Hairball in a urethral diverticulum has rarely been reported. These hairballs are usually formed in the diverticulum coated with a hair bearing epithelium and can lead to urinary obstruction or infection. Using laser is a safe way to ablate such stones

Bagher Tabrizi, Alireza

Hasanzadeh, Amin

Hosseini, Seyed Jalil

Mokhtarpour, Hooman

English

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Case Report  Urethroscopic Holmium: YAG Laser Ablation of Large Urethral Stone after Two-Stage Urethroplasty  Seyed Jalil Hosseini, Hooman Mokhtarpour, Alireza Bagher Tabrizi, Amin Hasanzadeh Hadad  Infertility and Reproductive Health Research Center, Reconstructive Urology, Shohada Tajrish Hospital, Shahid Beheshti  University of Medical Sciences, Tehran, Iran    Abstract:  Hairball in a urethral diverticulum has rarely been reported. These hairballs are usually formed in the diverticulum coated with a hair bearing epithelium and can lead to urinary obstruction or infection. Using laser is a safe way to ablate such stones.  Keywords: hairball stone; laser, holmium-YAG; urinary stone Please cite this article as follows:  Hosseini J, Mokhtarpour H, Bagher Tabrizi AR, Hasanzadeh Hadad A. Urethroscopic holmium: yag laser ablation of large urethral stone after two-stage urethroplasty. J Lasers Med Sci.2011;2(2):87-8  *Corresponding Author: Jalil Hosseini MD.; Associate Professor of Urology. Infertility and Reproductive Health Research Center, Reconstructive Urology, Shohada Tajrish Hospital, Shahid Beheshti university of Medical science, Tehran, Iran. Tel: +98-21-22432558, Fax: +98-21-22038462; Email:jhosseinee@gmail.com    Introduction  Two-stage urethroplasty using scrotal flap has some complications. Hair bearing urethra (1) and urethral diverticula (2), and each occurs at a rate of between 5% and 15% following hypospadias repair or urethroplasty. However, hairball stone formation in a urethral diverticulum has been reported in more rare cases (3). We present an interesting and rare case of giant hairball stone in urethral diverticulum after two-stage urethroplasty treated by Holmium: YAG Laser ablation.  Case report  A 70-year-old male presented with slowly decreasing urinary force and caliber. An open cystostomy had been performed for him in another center after unsuccessful try to pass a urinary catheter. The patient denied gross hematuria, and there was no history of urinary tract infection (UTI). There were not any constitutional signs or symptoms.  In past medical history, a history of PFUDD (urethral distraction defect associated with pelvic    fracture) was present from 30 years earlier and a two-stage urethroplasty using scrotal flap had been performed on him. The patient was symptom-free till two years before presentation, when the force and caliber of his urination was reduced. Physical examination revealed scar of previous urethroplasty in perineum (Figure 1). A solid stony mass was also palpable in perineum. The mass was not tender or painful. There was no adhesion to skin. No regional lymphadenopathy was detected.                   Figure 1. Pelvic X-ray with an opaque mass in perineum    Journal of Lasers in Medical Sciences  Volume 2  Number 2  Spring 2011 87 Urethroscopic Holmium : YAG Laser in Urethral Stone after Urethroplasty   Both testicles had normal size without any mass or nodules. Other physical findings were normal.  In urethroscopy, a wide-mouth diverticulum in penobulbar urethra was seen with a large hairball stone in it. The stone size was 3×2 cm. There was a moderate stricture proximal to the diverticulum.  We suggested the patient an excisional removal of the stone. But, as he did not accept to undergo perineostomy, we decided to use Holmium: YAG Laser to ablate the stone.  Under spinal anesthesia and in dorsal lithotomy position, cystourethroscopy was performed using a 17-French cystoscope and 0-degree lens. The stricture was dilated using coaxial urethral dilators over a guide wire. The rest of the urethra, prostate, bladder neck, and bladder were endoscopiclly normal.  