Prostatic Cave Stones Post-Cystolitholapaxy with TURP. A Rare Complication

Prostatic Cave Stones Post-Cystolitholapaxy with TURP. A Rare Complication | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Prostatic Cave Stones Post-Cystolitholapaxy with TURP. A Rare Complication Seham Madaka, Ward Basalat, Layth Al-Karaja, Laith Nassar, Khaled Alhashash, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4663816/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Prostatic cave stones, also known as prostatic utricular stones, are exceedingly rare complications following transurethral resection of the prostate (TURP) and cystolitholapaxy. These stones form within the prostatic utricle, a remnant of the Mullerian duct within the prostate gland. While TURP and cystolitholapaxy are common procedures for the management of benign prostatic hyperplasia (BPH) and bladder stones respectively, the occurrence of post-procedure prostatic cave stones is uncommon and not well documented in the literature. We report the rare development of prostatic cave stones following a combined cystolitholapaxy and transurethral resection of the prostate (TURP) procedure. Case presentation: a 55-year-old male patient with a history of recurrent kidney stones, urinary symptoms, and multiple different surgical interventions. He developed urinary bladder stones which required cystolitholapaxy and during the procedure partial prostate resection was performed via transurethral resection of the prostate (TURP) due to enlargement. As a result of this combined surgical procedure prostatic cave stones were formed. Conclusion Rare complications, such as prostatic cave stones, may occur post-urologic operatives, which require clinicians’ attention and consideration. This highlights the importance of recognizing and managing rare complications to ensure optimal patient care. Prostatic cave stones Prostatic utricle TURP Cystolitholapaxy Figures Figure 1 Background Prostatic cave stones, also known as prostatic utricular stones, are rare complications of transurethral resection of the prostate (TURP) and cystolitholapaxy. 3 There are 150,000 TURP procedures performed annually in the United States, as it remains the gold standard surgical treatment for benign prostatic hyperplasia (BPH). 2 Except for a few bleeding cases, urinary tract infections, and less commonly, prostatic cave stones; TURP is generally safe and effective. 1 The literature is not well-documented regarding the incidences of prostatic cave stones after TURP. However, urinary tract stones are common in BPH patients, which indicates TURP. 4 Cystolitholapaxy is often done with a concurrent TURP in patients with both BPH and bladder calculi. This has been found to result in good symptom improvement and prevention of stone recurrence. 5 It may however increase other risks like the formation of prostatic cave stones. After TURP and cystolithopaxy, the etiology of prostatic cave stones is not fully understood. A possible explanation is that remnants of stones from cystolithopaxy can find their way into the prostatic fossa created after TURP where they become niduses for stone formation. On the other hand, changes in urinary flow post-TURP may cause stone formation in its cavity. 3 , 6 The diagnosis of prostatic cave stones is difficult because it often mimics symptoms of other post-TURP complications or recurrent BPH. 3 Transrectal ultrasonography, KUB X-rays and CT scans are examples of imaging techniques used to identify these stones. However as illustrated by our case, early radiology examinations do not always provide any indication for the presence of such stones thus requiring a high degree of clinical suspicion and continued follow up. Prostatic cave stones are usually managed through endoscopic removal which may involve use of laser lithotripsy or pneumatic lithotripters. Prevention approaches such as adequate irrigation with an Ellik evacuator during initial procedure were also proposed to decrease risk for stone formation. 7 , 8 This case report underscores the significance of prostatic cave stones as a rare yet important complication following combined TURP and cystolitholapaxy procedures. It is on this background that we present this case study as a contribution to limited literature on this topic and emphasizing the need for precise post-operative follow-up and monitoring of patients undergoing these procedures. Case presentation A 55-year-old male with a history of recurrent renal stones and flank pain underwent many interventions, including percutaneous nephrolithotomy (PCNL) and lithotripsy, between 2007 and 2015. In 2022, he presented with recurrent urinary tract infections (UTIs), dysuria, and frequency voiding symptoms. Imaging test results revealed urinary tract stones. In 2023, the patient underwent cystolitholapaxy, during which an enlarged prostate was incidentally discovered. Given the presence of coexisting prostatic enlargement and the