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Saudi Journal of Kidney Diseases and Transplantation
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SPECIAL ARTICLE Table of Contents   
Year : 1998  |  Volume : 9  |  Issue : 2  |  Page : 157-168
Extraction of Urinary Stone


1 Division of Urology, Department of Surgery, School of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Physiology, School of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Division of Nephrology, Department of Medicine, School of Medicine, King Saud University, Riyadh, Saudi Arabia

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How to cite this article:
Abdul Haleem RA, Altwaijiri AS, Alfaquih SR, Mitwalli AH. Extraction of Urinary Stone. Saudi J Kidney Dis Transpl 1998;9:157-68

How to cite this URL:
Abdul Haleem RA, Altwaijiri AS, Alfaquih SR, Mitwalli AH. Extraction of Urinary Stone. Saudi J Kidney Dis Transpl [serial online] 1998 [cited 2020 Feb 26];9:157-68. Available from: http://www.sjkdt.org/text.asp?1998/9/2/157/39290

   Chapter Sixty - Extraction of a Stone Top


This is a quotation from the distinguished surgeon. Abu Al Kasern Khalaf Ibn Abbas Alzahrawi [1] (325-404 H), in his book of surgery "Al-Tasreef [2],[3]

I have previously mentioned the types of stones, their medical treatment, and the difference between the renal stone and the bladder stone including the need for resection and extraction of the latter, which usually gets impacted in the urethra [5] .

Here I will briefly describe the technique of the extraction of bladder stone [6] . I would like first to mention that this type of stone occurs mostly in male children. The symptoms and signs include passing dilute urine like water in consistency with sand in it. The patient often keeps playing with his penis He also has enlargement of penis, and may have perineumauxesis. Management of the children is easy up to age 14. It becomes more difficult in young adults, and is very difficult at both extremes of age. The larger the stone the easier the cure. The initial management should include rectal enema. Emptying the rectum helps finding the stone on physical exam [7] . Maneuvers to help descendance of the stones to the neck of the bladder, such as shaking legs or jumping from a high step several times, should be tried. The patient should assume erect position with hands beneath his thighs. This would help incline the bladder forward and make it easier to palpate. The examiner should palpate externally [1] . If the stone is easily palpated, operation should be performed immediately cutting down on it [2] . If the stone cannot be palpated then the physician enters his index (in the case of children) or middle finger (in case of those reaching puberty), after lubricating it with oil, in the rectum of the patient [3] .

This enhances palpation of the bladder and checking for a stone in it. If found by this maneuver, the stone should be carefully pushed toward the neck of the bladder against the wall of the abdomen and held steadily there in preparation for resection and extraction [4] . At the same time, an assistant should squeeze the bladder downward by pushing on the wall of the abdomen to keep the bladder close to surface [5] .

Another assistant pulls both testicles upward [6] by his right hand, while stretching the skin of the perineum away from the site of the resection with his left hand, in order to enhance the resection. The surgeon then uses the scalpel in Figure [1],[7] to incise the skin of the perineum closer to the left buttock [8] onto the stone site, while holding the stone by the finger in the rectum pressing it outward. The incision should be oblique, wide externally and narrowing inwards down to dimensions allowing the exit of the stone. Now, the finger pressing the stone can force it out through the incision without difficulty. The smoother the stone, the easier to get out. Enlarging the incision on the rough-edged stone may help it out. If this maneuver is not successful, then using a bulldog hemostat may be helpful in extracting the stone [9] . Alternatively a curved spoon can be slipped under the stone in order to force it out [10].

If this fails, the incision should then be enlarged further. If bleeding increases during these maneuvers then stop it with zage [1] . If more than one stone is encountered then the largest should be extracted first followed by the smaller ones [2] . It is inadvisable to make a very large incision in order to extract a very large stone. This would increase mortality, or morbidity due to chronic urinary fistula, which may not heal at all. In this situation, it is preferable to force the stone out or break it into pieces by a pincer; this enhances extraction. After extraction, the incision should be packed with Kandar [4] , Saber [5] and Shanan [6] . Tight bandaging should be applied on a dressing soaked in oil, syrup of wared [7], and cold water to reduce the swelling of the incision. The patient should be placed in recumbent position. The bandage should remain in place for three days. After removal of bandage, the wound should be rinsed with plenty of natulat of oil and water [8] followed by applying ointments (Palm oil, Basilicon) till healing of the wound is complete. If cankerous abscess, "Akkal" [9] or clots in bladder are suspected by the presence of urine accompanied by blood, then you should attempt to evacuate the blood from the bladder by finger to preclude spoiling or rendering the bladder rotten [1] , and follow it by rinsing the wound with vinegar, water and salt. The thighs of the patient should be tied together all the time till healing is complete to ensure continuous contact of medications applied to the wound.

