-Do you know what you're doing for lunch? -Not yet, but I am really hungry!
-Do you smell something? -Yeah, it smells like it's coming from in there.
-Okay, mm... -Maybe we can see what it is.
-Oh, what is that? -That looks nasty.
Oh, yep, that's it, that's the one!
That's... really bad sour cream...
-Hi, I'm Anna Dhody, Curator of the Mütter Museum, and welcome to another very special
Mütter unboxing because this time, I have Dr. Albert Ruenes from Doylestown Health.
And he is actually the one who is bringing us this specimen. So he obtained it for us
and is bringing it to us today. And I don't think we're going to explain what it is first,
we're just going to open it up and show it, because I'll say I've seen pictures, so I
sort of know what I'm getting into. -All right, fair enough. -So let's do this!
-As long as you know. -Dun, dun, duh!
I think people know that I'm not very good with the tape, so just, so you know, there's
no tape today! So I don't have to go cutting around. And I'm gonna lift it up. -I made
it easy that way, I saw some of those videos. -Wait, you saw my...? -I saw you trying to
unbox other things. -In my self-defense, when we were doing the heart unboxing video,
we had donated all of, not only our PPE, but our medical supplies to hospitals. So when
we got it, I was left with a dull, like, one of those mail cutter, boxes things, so that's
why. -Okay... -So I know how to use a scalpel! Let's just go... -All right. -So obviously
biohazard bag and, oh wow, yep. This is a sealed jar, but let me tell you, folks listening
at home, if you had smell-o-vision, you would not be happy with this right now. -It's like
a good cheese. -What type of cheese do you eat?
Sure, it's like good cheese that has been aged in a body of something. -Yeah, that's
not good. -Wow, okay so this smells this bad in a sealed jar!
The things I do for you people, the things I do for you people. -This is only gonna get
worse. -This is only gonna get worse! Oh my God. Oh God... First of all, it's wet. And
it's... Oh my God! I didn't realize how big this was. All right, so why don't you tell
the folks at home what we are--I'm not going to say seeing--what we are experiencing with
many of our sense. -Sure, sure. What unfortunately you at home are not experiencing, is the odor
of this, but what's here in my left hand is a stone that formed in a patient's bladder.
What you're seeing coming out of the stone is a medical device called a "stent" and that
curl at the top resided in this patient's kidney. The length of that stent then ran
the course of her ureter tube. And what you're not seeing, embedded in the middle of this
large stone, is another curl that would have been at the bottom of that stent in the patient's
bladder. -Wow, so let's say people, if you're looking: bladder, and then going all the way
up, and kidney. So you can see that's why it has to be this long, so that gives you
an idea of how long your ureters are, and how long the urine has to travel from your
kidneys to your bladder. So let's just talk about how something like this could possibly
form because it's forming around this medical device. Take us back to what happened in order
for this to happen. -Sure. So this story obviously has something to it because it's not the typical
kidney stone, bladder stone, stent story. So this stone was not present in the bladder
initially. This was a patient, 51 years old, who I adore, but has come to drive me crazy.
I met her first in March of 2020 at Doylestown Hospital when she was admitted with pyelonephritis,
an infection of her kidney, but complicated by large stones within her kidney. So the
stones in her kidney were harboring infection, she came in septic. She had not only a complicated
urinary tract infection, but she had bacteremia, blood in her urine. So she had bacteria in
her urine, bacteria in the bloodstream. So all we could do at that time, because she
was so sick, was to temporize her. So I placed a stent. The stent went from the bladder up
to the kidney to almost drain an abscess that was in the kidney. So it was a path of egress
for the infection, so that her antibiotics would work better. So after about seven to
ten days of antibiotics, she had recovered sufficiently well. She was discharged home
from the hospital. And because it was the height of COVID, she had plans to do a telehealth
with me, which just never happened. At the time of that scheduled telehealth, she was
going to make plans to have her kidney stone procedure done. And then, three months later
she gets hospitalized with infection in that kidney again. X-ray shows that this stent
is in good position, but the bottom is free of any bladder stone. She was supposed to
be here months ago and it's not surprising that she's sick. We made plans to do lithotripsy,
to use sound waves from outside to break the big stone in the kidney, and have those fragments
pass along the ureter down to the bladder to clear her in a minimally invasive way.