risk of recurrent calculi, a simultaneous transurethral resection of the prostate (TURP) was performed. Postoperatively, the patient experienced recurrent urinary retention, necessitating a suprapubic catheter due to failed transurethral catheterization attempts. An abdominal and pelvic ultrasound in May 2023 revealed an enlarged left kidney with ballooning dilation of the calyceal cysts and decreased cortical thickness, indicating moderate to severe hydronephrosis, along with multiple stones up to 1.6 cm in the lower pole. There was no perinephric edema or collection. The right kidney was normal, with no hydronephrosis. The urinary bladder was normal in shape but had diffuse wall thickening up to 6 mm and focal nodular thickening at the base, measuring approximately 5 x 7 mm near the prostate, which required follow-up. The prostate had a normal size and echo pattern. During the cystoscopic procedure, the prostatic urethra was successfully traversed by the scope without encountering any complications. The examination revealed the presence of bladder neck fibrosis, but no stenosis or abnormalities were observed at the level of the prostatic urethra. To address the fibrosis, an incision and dilation procedure were performed. However, following the operation, the patient experienced recurring visits to the emergency room due to symptoms of urinary retention and dysuria. This prompted the need for further paraclinical examinations, which included a KUB X-ray and a CT scan of the pelvis. Despite the initial ultrasound findings being normal, the KUB X-ray played a pivotal role in identifying the presence of prostatic urethral stones within the cavity that had formed after the partial removal of the prostate. This diagnosis was not initially detected during the initial cystoscopy. The KUB X-ray showed multiple radio-opaque renal stones in the lower part of the left kidney, up to 19 mm. No radio-opaque stones were seen in the right kidney or along either ureter. A few small radio-opaque stones were noted in the pelvis within the contour of the urinary bladder, but these findings were largely unremarkable except for the presence of residual stones within the prostatic cavity, likely secondary to the previous TURP procedure (Fig. 1 ). In August 2023, an Ascending & Micturating CystoUrethrogram was performed, and it showed a normal urinary bladder outline with no evidence of vesicoureteral reflux or trabeculation. However, the narrowing of the prostatic part of the urethra left the patient unable to micturate. As a result, an additional lithotripsy was performed, which successfully managed to treat the patient's condition. Although this intervention alleviated some of the patient's symptoms, the prostatic cavity stones persisted. Discussion The risk of developing further stones is increased in patients with a history of nephrolithiasis. 9 From 2005–2015, our patient’s history revealed flank pain and repetitive bilateral renal stones, which required different surgical approaches, such as percutaneous nephrolithotomy (PCNL), and laser lithotripsy. Over the years the patient suffered from recurrent kidney stones, UTIs, dysuria, renal colic, and frequency voiding symptoms. In 2023, the patient had a urinary bladder stone that was removed via cystolitholapaxy. During the cystolitholapaxy procedure, the patient’s prostate was found to be enlarged; therefore, it was concurrently partially resected via transurethral resection of the prostate (TURP). Synchronous cystolitholapaxy and the TURP procedure are common and well-accepted treatments for patients with both benign prostatic hyperplasia (BPH) and urinary bladder stones. This procedure is also indicated for large or multiple urinary bladder stones, and infravesical obstruction. 10 The combined procedure of cystolitholapaxy and TURP is generally effective and safe in patients with a hypertrophied prostate and renal stones. It is used as a protective method to decrease the risk of future stone formation and lowers the need for recystolitholapaxy. 11 , 12 However, the patient developed rare complications, such as prostatic cave stones and fibrosis of the neck of the urinary bladder post this combined surgical procedure. The key complications of the TURP procedure include UTIs, erectile dysfunction, retrograde ejaculation, urinary frequency and incontinence. 13 On the other hand, possible complications of cystolitholapaxy include urethral injury, bladder spasms, residual stone fragments, bladder perforation, and UTIs. 14 The combined procedure of TURP and cystolitholapaxy carries the risk for each, with the highest possibility for lower urinary tract symptoms, infection, hematuria, urethral injury, and bladder spasms. 15 Post-TURP prostatic cave stones are rare complications, and few studies in this topic have been reported. Hypothesised, fragments of stones made during cystolitholapaxy might have entered the prostatic urethra and remained in the prostatic cavity, thus triggering the formation of the stones. These stones are associated with recurrent urinary retention, dysuria, and other lower urinary tract symptoms, as was evident in this patient. 