In case the stone is small and impacted in the penile urethra causing obstruction of urine outflow, try using the sound (Almishab) which is described below, before considering incision operations. I have personally found this very useful and in many times obviates surgical intervention. [2]

Almishab is a pen-like sound with sharp triangular end with a wooden handle. Tie the penis proximal to the site of the stone to prevent its return to the bladder. Introduce gently the sound-metallic part in to the urethra to the stone. Attempt slowly piercing the stone. Success of this procedure is manifested by relief of obstruction and out flow of urine. After that, squeezing on the stone breaks it further easily, and it gets out with the urine, followed by complete healing (if Allah wishes). [3]

If the above procedure is not possible for any reason, as an alternative procedure, two threads around penis can be applied proximal [4] and distal [5] to the stone. Incise the penis on the stone site and extract the stone, and ensure hemostasis. The proximal thread serves to preclude return of the impacted stone to the bladder, while the distal one to stretch the skin away from the incision-site. [6] This latter thread helps retraction of skin so it may fall back into place so as to cover the wound after loosening the ligature. [7] The proximal thread should retract the skin similar to the distal one. Post surgical care of the wound should be continued till healing (in the name of Allah).


   Chapter sixty one - Stone extraction in women Top
[1]

Stones are less common in females. Extraction is more difficult in females than males due to: First, the female patient could be virgin. Second, women may be so shy or closely related to the examiner [2], which makes it difficult to perform examination. Third, there is hardly ever a woman-doctor, who is capable of performing surgeries. Lastly, deep incision is usually needed, in order to reach bladder stones in women, which is highly risky.

In case of a bladder stone in women, it is preferable to have a treating woman-doctor, or a modest and gentle male-doctor. If unavailable, then to have an experienced midwife attending with a male-doctor, who will instruct her to perform physical exam. First, the midwife should check for virginity. If so, approach should be rectal, otherwise it should be vaginal. If the stone is palpable and seizable by the midwife then she should proceed with incision under the doctor's supervision. In either approach the left hand of the midwife should push the bladder downward while the finger of the right hand is engaging in the rectum or the vagina. The midwife should attempt pushing the stone away of the bladder neck to the joint of the thigh. Incision should be opposite to the mid-vagina laterally, at either side. The stone should be stabilized all the time during the procedure. The incision should be small. The stone should be negotiated through the incision by Al­-Merwad . [3] The incision can be gradually increased to reach the minimum size for the stone to pass through.

Be advised that stones have various sizes, shapes and textures and may be multifaceted. You have to get familiar with them. If there is plenty of bleeding from the wound, then attempt hemostasis by applying Alzage-powder and pressing for a while (an hour) till the wound ceases to bleed then to resume operation to extract the stone.

All instruments necessary for operation (as mentioned in previous chapter) should be pre-prepared before operation.

In case of severe hemorrhage, arterial bleeding should be suspected. In such cases, the surgeon should apply hemostatic powder and strong bandage. The wound should be left untouched for several days before re-attempting extraction of stone (if Allah wishes) [4] , otherwise the patient may die during the operation.[24]

