Massive Bladder Calculus Formation in a Child with Myelomeningocele Treated Endoscopically

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Description

Massive bladder calculus formation in children with myelomeningocele represents a complex and multifactorial urological problem that continues to challenge pediatric specialists. Although bladder stones in the pediatric population are relatively uncommon in developed regions, their occurrence in children with neurogenic bladder dysfunction remains a significant concern. Myelomeningocele, the most severe form of spinal dysraphism, results in varying degrees of lower urinary tract dysfunction, often necessitating long-term catheterization and bladder management programs. The resulting urinary stasis, recurrent infections, and chronic catheter use create ideal conditions for stone formation. Advances in endoscopic surgery, particularly the introduction of holmium: Yttrium Aluminum Garnet (YAG) laser lithotripsy and miniaturized instruments, have allowed for minimally invasive management even of large stones that previously required open surgery. Understanding the etiopathogenesis, diagnosis, and management principles of such cases is essential for preventing renal damage and improving long-term outcomes.

Children with myelomeningocele develop neurogenic bladder dysfunction due to disruption of the sacral spinal cord segments that control micturition. Depending on the level and severity of the lesion, the bladder may be overactive, underactive, or completely atonic. Clean intermittent catheterization has become the standard method to ensure regular bladder emptying and to protect upper urinary tract function. However, despite optimal care, bladder stasis and colonization by urease-producing bacteria are frequent. When adherence to catheterization schedules or sterile technique is suboptimal, urinary retention and chronic infection accelerate crystal precipitation. The composition of stones in this group of patients is most often infection related, predominantly struvite (magnesium ammonium phosphate) and carbonate apatite.

A massive bladder calculus is generally defined as a stone exceeding four centimeters in diameter or weighing more than one hundred grams. Although uncommon, such stones can form insidiously over several months or years in children with persistent urinary stasis. Their presence can lead to significant clinical consequences, including recurrent urinary tract infections, bladder outlet obstruction, hematuria, and upper tract deterioration due to back pressure changes. In severe cases, chronic infection and inflammation can contribute to bladder wall thickening, diverticulum formation, and renal impairment. Early recognition of these complications requires vigilant surveillance of children with neurogenic bladder through regular ultrasound examinations and urine culture monitoring.

Radiologic evaluation plays a pivotal role in diagnosis. A plain X-ray of the kidneys, ureters, and bladder is usually sufficient to identify radiopaque calculi, while ultrasonography provides complementary information regarding stone size, location, and the condition of the upper urinary tract. In complex cases, computed tomography can delineate anatomy, detect concurrent upper tract calculi, and assist in surgical planning. Laboratory investigations typically reveal alkaline urine and infection with urease-producing organisms. Stone analysis, once obtained, confirms the composition and helps guide preventive measures.

Historically, open cystolithotomy was the treatment of choice for large bladder calculi in children. The procedure, though effective, was associated with postoperative pain, longer hospital stays, and visible scarring. In children with myelomeningocele, who often have undergone multiple surgeries for urological reconstruction or orthopedic correction, additional open procedures pose further risks, including wound complications and adhesions. The transition toward minimally invasive techniques has been transformative.

Prevention of stone recurrence represents the cornerstone of long-term management in children with neurogenic bladder. Recurrent calculi develop in a significant proportion of patients, often within a few years of initial treatment. The most important preventive strategy remains meticulous bladder emptying through regular clean intermittent catheterization performed at appropriate intervals. Education of caregivers regarding sterile technique, catheter type, and frequency is essential. 

In the broader context of pediatric urology, the evolution of endoscopic management for massive bladder stones demonstrates how technological advances have reshaped traditional surgical boundaries. The miniaturization of optics, improvements in irrigation systems, and refinement of laser lithotripsy have collectively reduced morbidity and improved cosmetic and functional outcomes for children. These developments exemplify the trend toward minimally invasive surgery that prioritizes recovery, comfort, and long-term bladder preservation.

Conclusion

Massive bladder calculus formation in children with myelomeningocele, though rare, serves as a reminder that even advanced surgical techniques cannot substitute for diligent preventive care. The condition arises primarily from chronic urinary stasis and infection-factors that can be mitigated through education, adherence, and regular surveillance. When stones do occur, endoscopic holmium laser lithotripsy provides an effective and safe means of removal, avoiding the morbidity of open cystolithotomy. The ultimate goal remains preservation of renal function, maintenance of continence, and improvement of quality of life for children living with neurogenic bladder dysfunction.