3 Compared to prostatic cave stones, urethral injury and bladder neck stenosis due to fibrosis are more commonly seen as late complications following combined surgical procedures. 16 This could be explained by prior bladder neck procedures, large resecting tools, and surgical techniques. 17 Conclusion Complexities occur in managing patients with recurrent kidney stones and lower urinary tract symptoms, especially after urological procedures. Prostatic cave stones are rare but significant complications of combined cystolitholapaxy and TURP, presenting with urinary retention and dysuria. Prostatic cave stones can pose considerable challenges after surgery, including urinary retention and dysuria. These stones may imitate other urological ailments, emphasizing the significance of step-by-step examination and the crucial role of KUB X-ray in identifying any residual stones that may have been missed during initial advanced investigations. By utilizing an Ellik bladder evacuator during combined procedures, clinicians can prevent stone fragments from lingering in the bladder and forming prostatic cavernous stones. It is imperative for healthcare professionals to maintain a heightened level of suspicion for such infrequent complications to ensure accurate diagnosis and effective treatment, ultimately enhancing patient outcomes and quality of life. Abbreviations Benign prostatic hyperplasia (BPH) Percutaneous nephrolithotomy (PCNL) Transurethral resection of the prostate (TURP) Urinary tract infection (UTI) Declarations Ethics approval and consent to participate Ethical approval was obtained from the Palestinian Ethical Constitution, and written informed consent was obtained from the patient for the participation in this case report. Consent for publication Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. Availability of data and materials All data and materials are available from the corresponding author on reasonable request. Competing of interests The authors declare that they have no competing interests. Funding This paper received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author’s contributions: Seham Madaka: Contributed to background research, literature review, discussion sections, and overall manuscript editing. Ward Basalat: Authored the abstract and conclusion. Saeda Abu Sneineh: Prepared the case presentation. Diya Asad: Assisted with proofreading and abstract preparation. Layth Al-Karaja, Laith Nassar, and Khaled Alhashhash: Obtained patient information, consent form, case materials, and ethical approval. Acknowledgments: We thank the patient for allowing us to report his medical record as a case report. Competing interests: The authors declare that they have no competing interests. References Rassweiler, J., Teber, D., Kuntz, R., & Hofmann, R. (2006). Complications of Transurethral Resection of the Prostate (TURP)—Incidence, Management, and Prevention. European Urology, 50(5), 969–980. doi:10.1016/j.eururo.2005.12.042 Professional, C. C. M. (n.d.). Transurethral Resection of the Prostate . Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/23369-transurethral-resection-of-the-prostate Taha DE. Prostatic resection cavity large stone post transurethral resection of the prostate (TURP). A rare case scenario. Int J Surg Case Rep. 2021 Apr;81:105726. doi: 10.1016/j.ijscr.2021.105726. Epub 2021 Mar 6. PMID: 33721825; PMCID: PMC7970351. SpU, F. R. (2024, May 10). PREVALENCE OF URINARY TRACT STONES IN PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA (BPH) UNDERGOING TRANS URETHRAL RESECTION OF THE PROSTATE (TURP) OPERATION | Indonesian Journal of Urology . https://juri.urologi.or.id/juri/article/view/959 Hasan AM, AbdelRazek M, Ali AF, Alsaghier OM, Ahmed AA, Alsaghier GA. Synchronous transurethral cystolitholapaxy and TURP reveals better results than transurethral cystolitholapaxy plus medical therapy for BPH: a randomized prospective study on 100 patients with concomitant urinary bladder stone(s) and BPH. World J Urol. 2022 Feb;40(2):483-487. doi: 10.1007/s00345-021-03882-4. Epub 2021 Nov 22. Hyun JS. Clinical Significance of Prostatic Calculi: A Review. World J Mens Health. 2018 Jan;36(1):15-21. doi: 10.5534/wjmh.17018. Epub 2017 Sep 25. Mohd Hashim MH, Shukor S, Azizi MH. Giant Prostatic Stones and a Massive Bladder Stone Leading to Obstructive Uropathy: A Rare Case Report. Cureus. 