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| Etiology and management of urethral calculi: A systematic review of contemporary series |
Andrew Mortona,b,Arsalan Tariqa,c,Nigel Dunglisonc,Rachel Eslerc,Matthew J. Robertsc,d,*( )
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aFaculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
bDepartment of Urology, Ipswich Hospital, Queensland, Australia
cDepartment of Urology, Royal Brisbane and Women's Hospital, Queensland, Australia
dThe University of Queensland Centre for Clinical Research, Herston, Australia |
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Abstract Objective: To conduct a systematic literature review on urethral calculi in a contemporary cohort describing etiology, investigation, and management patterns. Methods: A systematic search of MEDLINE and Cochrane Central Register of Controlled Trials (CENTRAL) databases was performed. Articles, including case reports and case series on urethral calculi published between January 2000 and December 2019, were included. Full-text manuscripts were reviewed for clinical parameters including symptomatology, etiology, medical history, investigations, treatment, and outcomes. Data were collated and analyzed with univariate methods. Results: Seventy-four publications met inclusion criteria, reporting on 95 cases. Voiding symptoms (41.1%), pain (40.0%), and acute urinary retention (32.6%) were common presenting features. Urethral calculi were most often initially investigated using plain X-ray (63.2%), with almost all radio-opaque (98.3%). Urethral calculi were frequently associated with coexistent bladder or upper urinary tract calculi (16.8%) and underlying urethral pathology (53.7%) including diverticulum (33.7%) or stricture (13.7%). Urethral calculi were most commonly managed with external urethrolithotomy (31.6%), retrograde manipulation (22.1%), and endoscopic in situ lithotripsy (17.9%). Conclusion: This unique systematic review of urethral calculi provided a summary of clinical features and treatment trends with a suggested treatment algorithm. Management in contemporary urological practice should be according to calculus size, shape, anatomical location, and presence of urethral pathology.
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Received: 18 July 2021
Available online: 20 January 2024
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Corresponding Authors:
*The University of Queensland Centre for Clinical Research, Herston, Australia. E-mail address: m.roberts2@uq.edu.au (M.J. Roberts).
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Preferred Reporting Items for Systematic reviews and Meta-Analyses flowchart: data collection and selection of studies. CENTRAL, Cochrane Central Register of Controlled Trials.
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| Characteristic | Total | Male | Female | | Patient, n (%) | 95 (100.0) | 78 (82.1) | 17 (17.9) | | Age, median (IQR), year | 39 (20-54) | 35 (14-50) | 54 (50-64)?? | | Presenting features, n (%) | | Palpable urethral mass | 55 (57.9) | 43 (55.1) | 12 (70.6) | | Voiding symptomsa | 39 (41.1) | 29 (37.2) | 10 (58.8) | | Painb | 38 (40.0) | 30 (38.5) | 8 (47.1) | | Acute urinary retention | 31 (32.6) | 27 (34.6) | 4 (23.5) | | Hematuria | 8 (8.4) | 5 (6.4) | 3 (17.6) | | Investigation, n (%) | | Plain X-ray | 60 (63.2) | 52 (66.7) | 8 (47.1) | | US | 31 (32.6) | 26 (33.3) | 5 (29.4) | | Cystourethrography | 26 (27.4) | 21 (26.9) | 5 (29.4) | | CT | 20 (21.1) | 15 (19.2) | 5 (29.4) | | MRI | 4 (4.2) | 1 (1.3) | 3 (17.6)?? | | Underlying urethral lesion, n (%) | | Urethral diverticulum | 32 (33.7) | 19 (24.4) | 13 (76.5)?? | | Stricture or stenosis | 13 (13.7) | 13 (16.7) | 0 | | Urethrocutaneous fistula | 8 (8.4) | 8 (10.3) | 0 | | Other urethral abnormality | 9 (9.5) | 9 (11.5) | 0 | | No associated