber revealed formation of stones 30 per cent of the time in sterile urine and 100 per cent in infected urine.6 Recent studies at Duke University Medical Center with polyglycolic acid suture failed to show gross stone formation at thirty days in dog bladders. In considering clinically reported urinary stones which have developed on foreign bodies, categorization of the location and manner of introduction makes the subject easily comprehensible. That the bladder is by far the most common repository for foreign body stones is documented in the literature. The second most common site is the kidney followed in order by the urethra, ureter, and ileal conduits. Specific foreign body stones may be separated according to the manner of introduction into the urinary tract: iatrogenic, accidental, autoin-

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troduction, penetration from adjacent organs, and autogenous. Iatrogenic foreign body stones include those left at the time of surgery and/or introduced via the urethra. Accidental foreign body stones are known to develop during periods of a few months to years after war wounds, injuries, and other mishaps. The category of autointroduction encompasses an incredible assortment of articles about which stones have developed. These occur in both females and males of all ages and result from introduction during masturbation, intoxication, exploration of sex organs, and other autoerotic manipulations. Stones developing about foreign bodies which have perforated into the urinary tract include ingested articles and eroding pelvic tumors. Last, one must consider autogenous foreign body stones which have been noted about sloughed renal papillae, blood clots, and balls of inspissated pus. I3 Comment Urethral foreign body stones discovered posturethroplasty result from hair nidi. Less common foreign body stones of the urethra include those formed about a darning needle,14 rubber gum,15 black silk suture,16 part of a brass curtain ring,” and hair pin. ” Reported in British journals are slippery elm batk stones. ‘**lgApparently this bark enjoys the reputation as being an agent for inducing abortion. Urethral and bladder stones forming about this bark, which is inadvertently introduced into the urethra, are documented. Foreign body stones of the bladder which have been described comprise a very long and exhausting list. Some of the more commonly reported types are: Foley balloon fragments,20-22 silk suture.qz3rz4chewing gum,25-28 and hair pins. 13,2g-32 Other foreign body bladder stones include those forming about a steel washer,32 safety pin,33 condom,33 leather bootlace, soldering wire,34 “bee-cell” anticonceptional device,35 prostate chip,36 candles,32,37 a crayon3’ a pubic callus,3s ballpoint pen, 4o fountain pen41 a biliary calCU~US,~~ ureteral catheters,43 acupuncture needles,44 pearl button, 45 bullets and shell fragments,46,47 bougies, 24 filiform guides,24 piece of wood shaped like a carpenter’s penci1,48 drainage tubes,24 swabs,24 compresses,24 bamboo twigs,4g various types of sutures,24,2g*32,50handle of scissors,51 knife blade, 2g clothing particles,46 sewing needles,52,53 and sutures and curved needles.2g Hanging bladder stones formed on unabsorbable suture and floating bladder stones formed about candle wax are described. 54-56A huge stone larger

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than a goose egg formed about chewing gum rolled into the shape of a bougie has been removed from a sixteen-year-old white male who had introduced this gum three years earlier during masturbation. 27 Formation of a bladder stone about a penetrating calcified fibromyoma of the uterus occurred in a sixty-five-year-old female who noted a three-year history of frequency, nocturia, dysuria, urgency, pyuria, and hematuria. 57 Stones of the bladder have also occurred on penetrating ovarian dermoids and a primary vesical teratoma. 58,5g Ureteral foreign body stones are very sparsely reported. Two cases of stones developing about grenade fragments have been documented. 60,61 Other examples include apparent iatrogenic stones forming on a rubber piece,@ wire materia1,63 and silk suture.“4 Foreign body stones in the kidney and renal collecting system are not rare and have been seen in association with ureteral catheters,65,66 nephrostomy tubes, 65unabsorbable sutures as mersilene used in a pyeloplasty,67 biliary stone,68 shell splinters, 6g shrapnel, ‘O needle and granite fragment, ” silk ligature, ” bone fragment,” sewing needle,73 machine-gun bullet,74 and a hair pin. 75 Recently a fifty-y ear-old Chinese male underwent nephrectomy as treatment for a staghorn calculus. In its center was found a wire 20 mm. in length. Presumably this represented an acupuncture needle in this native Chinese.76 A five-year-old French female with a urinary infection was found to have right renal pelvis stone, the core of which was a hair pin. Detailed history revealed that she had swallowed this three years earlier. 75 Another interesting and similar problem was discovered in a fifty-seven-year-old Scotsman who presented with fever, pyuria, hematuria, and bloody stools. He was found to have a left renal calculus, suppurative pyelonephritis, and a renocolic fistula. The stone was described as large, white, and soft, and composed of magnesium ammonium phosphate, calcium carbonate, and calcium phosphate. In its center a fish bone was noted.70 Foreign body stones in an ileal urinary conduit were reported in 1969. 77 Three stones noted in the base of the conduit contained heavy silk sutures. It was reasoned that these three sutures had been used to secure the conduit to the retroperitoneal tissues. Also documented are stones formed around metal staples which were used to close the proximal end of the isolated ileum.78 To conclude, several points about the production of foreign body stones in laboratory animals