2023 Aug 8;15(8):e43176. doi: 10.7759/cureus.43176. Kalathia J, Patel K, Agrawal S. Giant prostatic and bladder calculi: Endoscopic management and review of the literature. Urol Case Rep. 2020 Dec 9;35:101529. doi: 10.1016/j.eucr.2020.101529. Wang, K., Ge, J., Han, W. et al. Risk factors for kidney stone disease recurrence: a comprehensive meta-analysis. BMC Urol 22, 62 (2022).https://doi.org/10.1186/s12894-022-01017-4 Ali L, Hassan A, Orakzai N, Shahzad M, Khan I, Tariq K. Transurethral Resection of Prostate (TURP) and Vesicolithotomy for Large Bladder Stone in Single Session: The Third World Perspective. Res Rep Urol. 2020 Nov 4;12:547-554. doi: 10.2147/RRU.S273375. Mekke S, Roshani H, van Zanten P, Palacios LG, Egberts J, Hendriks N, Wijffelman M, Zonneveld W, Merks B, van Loopik S, Buddingh T. Simultaneous transurethral resection of the prostate and cystolithotripsy: A urological dilemma examined. Can Urol Assoc J. 2021 Jul;15(7):E361-E365. doi: 10.5489/cuaj.6743. Mekke S, Roshani H, van Zanten P, Palacios LG, Egberts J, Hendriks N, Wijffelman M, Zonneveld W, Merks B, van Loopik S, Buddingh T. Simultaneous transurethral resection of the prostate and cystolithotripsy: A urological dilemma examined. Can Urol Assoc J. 2021 Jul;15(7):E361-E365. doi: 10.5489/cuaj.6743. He K, Liu Y, Li D, Yu Q. Combination of transurethral resection of the prostate and flexible and rigid ureteroscopy for benign prostatic hyperplasia and ureteral calculus. Transl Androl Urol. 2021 Aug;10(8):3395-3401. doi: 10.21037/tau-21-523. Huizen, J. (2018, March 12). What happens if you have prostate surgery? https://www.medicalnewstoday.com/articles/321190 Manski, M. D. (n.d.). Cystolitholapaxy: Transurethral or Percutaneous Procedure . Dirk Manski. https://www.urology-textbook.com/cystolitholapaxy.html Cystoscopic Laser Lithotripsy and Stone Extraction (Cystolithalopaxy) » Department of Urology » College of Medicine » University of Florida . (n.d.-b). https://urology.ufl.edu/patient-care/stone-disease/procedures/cystoscopic-laser-lithotripsy-and-stone-extraction-cystolithalopaxy/ Geremew LM, Gelaw SA, Beyene AD. Assessing the Complications of Monopolar Transurethral Resection of the Prostate (M-TURP) Using Clavien-Dindo Complications Grading System. Ethiop J Health Sci. 2022 May;32(3):605-612. doi: 10.4314/ejhs.v32i3.17. Wen J, Nørby B, Osther PJS. Bladder Neck Contracture after Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia Treated with a Thermo-Expandable Metal Stent (Memokath® 045). Case Rep Urol. 2018 May 9;2018:2439421. doi: 10.1155/2018/2439421. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4663816","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":333043436,"identity":"4131dd83-2659-43f5-87c0-c99a76fec8f4","order_by":0,"name":"Seham Madaka","email":"data:image/png;base64,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","orcid":"","institution":"Al-Quds University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Seham","middleName":"","lastName":"Madaka","suffix":""},{"id":333043437,"identity":"5306989b-915f-4b83-bbdf-56e428b7d8ff","order_by":1,"name":"Ward Basalat","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ward","middleName":"","lastName":"Basalat","suffix":""},{"id":333043438,"identity":"5bcdf783-1917-42cf-a570-00a7262dc0b6","order_by":2,"name":"Layth Al-Karaja","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Layth","middleName":"","lastName":"Al-Karaja","suffix":""},{"id":333043439,"identity":"177e9327-202f-4fd7-a305-23f6c5becf46","order_by":3,"name":"Laith Nassar","email":"","orcid":"","institution":"Rafidia governmental hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Laith","middleName":"","lastName":"Nassar","suffix":""},{"id":333043440,"identity":"e6d7ba2a-9b7e-4165-b8a0-947b631b43cb","order_by":4,"name":"Khaled Alhashash","email":"","orcid":"","institution":"Rafidia governmental hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Khaled","middleName":"","lastName":"Alhashash","suffix":""},{"id":333043441,"identity":"40d339bb-a51e-46ee-9550-87ad39c7394c","order_by":5,"name":"Diya Asad","email":"","orcid":"","institution":"Al-Quds University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Diya","middleName":"","lastName":"Asad","suffix":""},{"id":333043442,"identity":"eb481464-4d29-4ea9-a993-c843f154d900","order_by":6,"name":"Saeda Abu Sneineh","email":"","orcid":"","institution":"National Pirogov Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Saeda","middleName":"Abu","lastName":"Sneineh","suffix":""}],"badges":[],"createdAt":"2024-06-30 17:36:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4663816/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4663816/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62135277,"identity":"8f6937bf-a986-431e-a011-e1d71f7acb71","added_by":"auto","created_at":"2024-08-09 16:15:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":205637,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eKUB showing residual stones within the prostatic cavity (red arrow).