Symptomatic prostatic calculi are rare occurrences with several management options, the most popular of which is currently transurethral laser lithotripsy. This is a generally well-tolerated procedure with minimal complications. To date, no reported episodes of steinstrasse at the urethral level following prostatic calculi lithotripsy have been documented to our knowledge. We report a unique case of acute urinary retention secondary to obstructive calculi fragments following a transurethral laser lithotripsy of large prostatic calculi, further complicated by stricture at the fossa navicularis.
Symptomatic and obstructive calculi of the prostatic urethra are an uncommon clinical entity. They are usually seen in older men and are typically incidental findings on digital rectal examination, CT, or other forms of radiological investigation [
Due to the rarity of large recurrent symptomatic prostatic calculi and the occurrence of urethral steinstrasse after laser lithotripsy, we chose to report this case, which occurred over the course of six months.
A 57-year-old male with a history of coronary artery disease and type 2 diabetes mellitus presented to the clinic after an isolated episode of gross hematuria and progressively worsening lower urinary tract symptoms (LUTS). He endorsed a history of prostatic calculi requiring surgical intervention as a teenager. His digital rectal examination demonstrated a diffusely firm prostate with an irregular contour. Prostate specific antigen was found to be 0.56 ng/mL and he had no known family history of prostate cancer. His postvoid residual (PVR) measured 13 mL. The remainder of his physical examination was unremarkable. A CT urogram was remarkable for only an enlarged prostate and several prostatic calculi, with the largest measuring 2.4 cm × 1.6 cm (Figures
Coronal view of CT abdomen and pelvis noting a large burden of prostate stones.
Axial view of CT abdomen and pelvis noting a large burden of prostate stones.
Cystoscopic view from the verumontanum noting a large burden of prostate stones.
The patient subsequently underwent a transurethral resection of the prostate (TURP) and holmium laser (200-micron fiber, 15–50 Hz, 0.2–0.8 J) lithotripsy of multiple prostatic calculi. The fragments were removed via a cystoscopic grasper and a Boston Scientific 1.9 French Zero-Tip basket. He was discharged with an indwelling catheter. Shortly after removal of the indwelling catheter, the patient experienced difficulty voiding and was found to be in urinary retention. Office cystoscopy revealed several fragmented stones at the level of the prostatic urethra, similar to steinstrasse. An indwelling catheter was placed to relieve obstruction and the patient underwent repeat cystoscopy under anesthesia with removal of the remaining fragments.
At 3-month follow-up, the patient returned to the clinic with restricted flow, a spraying stream, and a PVR of 87 mL. Office cystoscopy demonstrated an 8–10-French stricture in the fossa navicularis requiring a urethral meatotomy. Subsequent cystoscopy a month later demonstrated a normal urethra and a singular calculus in the prostatic fossa that was noted to be nonobstructive. Two weeks later at follow-up, the patient reported he was urinating well.
Prostatic calculi are thought to form during inflammatory conditions when prostatic secretions precipitate and the corpora amylacea calcify [
Prostatic calculi usually present with a normal clinical examination and are typically discovered incidentally. Stones generally range between 0.5 mm and 5 mm, although there have been bigger stones described [
Treatment and management of calculi are contingent on the condition of the urethra and the size, shape, and position of the calculus. Open surgery was previously the most common approach [
Steinstrasse is a rare complication most commonly described after ESWL for nephrolithiasis. Fragmentation after lithotripsy most commonly occurs in the distal ureter due to the narrowing at the ureterovesicular junction [
Urethral steinstrasse is uncommon because fragments that pass through the ureterovesical junction can often traverse a much larger caliber [
In this instance, the patient underwent a cystourethroscopy, although the indwelling catheter may have helped pass some of the residual stones. Steinstrasse in very rare cases can spontaneously resolve itself [
Patients require long-term surveillance to avoid recurrent stone formation, which can include metabolic evaluation or treatment of predisposing factors such as urethral stenosis or diverticula [
The authors declare no conflicts of interest regarding the publication of this paper.