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should be emphasized: (1) stones will develop about suitable foreign bodies in the absence of infection; (2) chronic diuresis and urine dilution inhibit stone formation; (3) infection with ureasplitting organisms always results in and enhances stone formation; (4) urinary acidification inhibits stone formation on foreign bodies; (5) nearly all types of suture material presently in use have been demonstrated to support stone formation. Thus, prevention of suture exposure to the urinary stream appears prudent. From a clinical point of view, the anatomic locations, types, and manner of introduction of foreign bodies which subsequently developed stones have been emphasized. One should continue to be aware that no area of the urinary tract is spared from foreign body stone formation, and that iatrogenic foreign bodies lead to a significant proportion of such stones. Durham, North Carolina 27710 (DR. GLENN) References 1. VERMEULEN,C. W., et al. : Experimental urolithiasis. I. Development ofcalculi upon foreign bodies surgically introduced into bladders of rats, J. Urol. 64: 541(1950). 2. EDWARDS, C. N., GARVEY, F. K., and BOYCE, W. H.: Studies on urothelium. III. Experimental vesical stone formation in the dog, ibid. 89: 207 (1963). 3. GROVE, W. J., VERMEULEN, C. W., GOETZ, R., and RAGINS, H. D.: Experimental urolithiasis. II. The influence of urine volume upon calculi experimentally produced upon foreign bodies, ibid. 64: 549 (1950). 4. KING, J. S., and BOYCE, W. H.: In vitro production of simulated renal calculi, ibid. 89: 546 (1963). 5. AURORA, A. L., and GUPTA, D. N.: Experimental production of bladder calculi. IV. Foreign bodies in the bladder, Indian J. Med. Sci. 24: 140 (1969). 6. POYNTER, J. H., DEAN, C. M., and MILLER, G. M. : Effect of silastic in the bladder of the rat, J. Urol. 92: 653 (1964). 7. DEAN, C. M., and MILLER, G. M.: Effect of teflon in the urinary bladder of the rat, ibid. 88: 624 (1962). 8. VERMEULEN, C. W., HELSBY, C. R., and GOETZ, R. : Experimental urolithiasis. V. Prevention and dissolution of foreign body calculi by infection with Salmonella enteritidis, ibid. 68: 790 (1952). 9. VERMEULEN,C. W., RACINS,H. D., GROVE, W. J., and GOETZ, R. : Experimental urolithiasis. III. Prevention and dissolution of calculi by alteration of urinary pH, ibid. 66: 1 (1951). 10. BALL, J. K., FIELD, W. E. H., ROE, F. J. C., and WALTERS, M. : The carcinogenic and co-carcinogenic effects of pa&in wax pellets and glass beads in the mouse bladder, Br. J, Urol. 36: 225 (1964). 11. WILLIAMS, R. E.: Long-term survey of 538 patients with upper urinary tract stone, ibid. 35: 416 (1963). 12. YUDOFSKY, S. C., and SCOTT, F. B.: Urolithiasis on suture materials: its importance, pathogenesis and

