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54 Challenging Concepts in Urological Surgery
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Figure 5.6 Fragmented stone particles slide out through the urethral Amplatz.
From Kumar et al. J Surg Tech Case Rep. 2013 Jul;5(2):109– 111.
entrapment sac, an Amplatz sheath can be inserted into the bag; the nephroscope and
lithotripsy device can then fragment and evacuate the calculi without the need to ‘chase’
fragments around the bladder.
● A ‘twin Amplatz sheath’ technique has been described in females with bladder stones >5 cm. The
stone fragmentation is performed via a suprapubic 30 Fr Amplatz sheath, while a second 28 Fr
sheath is placed via the urethra. With the patient positioned at 20o ‘feet down’, the bevelled end
of the sheath is placed at the bladder neck to act like a ‘water slide’ so that fragments wash out
passively via the urethral Amplatz tube.
Expert comment Stone size
Stone size is crucial in determining the operative approach.
Assuming a stone is a sphere, its volume can be calculated according to the formula V = 4/ 3 × π × r3.
Figure 5.7 shows the exponential increase in stone volume as the diameter increases in 5 mm
increments, such that a 40 mm stone has a volume eight times as much as a 20 mm stone and a
50 mm stone has a volume nearly 16 times as much.
Assuming the stone is purely fragmented (as opposed to ‘dusted’ and washed out), Figure 5.7 also
shows the number of fragments that need to be created to be retrieved via scopes of different
diameter, that is, a 22 Fr cystoscope, 26 Fr resectoscope, or removed with grasping forceps via a 30 Fr
Amplatz sheath. These values help demonstrate why a PCCL may be a better choice than a urethral
approach for a 35– 40 mm stone (particularly if the urethra would not accommodate a scope with a
larger calibre), and why an open cystolithotomy and lifting out a single stone >60 mm (which has a
volume 27 times as much as a 20 mm stone) is likely to be a faster operation, and guaranteed to be
totally stone free, than a PCCL for this size of stone.
600
500
Diameter of stone in mm
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400
300
200
100
55Case 5 Bladder stone management
0
Number of stone fragments
Fragments for 22 Fr sheathFragments for 26 Fr sheathFragments for 30 Fr PCCL
Stone
diameter (mm) Volume (cc)
No. of fragments
for 22 Fr sheath
No. of fragments
for 26 Fr sheath
No. of fragments
for 30 Fr PCCL
563 1 1 1
10 500 5 2 1
15 1688 16 8 5
20 4000 37 19 11
25 7813 72 37 21
30 13,500 125 64 37
35 21,438 198 102 59
40 32,000296 15288
45 45,563422 216125
50 62,500579 296 171
Figure 5.7 Stone diameter, volume, and fragments. The calculated stone volume as a spherical
stone increases in 5 mm diameter increments, with the number of fragments this would generate
to be removed via sheaths of increasing calibre from 22Fr cystoscope to 26Fr resectoscope to a
30 Fr Amplatz sheath. The curves for number of fragments show divergence around 30– 40 mm
(i.e. where PCCL may be faster and more effective than a urethral approach) and are widely
separated by 50 mm (i.e. where open cystolithotomy and removal of whole stones in single figures
is likely to be the preferred treatment).
Expert comment Neobladders and neuropaths
Augmented bladders
● Patients with augmented/ neobladder formation are at increased risk of urinary tract infections
due to poor drainage and the presence of mucus. All three of these factors predispose to stone
formation, which are often large or complex requiring percutaneous or open stone removal.
● After stone removal, bladder drainage should be optimized, which may include more frequent
self- catheterization and/ or saline bladder washouts. Metabolic assessment including the stone
56 Challenging Concepts in Urological Surgery
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biochemistry and urine pH may help with preventative advice (e.g. calcium phosphate stones in
association with alkaline urine may benefit from urinary acidification).
Neuropaths
● Patients with a high (i.e. cervical) level injury and those undergoing procedures with more than one
modality have been shown to be more likely to have a postoperative complication and longer length
of stay than lower level cord injury or stone burdens that can be treated with a single modality.
Clinical tip Treatment tips and tricks
● Stone treatment is a balance between sufficient irrigation to afford good vision for fragmentation
while avoiding overdistension of the bladder, particularly in a thin- walled neobladder.
● The inflow of saline should be as slow as vision permits, and can even be stopped and the
drainage outflow opened on the cystoscope to allow the bladder to empty and dust to drain while
continuing to treat the stone. This requires care not to empty the bladder fully, risking laser damage
to the urothelium. as vision will be lost as the bladder collapses around the scope.