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4663816/v1/c0410d1aca68dcbc4ea87ef6.png"},{"id":63997351,"identity":"0b01970e-58fe-497d-bd88-2697f7526104","added_by":"auto","created_at":"2024-09-04 17:12:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":485824,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4663816/v1/51528dd7-d9a6-4107-9396-c517f94b031c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eProstatic Cave Stones Post-Cystolitholapaxy with TURP. A Rare Complication\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eProstatic cave stones, also known as prostatic utricular stones, are rare complications of transurethral resection of the prostate (TURP) and cystolitholapaxy.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere are 150,000 TURP procedures performed annually in the United States, as it remains the gold standard surgical treatment for benign prostatic hyperplasia (BPH).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Except for a few bleeding cases, urinary tract infections, and less commonly, prostatic cave stones; TURP is generally safe and effective.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The literature is not well-documented regarding the incidences of prostatic cave stones after TURP. However, urinary tract stones are common in BPH patients, which indicates TURP.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCystolitholapaxy is often done with a concurrent TURP in patients with both BPH and bladder calculi. This has been found to result in good symptom improvement and prevention of stone recurrence.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e It may however increase other risks like the formation of prostatic cave stones.\u003c/p\u003e \u003cp\u003eAfter TURP and cystolithopaxy, the etiology of prostatic cave stones is not fully understood. A possible explanation is that remnants of stones from cystolithopaxy can find their way into the prostatic fossa created after TURP where they become niduses for stone formation. On the other hand, changes in urinary flow post-TURP may cause stone formation in its cavity.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe diagnosis of prostatic cave stones is difficult because it often mimics symptoms of other post-TURP complications or recurrent BPH.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Transrectal ultrasonography, KUB X-rays and CT scans are examples of imaging techniques used to identify these stones. However as illustrated by our case, early radiology examinations do not always provide any indication for the presence of such stones thus requiring a high degree of clinical suspicion and continued follow up.\u003c/p\u003e \u003cp\u003eProstatic cave stones are usually managed through endoscopic removal which may involve use of laser lithotripsy or pneumatic lithotripters. Prevention approaches such as adequate irrigation with an Ellik evacuator during initial procedure were also proposed to decrease risk for stone formation.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis case report underscores the significance of prostatic cave stones as a rare yet important complication following combined TURP and cystolitholapaxy procedures. It is on this background that we present this case study as a contribution to limited literature on this topic and emphasizing the need for precise post-operative follow-up and monitoring of patients undergoing these procedures.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 55-year-old male with a history of recurrent renal stones and flank pain underwent many interventions, including percutaneous nephrolithotomy (PCNL) and lithotripsy, between 2007 and 2015. In 2022, he presented with recurrent urinary tract infections (UTIs), dysuria, and frequency voiding symptoms. Imaging test results revealed urinary tract stones.\u003c/p\u003e \u003cp\u003eIn 2023, the patient underwent cystolitholapaxy, during which an enlarged prostate was incidentally discovered. Given the presence of coexisting prostatic enlargement and the risk of recurrent calculi, a simultaneous transurethral resection of the prostate (TURP) was performed.\u003c/p\u003e \u003cp\u003ePostoperatively, the patient experienced recurrent urinary retention, necessitating a suprapubic catheter due to failed transurethral catheterization attempts. An abdominal and pelvic ultrasound in May 2023 revealed an enlarged left kidney with ballooning dilation of the calyceal cysts and decreased cortical thickness, indicating moderate to severe hydronephrosis, along with multiple stones up to 1.6 cm in the lower pole. There was no perinephric edema or collection. The right kidney was normal, with no hydronephrosis. The urinary bladder was normal in shape but had diffuse wall thickening up to 6 mm and focal nodular thickening at the base, measuring approximately 5 x 7 mm near the prostate, which required follow-up. The prostate had a normal size and echo pattern.