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prophylaxis: an introduction to the monofilament teflon suture, J. Urol. 102: 745 (1969). 13. JoLY, J. S.: Stone and Calculous Disease of the Urinary Organs, St. Louis, C. V. Mosby Company, 1929, p. 415. 14. CAMPBELL, M. F. : Needles in the deep urethra; stone and periurethral abscess, Am. J. Surg. 21: 452 (1933). 15. HACKEL, W. : Fremdkorper als Ursache einer grossen Harnrohrenstein-und-divertikelbildung, Z. Urol. 61: 827 (1968). 16. FROMM, C. S.: Unusual primary urethral calculus: case report, Urol. Cutan. Rev. 51: 646 (1948). 17. JOLY, J. S.: Stone and Calculous Disease of the Urinary Organs, St. Louis, C. V. Mosby Company, 1929, p. 525. 18. WILLIAMS, B. : Two cases of slippery elm bladder calculus in pregnancy, J. Obstet. Gynaecol. Br. Commonw. 61: 499 (1954). 19. HOLMAN, C. C.: Unusual urethral calculus, Br. Med. J. 1: 1072(1935). 20. LOME, L. G., and NAVANI, S.: Foley calculus formation, Br. J. Radiol. 43: 487 (1970). 21. CHUTE, R.: Bladder calculi formed around retained fragments of ruptured Foley catheter balloons, J. Urol. 87: 355 (1962). 22. WEINGARTEN, C. J., and LAURAIN, A. R.: Foley catheter retained for 3 years, ibid. 94: 628 (1965). 23. ROBERTSON, J. P., and POSEY, L. C.: The formation of vesical calculi around a silk suture, Urol. Cutan. Rev. 44: 615 (1940). 24. JOLY, J. S.: Stone and Calculous Disease of the Urinary Organs, St. Louis, C. V. Mosby Company, 1929, p. 412. 25. MOORE, T.: Chewing-gum vesical calculus in the male, Br. J. Surg. 38: 103 (1950). 26. GIBSON, J. S.: Vesical calculus formed around chewing gum - a needle in rectum, Mil. Surgeon 66: 33 (1930). 27. MCKENZIE, J. A. : Huge bladder calculus with chewing gum core, J. Urol. 37: 280 (1937). 28. FISTER, G. M., and RUTLEDGE, G. D.: Chewing gum as the nucleus of a vesical calculus in the male, Urol. Cutan. Rev. 38: 118 (1934). J.A.M.A. 77: 1071 29. CRENSHAW, J. L.: Vesicalcalculus, (1921). 30. WALLER, J. I., and ADNEY, F.: Vesical calculi in young female children, Am. J. Dis. Child. 79: 684 (1950). 31. BANDLER, C. G.: Unusual foreign body with vesical calculus, Am. J. Surg. 7: 274 (1929). 32. CRISTOL, D. S., and GREENE, L. F.: Vesical calculi in women, Surg. Clin. North Am. 25: 987 (1945). 33. BADENOCH, A. W., and CAMPBELL, R. I.: Foreign bodies in the urinary bladder with a report of two cases, Br. J. Surg. 25: 133 (1937). 34. BRIDGES, J. P., and ANDERSON, J. B. : Foreign body of the bladder. Urol. Cutan. Rev. 48: 604 (1944). 35. FINTON, W. L.: “Bee-cell,” resulting in bladder stone and in vesicovaginal and rectovaginal fistulas, J.A. M.A. 89: 1057 (1927). 36. COLLICA, I. : New concepts of the pathogenesis of urinary lithiasis, Am. J. Surg. 76: 424 (1948). 37. SIMONS, E.: Zierkerze als Steinkern, Z. Urol. 54: 633 (1961). 38. MULVANEY, W. P.: Urinary calculi, Hosp. Med. 9: 50 (1973).