● The use of an Amplatz working sheath via the urethra to facilitate access, irrigation and drainage,
and fragment removal has been described in both male and female patients after prior urethral
dilatation. This allows small stone fragments to drain with the irrigating fluid while larger fragments
can be retrieved using grasping forceps in an analogous fashion to PCNL.
● Balloon dilatation for PCCL offers a rapid single- step method to create the track, but may not work if
there is significant fibrosis (e.g. a pre- existing suprapubic track). If so, alternative approaches include
metal dilators via the existing track, or a separate percutaneous puncture and creation of a new track.
● Following PCCL, the timing of suprapubic catheter removal depends on the circumstances— if
neobladder remove suprapubic catheter first, let the wound site heal, and then remove the
urethral catheter. If stones are likely secondary to bladder outlet obstruction, and this has not been
treated during the procedure, the urethral would be removed first for a trial of voiding, leaving the
suprapubic catheter clamped as a ‘fail safe’.
Case history 6: large- volume neobladder
A 57- year- old man who had undergone a radical cystoprostatectomy and neobladder reconstruction 4 years previously had haematuria following performing self- intermittent
catheterization per urethram. A CT scan showed seven spherical/ tetrahedral bladder
stones 20– 30 mm in maximum diameter (Figure 5.8). These were considered too large
a stone burden to manage endoscopically due to the potential for multiple procedures
or injury to the neobladder wall from a stone fragment. As such, an open surgical
removal was performed, extracting all seven stones whole. A postoperative cystogram
showed all stones had been removed and confirmed no leak from the neobladder before
removing the urethral catheter and resuming clean intermittent self- catheterization.
Clinical tip Open stone removal
Patients with large bladder calculi (perhaps 5 cm or larger) have traditionally been managed with
open cystolithotomy. Endoscopic management with cystolitholapaxy or electrohydraulic lithotripsy
can be more challenging for stones this size and above— procedures take longer and views are poorer
owing to the higher volume of stone fragments and dust. In turn, this means a greater chance of
bleeding and bladder damage (especially in the case of a thin- walled neobladder). Stone- free rates
are therefore lower for endoscopic management of large stones so it is often preferable to lift out
the stones whole through an open cystotomy, and thereby ensure a stone- free bladder in a single
procedure.
Figure 5.8 Large- volume neobladder. This CT KUB scan shows seven spherical/ tetrahedral bladder
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stones between 20 and 30 mm in maximum diameter in a neobladder. The ‘bone windows’ images
underneath show their laminated structure. These were removed whole by open cystolithotomy.
57Case 5 Bladder stone management
Learning point Choice of treatment
● If the appropriate modality of treatment is chosen, stones should be fully cleared in a single sitting.
● Nephroscopic stone treatment (either transurethrally or percutaneously) with combined pneumatic/
ultrasound fragmentation allows suction via the treatment probe, improving the endoscopic vision
and the ease of removing small stones/ stone dust.
● Transurethral nephroscopic treatment for larger stones is usually faster than treatment with a
laser via a cystoscope, but is associated with a greater number of urethral passages of the scope
(including an initial and final cystoscopy to assessment the stone burden).
● The percutaneous approach is more effective for patients with larger stones, especially if these are
in a neobladder, and has a lower risk of urethral trauma/ postoperative stricture than the urethral
approach. It is therefore particularly useful if the urethral route is difficult or impossible (urethral
stricture, artificial urinary sphincter, bladder neck closure).
● The disadvantage of PCCL is the added risk from suprapubic access compared with ‘natural orifice’
urethral surgery, which increases the morbidity of the procedure. Accordingly, PCCL patients
generally require more analgesia, have a longer length of stay, and have the risk of wound infection
at the suprapubic access/ postoperative catheter site.
● Transurethral and percutaneous treatments can be performed under local anaesthesia in selected
patients, with holmium laser lithotripsy using a flexible cystoscope the logical ‘next step’ if SWL is
inappropriate or ineffective.
Evidence base Stone- free rate for different treatments
A systematic review of bladder stone treatment, published in European Urology in 2019, assessed 25
studies including 2340 patients with the following conclusions:
● The stone- free rate (SFR) for adults with bladder stones is lower with SWL than TUCL.
● SFRs for TUCL were equivalent for laser and pneumatic stone fragmentation.
58 Challenging Concepts in Urological Surgery
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● SFRs were the same for TUCL and PCCL but with a shorter procedure duration (approximately a
10- minute saving) and hospital stay (0.8 days).
● SFRs were the same for open cystolithotomy versus TUCL and PCCL, with shorter procedures
catheterization time and hospital stay for the endoscopic approaches (but the reviewers
commented that this was based on low quality of evidence).