\u003c/p\u003e \u003cp\u003eDuring the cystoscopic procedure, the prostatic urethra was successfully traversed by the scope without encountering any complications. The examination revealed the presence of bladder neck fibrosis, but no stenosis or abnormalities were observed at the level of the prostatic urethra. To address the fibrosis, an incision and dilation procedure were performed. However, following the operation, the patient experienced recurring visits to the emergency room due to symptoms of urinary retention and dysuria. This prompted the need for further paraclinical examinations, which included a KUB X-ray and a CT scan of the pelvis. Despite the initial ultrasound findings being normal, the KUB X-ray played a pivotal role in identifying the presence of prostatic urethral stones within the cavity that had formed after the partial removal of the prostate. This diagnosis was not initially detected during the initial cystoscopy.\u003c/p\u003e \u003cp\u003eThe KUB X-ray showed multiple radio-opaque renal stones in the lower part of the left kidney, up to 19 mm. No radio-opaque stones were seen in the right kidney or along either ureter. A few small radio-opaque stones were noted in the pelvis within the contour of the urinary bladder, but these findings were largely unremarkable except for the presence of residual stones within the prostatic cavity, likely secondary to the previous TURP procedure (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn August 2023, an Ascending \u0026amp; Micturating CystoUrethrogram was performed, and it showed a normal urinary bladder outline with no evidence of vesicoureteral reflux or trabeculation. However, the narrowing of the prostatic part of the urethra left the patient unable to micturate. As a result, an additional lithotripsy was performed, which successfully managed to treat the patient's condition. Although this intervention alleviated some of the patient's symptoms, the prostatic cavity stones persisted.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe risk of developing further stones is increased in patients with a history of nephrolithiasis.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFrom 2005\u0026ndash;2015, our patient\u0026rsquo;s history revealed flank pain and repetitive bilateral renal stones, which required different surgical approaches, such as percutaneous nephrolithotomy (PCNL), and laser lithotripsy. Over the years the patient suffered from recurrent kidney stones, UTIs, dysuria, renal colic, and frequency voiding symptoms. In 2023, the patient had a urinary bladder stone that was removed via cystolitholapaxy. During the cystolitholapaxy procedure, the patient\u0026rsquo;s prostate was found to be enlarged; therefore, it was concurrently partially resected via transurethral resection of the prostate (TURP).\u003c/p\u003e \u003cp\u003eSynchronous cystolitholapaxy and the TURP procedure are common and well-accepted treatments for patients with both benign prostatic hyperplasia (BPH) and urinary bladder stones. This procedure is also indicated for large or multiple urinary bladder stones, and infravesical obstruction.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe combined procedure of cystolitholapaxy and TURP is generally effective and safe in patients with a hypertrophied prostate and renal stones. It is used as a protective method to decrease the risk of future stone formation and lowers the need for recystolitholapaxy.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, the patient developed rare complications, such as prostatic cave stones and fibrosis of the neck of the urinary bladder post this combined surgical procedure.\u003c/p\u003e \u003cp\u003eThe key complications of the TURP procedure include UTIs, erectile dysfunction, retrograde ejaculation, urinary frequency and incontinence.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e On the other hand, possible complications of cystolitholapaxy include urethral injury, bladder spasms, residual stone fragments, bladder perforation, and UTIs.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The combined procedure of TURP and cystolitholapaxy carries the risk for each, with the highest possibility for lower urinary tract symptoms, infection, hematuria, urethral injury, and bladder spasms.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePost-TURP prostatic cave stones are rare complications, and few studies in this topic have been reported. Hypothesised, fragments of stones made during cystolitholapaxy might have entered the prostatic urethra and remained in the prostatic cavity, thus triggering the formation of the stones. These stones are associated with recurrent urinary retention, dysuria, and other lower urinary tract symptoms, as was evident in this patient.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCompared to prostatic cave stones, urethral injury and bladder neck stenosis due to fibrosis are more commonly seen as late complications following combined surgical procedures.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e This could be explained by prior bladder neck procedures, large resecting tools, and surgical techniques.