 
   References Top

1.Castiglioni A. A Mstory of medicine. Translated from the Italian and edited by KB. Kiumhhaar. New York, Jasan Aronson, Inc., 1975.  Back to cited text no. 1    
2.Abuouleish E. Contribution of Islam to medicine. J Islamic Med Assoc (USA). 1979;28:45.  Back to cited text no. 2    
3.Campbell DC. Arabian medicine and its influence on the middle ages, 1st edition (reprint). Amsterdam. Philo Press, 1974;XI-XV.  Back to cited text no. 3    
4.Spink MS, Lewis TL. Albucassis on surgery and instruments (a definitive edition of the Arabic text with English translation and commentary). London, Wellcome Institute of the History of Medicine, 1973.  Back to cited text no. 4    
5.UllmannM. Islamic medicine. Islamic surveys no 11. Edinburgh, Edinburgh University Press, 1978;52-54.  Back to cited text no. 5    
6.Cranston CG. An introduction to the history of medicine from the time of the pharaoahs to the end of the XVffl century. London, Dawsons of Pall Mail, 1978;23­26,185-212.  Back to cited text no. 6    
7.Friend J. Histoire de la medecine, depuis Galien, jusqu'au commencement du sememe siecle, part 3. Leyden, Langerak, 1727;3:1-80.  Back to cited text no. 7    
8.Montagnani CA. Pediatric surgery in Islamic medicine from Middle age to renaissance. In Rickham PP, ed. Historical aspects of pediatric surgery, progress in pediatric surgery, Berlin, Heidelbergh, Springer-Vcrlag 1986;2U:39-51.  Back to cited text no. 8    
9.Sprengel K, Histoire de la medecine, depuis son origine jusqu'au dix-neuvieme siecle, vol 2. Paris, Deterville Libreure 1815.  Back to cited text no. 9    
10.Alzahrawi. Kitab Al-Tasreef Liman Ajaz An Al-Taalif, Manuscript no 502, vol. 1-2, Bashir Agha Collection, Sulaymaneyya Library, Istanbul. Reproduced and commented upon by Fouad Sezkin, Frankfurt Institute for the history of Arabic and Islamic Sciences.  Back to cited text no. 10    
11.Desnos E. The history of urology up to the latter half of the nineteenth century. In: Murphy LJT. (ed). The history of urology. Springfield, Thomas 1972.  Back to cited text no. 11    
12.Margotta R. In: Lewis P (ed). An illustrated history of medicine. Feltham, Middlesex, PaulHamlyn 1968.  Back to cited text no. 12    
13.Abdel-Halim RE. Lithotripsy - a historical review. In: E. Matouschek el al (eds). Proceedings of tile Third Congress of the International Society of Urologic Endoscopy. Baden Baden, bau-Verlag Werner Steinbruck 1985;474-476.  Back to cited text no. 13    
14.Abdel-Halim RE. Pediatric urology 1000 years ago. In: Rickham PP (Ed), progress in pediatric urology, Berlin, Heidlberg, Spriger-Verlag 1986;20:256-264.  Back to cited text no. 14    
15.Paulus Aegineta. The seven books of Paulus Aegineta, translated by F. Adams. London, Sydenham Society 1844-1847;vol 1-3.  Back to cited text no. 15    
16.Celcus de Medicina. London, Heinmann, Cambrige, Harvard University Press 1938; vol 1-3.  Back to cited text no. 16    
17.Alrazi. Kitab al-Hawi fit-tibb (The book of the collector of medicine) (Rhazes, Liver continents), 1st edn. Hyderabad, Osmania Oriental Publications, Osmania University 1961;10:110-153.  Back to cited text no. 17    
18.Kirkup JR. The history and evolution of surgical instruments. I. Introduction. Ann R Coll Surg Engl 1981;63:279-85.  Back to cited text no. 18    
19.El-Faqih S, Wallace DM. Ultrasonic lithotriptor for urethral and bladder stones. B J Urol 1978;50:255-256.  Back to cited text no. 19    
20.Andreas a Cruce. In a system of surgery, by Alexander Bell, Second Edition, Edinburg, C. Elliot publisher 1785 quoted by Wallace DM. Ultrasonic lithotripsy for bladder and urclhral calculi. Emirate Medical Journal (1979);1,Supplement 41-44).  Back to cited text no. 20    
21.Abulcasis. Chirurgica et ars medica. 1582. Trans., Leclerec L., 1861, (quoted by Desnos E. The history of urology up to the latter half of the nineteenth century. In; Murphy LJT. (ed) The history of urology. Springfield, Thomas 1972;Fig. 3.1:37).  Back to cited text no. 21    
22.Marianus Sanctus. Libellus aureus de lapide vesicae per incisionem extrahendo. Venetis, 1543, (quoted by Desnos E. History of urology up to the latter half of the nineteenth century. In; Murphy LJT. (ed) The history of urology. Springfield, Thomas, 1972;Fig. 5.2,:91).  Back to cited text no. 22    
23.Deschamps. Traite' historique et dogmatique de la taille, 1796, (quoted by Desnos E. The history of urology up to the latter half of the nineteenth century. In: Murphy LJT. (ed). The history of urology. Springfield, Thomas 1972;Fig. 5.29:108).  Back to cited text no. 23    
24.Marianus Sanctus. Libellus aureus de lapide vesicae per incisionem extrahendo. Venetis, 1543, (quoted by Desnos E. The history ofurology up to the fatter half of the nineteenth century. In: Murphy LJT. (ed). The history of urology. Springfield, Thomas 1972;Fig.5.6:92.  Back to cited text no. 24    

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Correspondence Address:
Ali Sulaiman Altwaijiri
Department of Physiology, School of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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