A 550-micron holmium: YAG Laser fiber was used to ablate the hairball stone. Laser settings of 400 W and 1.8 Hz and 7 pulses per second were used. Urethral hairball stone destruction was performed successfully and completely. A two-prong grasper was used to remove all remaining of the stone that had not been irrigated out. The patient was discharged on the next day and the foley catheter was removed a week later.  Discussion  Skin flap urethroplasty can lead to some complications such as recurrent stricture, troublesome post-void dribbling, and diverticulum formation (4). Stones are rarely seen in the urethra and are usually encountered in men with urethral stricture and diverticulum. Urethral diverticulum and hair bearing urethra are known complications of hypospadias repair and urethroplasty. These complications are more frequent in two-stage urethroplasty rather than one-stage technique. Fortunately, the incidence of hair bearing urethra following urethroplasty is decreasing due to the prevention strategies (5). Several methods have been used to prevent the growth of urethral hair, including avoidance of the use of hair- bearing skin (6), the use of depilating agents (7), and the use of preoperative thermocoagulation procedures (8).  Urethral hair may act as a nidus for UTI and a urethral hairball may result in obstruction of the urine flow.  Hairballs forming within a urethral diverticulum   have rarely been reported. Our patient was treated due to the symptoms of urinary obstruction. On initial workup, there was no hematuria. There was no history of UTI or urinary stone.  As the stone found in the diverticulum was giant, the patient was suggested to undergo a surgical excision; but, as he did not accept to have a perineostomy, we decided to use laser. We chose the Holmium: YAG Laser, because of its familiarity to urologists, its wide safety margin when working in a closed space, such as the urethra, and its known effectiveness for destruction of the urinary stones.    Conclusion  Urethral stone and hairball formation is a complication mostly observed in patients treated with two-stage urethroplasty using scrotal flap. In order to ablate urethral stones, holmium: YAG Laser represents a minimally invasive approach that uses equipment and techniques that are familiar to the endourologists.  References  1. Barbagli G, De Angelis M, Palminteri E, Lazzari M. Failed hypospadias repair presenting in adults. Eur Urol 2006;49:887-94.   2. Synder CL, Evangelidis A, Synder RP, Stile DG, Gatti JM, Murphy JP. Management of urethral diverticulum complicating hypospadias repair. J Pediatr Urol 2005;1:81-3.   3. Crew JP, Nargund V, Fellows GJ. Symptomatic urethral hair ball and diverticulum complicating island flap urethroplasty. Scand J Urol Nephrol 1996;30:231-3.   4. Hosseini J, Kaviani A, Mazloomfard MM, Golshan AR. Monti’s procedure as an alternative technique in complex urethral distraction defect. Int Braz J Urol. 2010; 36(3):317-26.   5. Beiko D, Pierre SA, Lonard MP. Urothroscopic Holmium:YAG laser epilation of urethral diverticular hair follicles following hypospadias repair. J Pediatr Urol. 2011 Apr;7(2):231-2. Epub 2010 Oct 20.   6. Finkestein LH, Blatstein LM. Epilation of hair-bearing urethal grafts using the neodium:YAG laser. J Urol 1991;146:840-2.   7. Bagsha HA, Flynn JT, James AN, Johanston SR, Blandy JP. The use of thioglycolic acid in hair- bearing skin inlay urethroplasty.Br J Urol 1980;52:546-8.   8. Gil-Vernet A, Arango O, Gil-Vernet JR J. Gelabert-Mas A. Scrotal flap epilation in urethroplasty: concepts and technique. J Urol 1995;154:1723-6.     88 Journal of Lasers in Medical Sciences  Volume 2  Number 2  Spring 2011  

Urethroscopic Holmium: YAG Laser Ablation of Large Urethral Stone after Two-Stage Urethroplasty

https://journals.sbmu.ac.ir/jlms/article/download/2289/2047

Urethroscopic Holmium: YAG Laser Ablation of Large Urethral Stone after Two-Stage Urethroplasty

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