● SFRs were the same for TUCL using a nephroscope or a cystoscope but shorter by a mean
difference of nearly 23 minutes with a nephroscope.
A final word from the expert
As stone volumes increase, so does the number of fragments created when treating them.
Although SWL may be appropriate for small- volume stones <10 mm (especially if aiming
to avoid general/ regional anaesthesia), the mainstay of stone treatment is performed as an
endourological procedure. This is achieved per urethram in the majority of cases, reserving
the percutaneous approach for larger- volume stones (30– 40 mm or more), particularly in
patients with complex anatomy (lack of urethral access or bladder reconstruction). Open
surgery is needed in a small minority of patients, generally because of huge stones of
50– 60 mm or more.
Provided the stone size is appropriate, endoscopic treatments have excellent (i.e. close to 100%)
stone clearance rates with shorter catheter dwell time and faster convalescence than open
surgery. TUCL has less risk and a shorter hospital stay than the percutaneous approach so is the
treatment of choice for bladder stones when feasible; the use of a nephroscope via the urethra
provides a rapid, safe, and effective means to treat bladder stones with a long- term urethral
stricture rate similar to a cystoscopic technique.
The ‘index patient’, that is, a man with bladder stones secondary to benign prostatic
enlargement, can safely have both issues treated at once. Simultaneous holmium laser
enucleation of the prostate and holmium laser cystolitholapaxy increases the total operation
time, but does not influence the risk of important postoperative complications or treatment
outcome. Stones of any size and composition, and prostates of practically any size can be
treated endoscopically using the holmium laser. TURP can also be combined with PCCL as
a faster alternative to TURP following TUCL in patients with large bladder calculi and large
prostates, reducing the fragmentation time for the former and using the suprapubic access site
as an outflow channel to improve the vision during the latter.
Adaptations to PCCL include the use of a bladder evacuator to wash out fragments via the
Amplatz sheath, or deploying a laparoscopic entrapment sac to retain the stones in close
proximity of the nephroscope for treating them. These modifications facilitate the treatment of
larger calculi, including those in urinary diversions, to achieve complete stone clearance in a
single sitting.
In conclusion, the combination of endourological techniques allows a bespoke approach to
manage bladder stones in most situations, and will no doubt continue to extend the threshold
for open cystolithotomy, and thereby confirm John Wickham’s observation that ‘only the largest
renal tract stones still require open surgery’.
Further reading
History/ overview/ general references
DeFoor W, Minevich E, Reddy P, et al. Bladder calculi after augmentation cystoplasty: risk fac-
tors and prevention strategies. J Urol. 2004;172(5 Pt 1):1964– 1966.
Donaldson JF, Ruhayel Y, Skolarikos A, et al. Treatment of bladder stones in adults and chil-
https://t.me/med1917
dren: a systematic review and meta- analysis on behalf of the European Association of
Urology Urolithiasis Guideline Panel. Eur Urol. 2019;76(3):352– 367.
Papatsoris AG, Varkarakis I, Dellis A, Deliveliotis C. Bladder lithiasis: from open surgery to
lithotripsy. Urol Res. 2006;34(3):163– 167.
Philippou P, Moraitis K, Masood J, Junaid I, Buchholz N. The management of bladder lithiasis
in the modern era of endourology. Urology. 2012;79(5):980– 986.
Stav K, Dwyer PL. Urinary bladder stones in women. Obstet Gynecol Surv. 2012;67(11):715– 725.
Wickham JE. Treatment of urinary tract stones. BMJ. 1993;307(6916):1414– 1417.
Technique
Bansal A, Kumar M, Sankhwar S, et al. Prospective randomized comparison of three endoscopic
modalities used in treatment of bladder stones. Urologia. 2016;83(2):87– 92.
Breda A, Mossanen M, Leppert J, Harper J, Schulam PG, Churchill B. Percutaneous cystolithotomy
for calculi in reconstructed bladders: initial UCLA experience. J Urol. 2010;183(5):1989– 1993.
Elbahnasy AM, Farhat YA, Aboramadan AR, Taha MR. Percutaneous cystolithotripsy using
self- retaining laparoscopic trocar for management of large bladder stones. J Endourol.
2010;24(12):2037– 2041.
Ener K, Agras K, Aldemir M, Okulu E, Kayigil O. The randomized comparison of two different
endoscopic techniques in the management of large bladder stones: transurethral use of
nephroscope or cystoscope? J Endourol. 2009;23(7):1151– 1155.