urethral abnormality | 44 (46.3) | 40 (51.3) | 4 (23.5) | | Associated factor, n (%) | | Coexistent bladder or upper tract stone | 32 (33.7) | 19 (24.4) | 1 (5.9) | | Previous urethral surgery | 14 (14.7) | 13 (16.7) | 1 (5.9) | | Calculus characteristicc | | Size, median (IQR), mm | 20 (10-50) | 20 (10-54) | 30 (18.5-35.0) | | Calculus location, n (%) | | Fossa navicularis | - | 8 (10.3) | - | | Penile or bulbar urethra | - | 42 (53.8) | - | | Posterior urethra | - | 22 (28.2) | - | | Posterior and anterior urethra | - | 6 (7.7) | - | | Calculus compositiond, n (%) | | Struvite | 15 (48.4) | 13 (50.0) | 2 (40.0) | | Calcium phosphate | 14 (45.2) | 12 (46.2) | 2 (40.0) | | Calcium oxalate | 10 (32.3) | 8 (30.8) | 2 (40.0) | | Urate | 5 (16.1) | 4 (15.4) | 1 (20.0) | | Cysteine | 2 (6.5) | 2 (7.7) | 0 (0) | | Initial management, n (%) | | Urethroscopy | 57 (60.0) | 44 (56.4) | 13 (76.5) | | SPC | 15 (15.8) | 15 (19.2) | 0 (0) | | Definitive management, attempt/success, n (%) | | Anterograde extraction | 11 (11.6)/3 (27.3) | 10 (12.8)/3 (30.0) | 1 (5.9)/0 | | Retrograde manipulation | 21 (22.1)/14 (66.7) | 17 (21.8)/13 (76.5) | 4 (23.5)/1 (25.0) | | Endoscopic retrieval | 7 (7.4)/7 (100.0) | 7 (9.0)/7 (100.0) | 0 | | Endoscopic in situ lithotripsy or holmium | 17 (17.9)/16 (94.1) | 13 (16.7)/12 (92.3) | 4 (23.5)/4 (100.0) | | Meatotomy | 7 (7.4)/7 (100.0) | 7 (9.0)/7 (100.0) | 0 | | External urethrolithotomy | 30 (31.6)/30 (100.0) | 19 (24.4)/19 (100.0) | 11 (64.7)/11(100.0)?? | | Urethroplasty | 11 (11.6)/11 (100.0) | 11 (14.1)/11 (100.0) | 0 | | Suprapubic cystolithotomy | 4 (4.2)/4 (100.0) | 3 (3.8)/3 (100.0) | 1 (5.9)/1 (100.0) | | Outcome | | Discharge, n (%) | 95 (100.0) | 78 (100.0) | 17 (100.0) | | Length of stay, median (IQR), day | 4.0 (2.0-6.3) | 4.0 (1.5-6.5) | 4.0 (2.0-5.0) |
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Summary of published cases on urethral calculi in a contemporary series according to sex.
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| Characteristic | Any urethral abnormality | No urethral abnormality | | Patient with individual data available, n (%) | 51 (53.7) | 44 (46.3) | | Age, median (IQR), year | 41.0 (31.0-55.5) | 29.5 (7.8-52.3)?? | | Presenting features, n (%) | | Palpable mass | 35 (68.6)? | 20 (45.5) | | Voiding symptoms | 23 (45.1) | 16 (36.4) | | Pain | 19 (37.3) | 19 (43.2) | | Acute urinary retention | 13 (25.5) | 18 (40.9) | | Hematuria | 3 (5.9) | 5 (11.4) | | Investigation, n (%) | | Plain X-ray | 28 (54.9) | 32 (72.7) | | US | 16 (31.4) | 15 (34.1) | | Cystourethrography | 20 (39.2) | 6 (13.6)?? | | CT | 13 (25.5) | 7 (15.9) | | MRI | 3 (5.9) | 1 (2.3) | | Associated factors, n (%) | | Coexistent bladder or upper tract calculus | 4 (7.8) | 12 (27.3)? | | Previous urethral surgery | 11 (21.6) | 3 (6.8) | | Calculus size, median (IQR), mm | 35 (20.0-58.5) | 12 (10.0-25.0) | | Initial management, n (%) | | Urethroscopy | 28 (54.9) | 29 (65.9) | | SPC | 7 (13.7) | 8 (18.2) | | Definitive management, attempt/success, n (%) | | Anterograde extraction | 3 (5.9)/0 (0) | 8 (18.2)/3 (37.5) | | Retrograde manipulation | 3 (5.9)/2 (66.7) | 18 (40.9) /12 (66.7)?? | | Endoscopic retrieval | 3 (5.9)/3 (100.0) | 4 (9.1)/4 (100.0) | | Endoscopic in situ lithotripsy | 9 (17.6)/8 (88.9) | 8 (18.2)/8 (100.0) | | Meatotomy | 3 (5.9)/3 (100.0) | 4 (9.1)/4 (100.0) | | External urethrolithotomy | 23 (45.1)/23 (100.0)?? | 7 (15.9)/7 (100.0) | | Urethroplasty | 10 (19.6)/10 (100.0)?? | 1 (2.3)/1 (100.0) | | Suprapubic cystolithotomy | 1 (2.0)/1 (100.0) | 3 (6.8)/3 (100.0) | | Outcome | | Discharge, n (%) | 51 (100.0) | 44 (100.0) | | Length of stay, median (IQR), day | 5 (3-8) | 2 (1-5) |
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Summary of published cases on urethral calculi in a contemporary series according to presence of any underlying pathology.
