The UTI should be treated, the stones should be removed. It is possible to remove the the residual adenomous tissue in the same session.

I agree with Dr. Claus and I think the adenomatous tissue is best managed by TUR.

According to AUA guide lines 2010, with flowmetry >or = 20ml/sec. it is risky to do prostatectomy and these risks of incontinence(urge),& persistant filling symptoms should be explained fully to the patient...however the presence of multiple stones in UB and their recurrence albeit denote the presence of some sort of infravesical obstruction, but there is another cause though uncommon but in my opinion is working in this case ( recurrence due to recurrent renal stone formation)....

Good morning my colleagues. If I faced such case I will treat him by cystolitholapaxy (crushing) of the bladder stones + TURP. Reasons: 1.He has recurrence of bladder stones for the second time (this means, there is some degree of outlet obstruction as dr.Ahmed proposed). 2.Endoscopy revealed obstructing lateral lobes of the prostate. 3.These irritative symptoms may be related to bladder stones and UTI.

But in case, if the patient is not willing for TURP , we can do crushing of bladder stones only and treat his UTI and do for him cystometry with pressure flow study to verify any evidence of obstruction before TURP in another cession if still needed.

I think the second option is logic although multistaged , but if you consider the scenario of the first choice , that the prostate is removed for no or conflicting evidence of obstruction specially with flow metry 20ml/sec. which is against the ICS definition of obstruction. furthermore , as you know our patient usually do not know the scientific basis of treatments offered to him and leave the decision for the treating doctor .....

Good evening dr.Ahmed

I agree with you in selecting the second option. Type of patient and your personal judjment regarding his preference are important factors in decision making. I did TURP for younger people but were having evident obstruction not responding to medical treatment but in such case there is some confusion as he has secondary bladder stones with UTI and good urine flow with no PVRU. So, crushing + treatment of UTI and re-evaluation of his voiding pattern may save hime unnecessary TURP.

At first we must check PSA titer and treat UTI,Then because of good urine flow 20ml/sec recection of prostate is not neccessary and if size of stones are small(sum of them less than 20 -30 milimeter )we can crush stones transurethral by Litholapaxy or Lithotripsy,but in larger stones and because of previos surgery after filling of bladder i prefer percutaneous cyctolithotripsy(PCCL) .

Dr.Sadrollah Mehrabi Actually you may find PSA a little pit high in the presence of UTI .

Good evening to all

Were cited various treatment options.

We have some data to consider: 1-Flowmetry> 15 ml / sec does not exclude outlet obstruction. 2 - Analysis of the urine flow is impaired by the presence of bladder stones. 3 - US can help in mention the thickness of the bladder wall (bladder effort ?) .4 - Cystoscopy will help to assess the degree of bladder neck obstruction and therefore the indication or not of TURP.

Thank you, I agree with No .1 but please explain more how bladder stones impair the analysis of flowmetry curve and causing 20 ml/sec bell- shaped flow, U/s examination showed thickness of bladder wall 0.5 cm while full. and of course cystoscopy will show the bladder neck but under anaesthesia other factors playing in micturition act can not be assessed well(not every BPH is obstructing and not every BPH needs TURP)

Good afternoon Dr. Ahmed

Thanks for your attention. Of course the presence of bladder stones usually creates a difficulty in emptying the bladder and the flowmetry is not as good as 20 ml/sec. I meant that generally the analysis of flowmetry is impaired by the presence of stones in the bladder and so the reference number 2 is not applicable to this case . I add that not all BPH needs treatment. Congratulations. Your case is very interesting.

Thank you, I hope all the best for you

This person was operated for stones and still ultrasoind shows bladder stone, have you worked up for repeated stones as 24 hours uriney calcium oxalates citrate levels

this patient is stone former and I agree with you that he needs metabolic assessment of blood and urine work up...and i think that the proper timing for that is 1 month after removal of his stones... to allow for stone analysis and after his UT settle down....

Dr Maher,

Very interesting case. Shows that young men can have bladder stone without prostatism. I would ask for urodynamics to understand the physiopathology of stone formation in his case. Either this is normal and I would propose the removal of stones only or there is asymptomatic high pressure obstruction and I would go for TUR. Yours

with high pressure obstruction there should be a pop off mechanism, either reflux into one or both ureters, diverticula formation or in the form of incontinence, in our case there were neither , so TUR of the prostate carries such risk of incontinence and should be discussed properly with the patient....

In a young patient with PH of bladder lithiasis, after antimicrobic treatment and endoscopic laser stone defragmentation and evacuation, urodynamic evaluation should be done.

Right, a step by step approach to such problem is better than having patient with incontinence, whatever the technology used in treatment.

as the pt has history of LUTs with recurrent bladder stone,with enlarge prostate,he needs TURP along with stone removal. hope u got it.

Actually the decision is not that easy ,you should consider the prognosis and sequelea of treatments offered to such case, you do not want to convert a continent patient into incontinent one.....

I would recommend pressure/flow study to determine if he is obstructed even with high flow rate, specially if he has high residual urine. Ultimately he may need bladder outlet reduction procedure plus cystolithotripsy. My preference would be Prostate Photovaporization and Holmium laser lithotripsy.

thank you Prof. ghoneim, actually the plan was the same but the presence of multiple bladder stones made a priority to removal of the stones endoscopically first followed by P/Q study to determine BOO.Prostate photovaporization will be the best, but apart from its costs does it confer advantage over bipolar vaporization...

Just because he has a max flow of 20 and no residual he still has an obstructed prostate. He needs a SPP with removal of all calculus. Then three months later do a 24 hr urine collection.

@zaghloul: i glad to know that your plan is the same i sadid u before. bladder stone in this case secondary to BOO. and no reccomendation still present for metabolic evaluation. u may go for urodynamic study.but i think urodynamic wil not help u in decision making. what do u want to know from prssure flow study? the answer is present already.

Dear Rajendra Ray please review the early answers for more clarification..of the problem