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eComplexities occur in managing patients with recurrent kidney stones and lower urinary tract symptoms, especially after urological procedures. Prostatic cave stones are rare but significant complications of combined cystolitholapaxy and TURP, presenting with urinary retention and dysuria.\u003c/p\u003e \u003cp\u003eProstatic cave stones can pose considerable challenges after surgery, including urinary retention and dysuria. These stones may imitate other urological ailments, emphasizing the significance of step-by-step examination and the crucial role of KUB X-ray in identifying any residual stones that may have been missed during initial advanced investigations. By utilizing an Ellik bladder evacuator during combined procedures, clinicians can prevent stone fragments from lingering in the bladder and forming prostatic cavernous stones. It is imperative for healthcare professionals to maintain a heightened level of suspicion for such infrequent complications to ensure accurate diagnosis and effective treatment, ultimately enhancing patient outcomes and quality of life.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBenign prostatic hyperplasia (BPH)\u003c/p\u003e\n\u003cp\u003ePercutaneous nephrolithotomy (PCNL)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTransurethral resection of the prostate (TURP)\u003c/p\u003e\n\u003cp\u003eUrinary tract infection (UTI)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEthical approval was obtained from the Palestinian Ethical Constitution, and written informed consent was obtained from the patient for the participation in this case report.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll data and materials are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting of interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis paper received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSeham Madaka: Contributed to background research, literature review, discussion sections, and overall manuscript editing.\u003c/p\u003e\n\u003cp\u003eWard Basalat: Authored the abstract and conclusion.\u003c/p\u003e\n\u003cp\u003eSaeda Abu Sneineh: Prepared the case presentation.\u003c/p\u003e\n\u003cp\u003eDiya Asad: Assisted with proofreading and abstract preparation.\u003c/p\u003e\n\u003cp\u003eLayth Al-Karaja, Laith Nassar, and Khaled Alhashhash: Obtained patient information, consent form, case materials, and ethical approval.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWe thank the patient for allowing us to report his medical record as a case report.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRassweiler, J., Teber, D., Kuntz, R., \u0026amp; Hofmann, R. (2006). \u003cem\u003eComplications of Transurethral Resection of the Prostate (TURP)\u0026mdash;Incidence, Management, and Prevention. European Urology, 50(5), 969\u0026ndash;980.\u003c/em\u003e doi:10.1016/j.eururo.2005.12.042\u003c/li\u003e\n\u003cli\u003eProfessional, C. C. M. (n.d.). \u003cem\u003eTransurethral Resection of the Prostate\u003c/em\u003e. Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/23369-transurethral-resection-of-the-prostate\u003c/li\u003e\n\u003cli\u003eTaha DE. Prostatic resection cavity large stone post transurethral resection of the prostate (TURP). A rare case scenario. Int J Surg Case Rep. 2021 Apr;81:105726. doi: 10.1016/j.ijscr.2021.105726. Epub 2021 Mar 6. PMID: 33721825; PMCID: PMC7970351.\u003c/li\u003e\n\u003cli\u003eSpU, F. R. (2024, May 10). \u003cem\u003ePREVALENCE OF URINARY TRACT STONES IN PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA (BPH) UNDERGOING TRANS URETHRAL RESECTION OF THE PROSTATE (TURP) OPERATION | Indonesian Journal of Urology\u003c/em\u003e. https://juri.urologi.or.id/juri/article/view/959 \u003c/li\u003e\n\u003cli\u003eHasan AM, AbdelRazek M, Ali AF, Alsaghier OM, Ahmed AA, Alsaghier GA. Synchronous transurethral cystolitholapaxy and TURP reveals better results than transurethral cystolitholapaxy plus medical therapy for BPH: a randomized prospective study on 100 patients with concomitant urinary bladder stone(s) and BPH. World J Urol. 2022 Feb;40(2):483-487. doi: 10.1007/s00345-021-03882-4. Epub 2021 Nov 22. \u003c/li\u003e\n\u003cli\u003eHyun JS. Clinical Significance of Prostatic Calculi: A Review. World J Mens Health. 2018 Jan;36(1):15-21. doi: 10.5534/wjmh.17018. Epub 2017 Sep 25. \u003c/li\u003e\n\u003cli\u003eMohd Hashim MH, Shukor S, Azizi MH. Giant Prostatic Stones and a Massive Bladder Stone Leading to Obstructive Uropathy: A Rare Case Report. Cureus. 2023 Aug 8;15(8):e43176. doi: 10.7759/cureus.43176. \u003c/li\u003e\n\u003cli\u003eKalathia J, Patel K, Agrawal S. Giant prostatic and bladder calculi: Endoscopic management and review of the literature. Urol Case Rep. 2020 Dec 9;35:101529. doi: 10.1016/j.eucr.2020.101529. \u003c/li\u003e\n\u003cli\u003eWang, K., Ge, J., Han, W. \u003cem\u003eet al.