-Will the stent still have been in there? -That's right. Now these stents are designed
to remain inside a person's body anywhere from as short as three or four days, following
a simple stone procedure, to as many as maybe three to four months following some reconstructive
surgery. So we use them for other things in urology, not just for stent surgery. She comes
back, she has that surgery. It's done in a minimally invasive fashion with sound waves
and, shame on me, she's supposed to come back and see me three weeks later to get the stent
removed. So that was July of 2020. She doesn't show up, she doesn't show up, she doesn't
show up, and we lose track of each other. She ends up in our emergency department with
a urinary tract infection. They call me, they discharged her home, they thought it was a
straightforward infection. She failed to tell them that she had a stent placed and hadn't
had it removed. So when I got that culture report across my desk, I called her and said,
"You need to get an x-ray from me because this stent now has been in there far too long."
-What was the time? Like, how many months at this point? -Now it's a year and a half.
-Oof, okay. -Yeah, too long. Surprisingly, you know, most people who have a stent hate
them. If you talk to anybody who's had stone surgery, right? Yeah! -Three days, I think.
-So stents are irritating, aggravating, annoying. Most people can't wait to get them out. -She
goes eventually to the hospital, gets an outpatient one-shot x-ray, and on that x-ray--to my horror--not
only is the proximal, the upper curl, in the kidney, but now there's more stone there than
there was before her procedure, a year earlier. And then, it looked like there was an egg
in her bladder that was so unusual and large, that at first I thought, "There's no way that
could be a stone. It must be some artifact, something that was in her pocket in her pants
when they took the x-ray." -Oh yeah, yeah... Nope. -Uh, no. So I brought her into the office,
I put a scope into her bladder, and basically this filled her decompressed bladder. -Oh
my gosh! -So now we've got a problem because this is, you know, an older stent, but you
can see ,it's got this memory. It's constructed so that it can straighten out over a wire.
If you pull it out, it'll straighten out. But the upper curl was locked in the kidney
stone, which would resemble this but was smaller. -Oh wow, okay. -And then this lower curl is
locked in this stone, so none of it could be pulled out. Now she's got what we call
a "retained stent." Brought her back to the hospital just about two months ago. Through
a scope that we put in through her flank into the hollow of her kidney, Dr. Roland and I,
one of my partners, were able to drill out and break up the stone that was on this upper
curl, freeing it. She was prone for that, so she was on her belly, intubated. Before
we extubated her, we turned her belly side up, and then through a pfannenstiel, a lower
abdominal transverse incision, I opened her bladder, grabbed the stone, and from there,
pulled the specimen out. -Wow. -Sewed up her bladder, closed up her incision, and when
you do that, you have to put in another stent. -Yeah, uh-huh. So what is the function of
the stent? Why do you need the stent in there? -So after a surgery like that, you know, you
can imagine the diameter of that ureter tube is only a few millimeters, and that inside
lining is like any mucous membrane in your body. So once it's beaten up, it'll swell
a little bit, and it doesn't take much swelling to close off that ureter. So yeah the stent
is designed to keep that ureter open so that the patient doesn't end up with a complicated
infection, abscess, or sepsis again. -So what is shocking to me is that, you know, a year
and a half when it comes to a stone formation, to me, seems like such a short period of time
to have something so big. -Yeah, so that's what makes this kind of unique. And everybody's
urine chemistry is different. I mean I have some patients who have permanent stents that
I change now as infrequently as once a year. -Oh my God. -And they do not get encrusted.
What happened here is, this is a particular type of stone called a "struvite" stone, which
is an infection stone. So there are certain bacteria that will accelerate the growth of
stones. -So let's talk about that really briefly because my brief understanding of stones is
that the vast majority of people who get these types of stones, are they more calcium based?
-Yeah, exactly. -So what is that, like 80%? -Yeah, the most common stone is calcium oxalate,
probably the one you had. -Yes, yes, it was. They tested it! -Calcium oxalate stone, and
any kind of stone, regardless of whether it's an infection stone, calcium oxalate stone,
cystine or uric acid stones, form because there's a super saturation of minerals, right.