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| Characteristic | Fossa navicularis | Penile or bulbar urethra | Posterior urethra | Anterior and posterior urethra | | Patient, n (%) | 8 (10.3) | 42 (53.8) | 22 (28.2) | 6 (7.7) | | Age, median (IQR), year | 25.0 (16.3-38.8) | 35.0 (20.5-48.3) | 35.5 (7.3-47.8) | 54.0 (27.3-66.5) | | Presenting features, n (%) | | Palpable mass | 3 (37.5) | 31 (73.8)?? | 4 (18.2)?? | 5 (83.3) | | Voiding symptom | 3 (37.5) | 15 (35.7) | 10 (45.5) | 1 (16.7) | | Pain | 0? | 20 (47.6) | 6 (27.3) | 4 (66.7) | | Acute urinary retention | 1 (12.5) | 12 (28.6) | 11 (50.0) | 2 (33.3) | | Hematuria | 1 (12.5) | 1 (2.4) | 3 (13.6) | 0 | | Investigation, n (%) | | Plain X-ray | 8 (100.0)? | 24 (57.1) | 14 (63.6) | 6 (100.0) | | US | 3 (37.5) | 14 (33.3) | 6 (27.3) | 3 (50.0) | | Cystourethrography | 0 | 15 (35.7) | 6 (27.3) | 0 | | CT | 0 | 11 (26.2) | 3 (13.6) | 1 (16.7) | | MRI | 0 | 1 (2.4) | 0 | 0 | | Underlying urethral lesion, n (%) | | Urethral diverticulum | 0 | 17 (40.5)?? | 2 (9.1) | 0 | | Stricture or stenosis | 3 (37.5) | 8 (19.0) | 0? | 2 (33.3) | | Urethrocutaneous fistula | 0 | 7 (16.7) | 1 (4.5) | 0 | | Other urethral abnormality | 0 | 8 (19.0)? | 1 (4.5) | 0 | | No associated urethral abnormality | 5 (62.5) | 13 (31.0)?? | 18 (81.8)?? | 4 (66.7) | | Associated factor, n (%) | | Coexistent bladder or upper tract calculus | 0 | 7 (16.7) | 5 (22.7) | 3 (50.0) | | Previous urethral surgery | 0 | 11 (26.2)? | 1 (4.5) | 1 (16.7) | | Calculus sizea, median (IQR), mm | 8.0 (5.5-17.5) | 27.5 (10.0-58.5) | 12.0 (10.0-40.0) | 67.5 (65.0-100.0)?? | | Initial management, n (%) | | Urethroscopy | 1 (12.5)? | 22 (52.4) | 19 (86.4)?? | 3 (50.0) | | SPC | 0 | 10 (23.8) | 3 (13.6) | 2 (33.3) | | Definitive management, attempt/success, n (%) | | Anterograde extraction | 5 (62.5)/1 (20.0) | 5 (11.9)/2 (40.0) | 0 | | | Retrograde manipulation | 0 | 3 (7.1)/1 (33.3)?? | 11 (50.0)/11 (100.0)?? | 3 (50.0)/1 (33.3) | | Endoscopic retrieval | 0 | 3 (7.1)/3 (100) | 4 (18.2)/4 (100.0) | 0 | | Endoscopic in situ lithotripsy | 0 | 9 (21.4)/8 (88.9) | 4 (18.2)/4 (100.0) | 0 | | Meatotomy | 6 (75.0)/6 (100.0)?? | 0?? | 0 | 1 (16.7)/1 (100.0) | | External urethrolithotomy | 0 | 16 (38.1)/16 (100.0)? | 2 (9.1)/2 (100.0) | 1 (16.7)/1 (100.0) | | Urethroplasty | 0 | 10 (23.8)/10 (100.0)?? | 0? | 1 (16.7)/1 (100.0) | | Suprapubic cystolithotomy | 0 | 1 (2.4)/1 (100.0) | 1 (4.5)/1 (100.0) | 1 (16.7)/1 (100.0) | | Outcome | | Discharge, n (%) | 8 (100.0) | 42 (100.0) | 22 (100.0) | 6 (100.0) | | Length of stay, median (IQR), day | 1.0 (1.0-1.0) | 4.0 (2.0-6.0) | 4.5 (2.5-7.8) | 1.0 (1.0-1.0) |
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Summary of published cases on urethral calculi in a contemporary series according to stone location (males only, n=78).
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