Multiple impacted urethral calculi within a large bulbar urethral diverticulum complicated by urethrocutaneous fistula: a case report

Introduction: Urethral calculi are rare and are often associated with underlying urethral abnormalities such as strictures or diverticula. Chronic impaction may cause obstruction, infection, tissue erosion, and, rarely, urethrocutaneous fistula. Case presentation: A 72-year-old man presented with progressive voiding difficulty, urinary leakage, and an enlarging penile mass. Retrograde urethrography demonstrated a bulbar urethral diverticulum containing calculi with contrast extravasation through a urethrocutaneous fistula. Urethroscopy showed complete obstruction by multiple impacted calculi. Suprapubic cystostomy was performed, followed by 2 months of urethral rest. Perineal exploration identified an 80 × 40 mm diverticulum containing four calculi measuring 35, 25, 20, and 15 mm. The fistulous tract, which communicated directly with the diverticulum, was excised together with it, leaving a 55-mm longitudinal urethral defect with preservation of the posterior wall. Tension-free one-layer primary repair was performed without spatulation, followed by spongioplasty. At 1 month, retrograde urethrography showed no extravasation. At 3 months, the patient showed no micturition complaints and reported an adequate urinary stream. Discussion: While uncomplicated urethral calculi are often managed endoscopically, complex cases involving large stones, diverticula, and fistulae necessitate open surgical excision and primary urethral reconstruction. This case is distinguished by multiple calculi within a large diverticulum, direct diverticulum–fistula communication, a substantial urethral defect after excision, staged urinary diversion, and tension-free urethral and spongiosal reconstruction. Conclusion: Staged urinary diversion followed by diverticulectomy, fistula excision, and primary urethral reconstruction achieved satisfactory early anatomical and patient-reported functional outcomes. Longer follow-up is required to assess late stricture, fistula, and stone recurrence.