That's what ultimately causes a stone to form. What those minerals are determines what type
of stone it is. So when we saw this x-ray, we thought, "Well, there's no way. There's
no way that's a stone. There's no way that's a stone that big even though it is a year
and a half. -Wow! So I know there's probably people out there who've had, what we call
a "kidney stone" or "stone attack," you know, and it's a pain that everybody describes differently.
And you know, for me, it was definitely one of my top three most painful experiences of
my life. But that was, from my understanding, because the stone was trying to make a break
for it. It was trying to move and then it couldn't. Now this one was already in her
bladder, and let's just say there was no way that could have formed in the kidney and made
its way down. -Exactly. -So there's stones that form in the kidney and they they may
or may not try to move, and those are very small usually. But that movement and getting
stuck is that pain that people experience. -Right. -So if somebody has a bladder stone,
does it hurt as much? -So bladder stones are most common in men, and they result generally
from stagnation in the urine and settling out of minerals in the lower portion of the
bladder. The symptoms of that are going to be, you know, heightened urgency, frequency
to urinate, maybe some burning when you urinate, and blood in the urine on occasion. This patient
had all of those except blood. -Really? -Yeah, remarkably or at least to what she-- -It's
not a spiky one though. -So right, so this is not like one of those jack stones that
we have upstairs, those bladder stones that look like kind of sea mines. -I was just going
to say, they look like in Finding Nemo, those mines. -Right, yeah, this is more like, you
know, you wouldn't put this on a necklace, but it's more like a pearl. -I can't believe
I just touched it. It's grainy. -Yeah, it's grainy. -And it's... yeah. -Yeah. So it formed
layer upon layer around this. So it probably first made a ring, a calcified ring, and then
almost like, you know how a pearl, a grain of sand in an oyster will create a pearl,
right? So this... -Human pearl! Wow, that's not a jewel that I would wanna wear... -That's
not something you'd wear around your neck.
Not today. -Do bladder stones form independent of a kidney stone? Or could you have also
a kidney stone that makes its way down the ureter and goes into the bladder, and then
has the opportunity to get bigger? -That's a great question and the answer is yes to
both of those. A lot of bladder stones form de novo in the bladder, but probably more
than we come to realize originate in the kidney, drop down the ureter, get stuck in the bladder,
and then and grow to a larger size. Now you're right, a stone like this is never going to
be passed out the urethra, the tube we urinate through. The stone that she had up in her
kidney was never going to drop into this ureter and make its way down. Unfortunately, she
was never in tremendous pain or she'd have found her way back. -Yeah, that pain, let's
face it, pain is the great motivator to get medical attention. And to be clear, for those
lucky enough that have never had a kidney stone attack, I couldn't imagine you not going
to get help because it is chronic. Like I've had labor contractions, too. Those come and
they go, but one of the hallmarks of the kidney stone pain is absolutely unremitting, constant,
quite significant pain. And you're writhing around and you're going into all different
positions because you're convinced that you're going to find that one position that's going
to make the pain lessen. You're not, trust me on that, what's going to lessen the pain?
Dilaudid. -Yes,
-That was the only thing that did it for me. -And it's magical. -It is so magical. I'm
not promoting recreational drug use, please know that, but when you are having a kidney
stone attack... And I'll say one thing, my funny personal story on this one and--they
know I share way too much. I went to the hospital, I went to the emergency room, they had me
go in the thing. I'm just like moaning and writhing. -They knew what you had. -Yes, they
did, but the nurse comes in and says, "Well, we cannot by procedure give you any medication
until the doctor sees you." And he's got like five more patients. You know what I found
out? If you throw up on the nurse's shoes, suddenly the doctor comes right back in. And
that was a very unique sensation because I've heard other people have those kind of stories,
like "it hurt so much, I threw up." -Yeah, yeah. -I never understood, what does nausea
have to do with pain? -Right, it's bizarre, right? And that's one of those things. -I
wasn't even nauseated. -The dry heaves, and all of a sudden, you're just retching. -That
base part of your brain, I think they're saying, "Something so bad is going on, you're going
to have to eliminate what's in your stomach so you can run and save your life." -Yeah,
I think it's just such a violent upheaval of the stomach, and the visceral nervous system.