\u003c/em\u003e Risk factors for kidney stone disease recurrence: a comprehensive meta-analysis. \u003cem\u003eBMC Urol\u003c/em\u003e 22, 62 (2022).https://doi.org/10.1186/s12894-022-01017-4 \u003c/li\u003e\n\u003cli\u003eAli L, Hassan A, Orakzai N, Shahzad M, Khan I, Tariq K. Transurethral Resection of Prostate (TURP) and Vesicolithotomy for Large Bladder Stone in Single Session: The Third World Perspective. Res Rep Urol. 2020 Nov 4;12:547-554. doi: 10.2147/RRU.S273375. Mekke S, Roshani H, van Zanten P, Palacios LG, Egberts J, Hendriks N, Wijffelman M, Zonneveld W, Merks B, van Loopik S, Buddingh T. Simultaneous transurethral resection of the prostate and cystolithotripsy: A urological dilemma examined. Can Urol Assoc J. 2021 Jul;15(7):E361-E365. doi: 10.5489/cuaj.6743.\u003c/li\u003e\n\u003cli\u003eMekke S, Roshani H, van Zanten P, Palacios LG, Egberts J, Hendriks N, Wijffelman M, Zonneveld W, Merks B, van Loopik S, Buddingh T. Simultaneous transurethral resection of the prostate and cystolithotripsy: A urological dilemma examined. Can Urol Assoc J. 2021 Jul;15(7):E361-E365. doi: 10.5489/cuaj.6743. \u003c/li\u003e\n\u003cli\u003eHe K, Liu Y, Li D, Yu Q. Combination of transurethral resection of the prostate and flexible and rigid ureteroscopy for benign prostatic hyperplasia and ureteral calculus. Transl Androl Urol. 2021 Aug;10(8):3395-3401. doi: 10.21037/tau-21-523.\u003c/li\u003e\n\u003cli\u003eHuizen, J. (2018, March 12). \u003cem\u003eWhat happens if you have prostate surgery?\u003c/em\u003ehttps://www.medicalnewstoday.com/articles/321190 \u003c/li\u003e\n\u003cli\u003eManski, M. D. (n.d.). \u003cem\u003eCystolitholapaxy: Transurethral or Percutaneous Procedure\u003c/em\u003e. Dirk Manski. https://www.urology-textbook.com/cystolitholapaxy.html \u003c/li\u003e\n\u003cli\u003e\u003cem\u003eCystoscopic Laser Lithotripsy and Stone Extraction (Cystolithalopaxy) \u0026raquo; Department of Urology \u0026raquo; College of Medicine \u0026raquo; University of Florida\u003c/em\u003e. (n.d.-b). https://urology.ufl.edu/patient-care/stone-disease/procedures/cystoscopic-laser-lithotripsy-and-stone-extraction-cystolithalopaxy/ \u003c/li\u003e\n\u003cli\u003eGeremew LM, Gelaw SA, Beyene AD. Assessing the Complications of Monopolar Transurethral Resection of the Prostate (M-TURP) Using Clavien-Dindo Complications Grading System. Ethiop J Health Sci. 2022 May;32(3):605-612. doi: 10.4314/ejhs.v32i3.17. \u003c/li\u003e\n\u003cli\u003eWen J, N\u0026oslash;rby B, Osther PJS. Bladder Neck Contracture after Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia Treated with a Thermo-Expandable Metal Stent (Memokath\u0026reg; 045). Case Rep Urol. 2018 May 9;2018:2439421. doi: 10.1155/2018/2439421. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prostatic cave stones, Prostatic utricle, TURP, Cystolitholapaxy","lastPublishedDoi":"10.21203/rs.3.rs-4663816/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4663816/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eProstatic cave stones, also known as prostatic utricular stones, are exceedingly rare complications following transurethral resection of the prostate (TURP) and cystolitholapaxy. These stones form within the prostatic utricle, a remnant of the Mullerian duct within the prostate gland. While TURP and cystolitholapaxy are common procedures for the management of benign prostatic hyperplasia (BPH) and bladder stones respectively, the occurrence of post-procedure prostatic cave stones is uncommon and not well documented in the literature. We report the rare development of prostatic cave stones following a combined cystolitholapaxy and transurethral resection of the prostate (TURP) procedure.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003ea 55-year-old male patient with a history of recurrent kidney stones, urinary symptoms, and multiple different surgical interventions. He developed urinary bladder stones which required cystolitholapaxy and during the procedure partial prostate resection was performed via transurethral resection of the prostate (TURP) due to enlargement. As a result of this combined surgical procedure prostatic cave stones were formed.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRare complications, such as prostatic cave stones, may occur post-urologic operatives, which require clinicians\u0026rsquo; attention and consideration. This highlights the importance of recognizing and managing rare complications to ensure optimal patient care.\u003c/p\u003e","manuscriptTitle":"Prostatic Cave Stones Post-Cystolitholapaxy with TURP. A Rare Complication","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 16:15:53","doi":"10.21203/rs.3.rs-4663816/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0362eb86-e213-4c77-aba4-4a7baad9fa33","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-22T20:38:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-09 16:15:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4663816","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4663816","identity":"rs-4663816","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}