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PATOIR, G., LEMAIRE, G., and PATOIR, A.: Lithiase vesicale avec calcul developpi: sur cal pubien, J, Urol. Nephrol. (Paris) 78: 933 (1972). MICHAEL, D. : Kugelschreiber als Steinkern in der Blase, Z. Urol. 57: 669 (1964). BREWER, A. C., and MARCUS, R. : Foreign body in the urinary bladder: an unusual case, Br. J. Surg. 35: 324 (1948). ADRIAN, C. : Biliary calculi in bladder of woman, Bull. Sot. Franc. d’urol. 12: 386 (1933). HAGEMANN, D. : Ungewiihnliche Ursache einer Blasensteinbildung, Z. Urol. 51: 741 (1958). PATTERSON, N. G.: Calculus resulting from needling, Chinese M. J, 47: 401 (1933). CRANCE, A. M., and POLLACK, B.: Foreign bodies in the urinary bladder, Urol. Cutan. Rev. 36: 436 (1932). JOLY, J. S.: Stone and Calculous Disease of the Urinary Organs, St. Louis, C. V. Mosby Company, 1929, p. 413. ADAMEK, J.: Isolated injury with subsequent formation of calculus around retained shell fragment, Rozhl. Chir. 27: 58 (1948). MCCLINTON, J. B.: Large bladder stone in young female, Can. Med. Assoc. J. 49: 204 (1943). HIRAGA, Y.: Unusual foreign bodies: bamboo twigs penetrating during impalement trauma and forming nucleus of calculi: cases, Jap. J. Dermat. Urol. 40: 145 (1936). DOROSHOW, L. W., and CHERRY, J. M.: Urologic complications of the Into needle operation for urinary stress incontinence, Obstet. Gynecol. 39: 550 (1972). PAVONE-MACALUSO, M., and PIAZZA, B.: Ungewijhnliche Falle von Fremdkiirpern in der Harnblase mit sekundarer Steinbildung, Z. Urol. 60: 193 (1967). NAIL, M.: Un curieux cas de corps e’tranger de la vessie inclus dans un calcul, Presse Med. 42: 856 (1934). PHILIP, P. F.: Needle calculus in the male urinary bladder, Br. J. Urol. 27: 242 (1955). WESTON, B. : Hanging bladder stones, ibid. 29: 146 (1957). LEVACK, J. H.: Hanging bladder stones formed on unabsorbable suture and ligature, ibid. 27: 239 (1955). MILWARD, F. J.: Floating stone, ibid. 25: 162 (1953). WEINER, I., BURKE, L., and SHERMAN, J.: Vesical calculi originating from penetrating calcified fibromyoma of the uterus, J. Urol. 63: 625 (1950). DANDIA, S. D. : Rectovesical fistula following an ovarian dermoid with recurrent vesical calculus: a case report, ibid. 97: 85 (1967). LAZEBNIK, J., and KAMHI, D.: A case of vesical teratoma associated with vesical stones and diverticulum, ibid. 85: 796 (1961). BORM, D.: Ureterverlegung durch Granat-SplitterStein, Z. Urol. 52: 391 (1959). ARNONE, G. : Ureteral calculus from fragment of grenade, Cultura Med. Mod. 6: 495 (1927). ERDMANN, T. : Gummilasche als Ursache einer Harnsteinbildung im Ureter, Z. Urol. 58: 347 (1965). KASZTELAN, Z., and STENGERT, H.: Fremdkorperstein im Harnleiter, ibid. 63: 649 (1970). SILBER, S. J., and THORNBURY, J.: The fate of nonabsorbable intraureteral suture, J. Urol. 110: 40 (1973). FLOCKS, R. H., and CULP, D. A.: Renal urolithiasis, in Karafin, L., and Kendall, A. R., Eds.: Urology, Hagerstown, Maryland, Harper and Row, 1973, p. 5.

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66. PAIS, V. M., SPELLMAN, R. M., STILES, R. E., and MAHONEY, S. A. : Internal ureteral splints, Urology 5: 32 (1975). 67. LANGE, D. : Lithiase pyelique sur fil non r&sorbable, J. Urol. Nephrol. (Paris) 78: 558 (1972). 68. BADANO REPETTO, J. L.: Calculos b&ares en el aparato urinario; a proposito de una observation, Bol. Sot. cir. Uruguay 29: 70 (1958). 69. LATTEN, W. : Nierensteinentstenhung durch Kriegsverletzung, Z. Urol. 52: 17 (1959). 70. BOULTER, P. S., and GROV& S. S.: Renal calculus and perinephric suppuration due to a penetrating bone fragment, Br. J. Ural 29: 142 (1957). 71. SCHRBDER, A.: Seltene Fremdkorper in Neirenbecken und Ureter mit Steinbildung, Z. Ural. 51: 246 (1958). 72. PICATOSTE, J.: Recurrence ofcalculus on silk ligature; case, An. Casa de Salud Valdecilla 4: 147 (1933). 73. BLAINE, E. S.: An unusual foreign object in the kid-

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ney, Radiology 12: 207 (1929). 74. B~HM, L. : Formation of calculus around machine gun bullet in pelvis: case, Med. Welt. 8: 339 (1934). 75. BILGER, F., and GREINER, G.: Calcul du bassinet chez un enfant de cinq ans developpe autour d’une barrette ingeree vraisemblablement trois ans auparavant et ayant per fore le colon guerison aprts nephrectomie, J. Urol. Paris 55: 259 (1949). 76. KELLER, W. J., PARKER, S. G., and GARVIN, J. J. A. M.A. 222: P. : Renal complication of acupuncture, 1559 (1972). 77. HALVERSTADT, D. B., and FRALEY, E. E.: Perforation of ileal segment by calculi formed on nonabsorbable suture material: unusual complication of ileal conduit diversion, J. Urol. 102: 188 (1969). 78. ASSADN~A,A., LEE, C. N., PETRE, J. H., and LYONS, R. C. : Two cases of stone formation in ileal conduits after using staple gun for closure of proximal end of isolated loop, ihid. 108: 553 (1972).

Foreign bodies and urinary stones.

REVIEW ARTICLE FOREIGN BODIES AND URINARY STONES DAVID L. DALTON, JACK HUGHES, JAMES M.D. M.D. F. GLENN, M.D. From the Division of Urology, D...
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