And, interestingly, you know the pain of a kidney stone is not the stone scratching or
working its way down that tube. It's not a sharp pain like that. The pain comes from
the fact that, if the stone is in the upper part of the ureter, blocking the kidney, that
urine that the kidney is still making can't get past it to the bladder. So the pressure
builds up. So a lot of people, when they first have a kidney stone, think, "Man, if I could
just move my bowels or pass some gas, I'm going to feel relief," because it's that gas
crampy pain. And then that doesn't happen. -Nope. -And the pain gets worse, and then,
you're right, you're on your knees, dry heaving. -Yeah, then what they give you is a very undignified
little colander or sieve that you're supposed to pee into. So for me, I did that for weeks
and it was just not going anywhere. And I love that they gave me a men's prostate medication.
-Oh yeah, tamsulosin, Flowmax. Generic Flomax, tamsulosin. -Yeah, Flomax!
When you go to the pharmacy and they're like, "Yeah, this is in your husband's name." "Nope,
for me." Don't judge!! I love the fact that there's different drugs and some of them, and
they have multiple different uses, but the idea was to try to get me to pass it, which
from what I gather would not have been a picnic. But it would have probably been better than
what they did, which is, they didn't do the lithotripsy. They did it with a scope, they
called it a "basket" something. What's it called? -Right, so they took a a small scope,
an endoscope, went into the bladder, then found that opening. So this would enter the bladder
about here, through a pinpoint opening into the bladder. So they went up into this ureter
tube by the scope and then a tiny laser fiber or just the basket, a little collapsible basket,
and they either broke that up first and basketed those fragments or they basketed your stone
whole and removed it. And then they put in your stent. -So I said that I wanted it whole,
obviously, because I wanted it in the collection. -Disappointing specimen. -Oh, it was 3 mm!
And I feel so inadequate, I feel so inadequate. But I will say, that
one 3 mm caused me more pain than I experienced in my life. And the funny
thing is, I did not prepare well because I should have gone to the collection and tried
to find it, and been like, "Compare it!" But I do have it somewhere, but we're doing some
kind of renovations and stuff. But if I can find it or I'll find a picture of it because
I did turn it into my Christmas card that year. -Nice! -Because they gave it to me in a
little vial and it still had a little blood in it. And it was like a red vile. -It didn't smell like this?
-I've never opened the vial because I was afraid of breaking the seal, so it's still in the glass
vial, it had a red top and I tied a green bow on it. And of course you know what it said,
right? "Hope your holiday rocks!" Now you know what it's like to have me as a friend. It's
almost as painful as the kidney stone! At least that's what they said. -And listen, in your defense,
the amount of pain that someone experiences is not directly related to the size of the stone.
-There you go, thank you! I feel much better. -It's all about the degree of obstruction that's
created by that stone and the urine not able to get past it. -I'm telling you, and like drop
some comments online, tell us your stories about your, whatever stones you want to tell
us about. But I will say that, to this day, if I ever like get any kind of twinge there, you
just kind of have to stop and go, "Oh, is it happening? Is it happening?!" And you're like,
"Oh, please no, please no! I've been drinking water!" And then it comes, it passes, and you're
like, "Okay..." -Right, so in our office, we always take special notice when a patient who's had
a stone calls up and says, "Oh no, this is my kidney stone pain." I mean, you have to
do it one, you know it. -You respect it, it's a pain like... -We do, when they say that because we trust
that they know what they're talking about. -Yeah, it's like, "Oh, I've been down this road before."
And I can say that it's been many, many years, and I've not had a recurrence. I mean, we don't
know for sure, I guess technically I could have could have some... -In there and not know it.
-That's a new level of anxiety, right?
-And also, I almost brought my hands too close to my face.
-No, don't rub your nose! Oh my God... -Yeah, no. -That'll linger...
-So grab it by the stone, and then you can, you know, stone down below
and the tip of the stent up top, and that'll kind of orient it.