Eyre KS, Eyre DW, Reynard JM. Morbidity associated with operative management of bladder
stones in spinal cord- injured patients. Spinal Cord. 2015;53(11):795– 799.
Floyd MS Jr, Stubington SR. Mitrofanoff cystolitholapaxy: an innovative method of stone clear-
ance in a hostile abdomen with an inaccessible urethra. Urol J. 2015;12(2):2115– 2118.
Kara C, Resorlu B, Cicekbilek I, Unsal A. Transurethral cystolithotripsy with holmium laser
under local anesthesia in selected patients. Urology. 2009;74(5):1000– 1003.
Kumar A, Dalela D, Dalela D, Goel A, Paul S, Sankhwar SN. The twin Amplatz sheath
method: a modified technique of percutaneous cystolithotripsy for large bladder stones in
female patients. J Surg Tech Case Rep. 2013;5(2):109– 111.
Loeb S, Semins MJ, Matlaga BR. Novel technique for fragment removal after percutaneous man-
agement of large- volume neobladder calculi. Urology. 2012;80(2):474– 476.
Okeke Z, Shabsigh A, Gupta M. Use of Amplatz sheath in male urethra during cystolitholapaxy
of large bladder calculi. Urology. 2004;64(5):1026– 1027.
Paez E, Reay E, Murthy LN, Pickard RS, Thomas DJ. Percutaneous treatment of calculi in recon-
structed bladder. J Endourol. 2007;21(3):334– 336.
Teichman JM, Rogenes VJ, McIver BJ, Harris JM. Holmium:yttrium- aluminum- garnet laser
cystolithotripsy of large bladder calculi. Urology. 1997;50(1):44– 48.
Tugcu V, Polat H, Ozbay B, Gurbuz N, Eren GA, Tasci AI. Percutaneous versus transurethral
cystolithotripsy. J Endourol. 2009;23(2):237– 241.
Wollin TA, Singal RK, Whelan T, Dicecco R, Razvi HA, Denstedt JD. Percutaneous suprapubic
cystolithotripsy for treatment of large bladder calculi. J Endourol. 1999;13(10):739– 744.
59Case 5 Bladder stone management
Benign prostate hyperplasia and stones
Aron M, Goel R, Gautam G, Seth A, Gupta NP. Percutaneous versus transurethral
cystolithotripsy and TURP for large prostates and large vesical calculi: refinement of tech-
nique and updated data. Int Urol Nephrol. 2007;39(1):173– 177.
Bosco PJ, Nieh PT. Extracorporeal shock wave lithotripsy in combination with transurethral
surgery for management of large bladder calculi and moderate outlet obstruction. J Urol.
1991;145(1):34– 36.
Nseyo UO, Rivard DJ, Garlick WB, Bennett AH. Management of bladder stones: should trans-
urethral prostatic resection be performed in combination with cystolitholapaxy? Urology.
1987;29(3):265– 267.
60 Challenging Concepts in Urological Surgery
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Romero- Otero J, García González L, García- Gómez B, et al. Analysis of holmium laser enucle-
ation of the prostate in a high- volume center: the impact of concomitant holmium laser
cystolitholapaxy. J Endourol. 2019;33(7):564– 569.
Shah HN, Hegde SS, Shah JN, Mahajan AP, Bansal MB. Simultaneous transurethral
cystolithotripsy with holmium laser enucleation of the prostate: a prospective feasibility
study and review of literature. BJU Int. 2007;99(3):595– 600.
Sinik Z, Isen K, Biri H, et al. Combination of pneumatic lithotripsy and transurethral prostatec-
tomy in bladder stones with benign prostatic hyperplasia. J Endourol. 1998;12(4):381– 384.
Sofer M, Kaver I, Greenstein A, et al. Refinements in treatment of large bladder cal-
culi: simultaneous percutaneous suprapubic and transurethral cystolithotripsy. Urology.
2004;64(4):651– 654.
Tangpaitoon T, Marien T, Kadihasanoglu M, Miller NL. Does cystolitholapaxy at the time of
holmium laser enucleation of the prostate affect outcomes? Urology. 2017;99:192– 196.
Zhao J, Shi L, Gao Z, Liu Q, Wang K, Zhang P. Minimally invasive surgery for patients with
bulky bladder stones and large benign prostatic hyperplasia simultaneously: a novel design.
Urol Int. 2013;91(1):31– 37.
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SECTION 3
Upper urinary tract
benign disease
Case 6 Ureteropelvic junction obstruction
Case 7 Oncocytoma
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6
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CASE
Ureteropelvic junction
obstruction
Sanjeev Pathak
Expert commentary Neil Oakley
Case history
A 29- year- old male presented to the emergency unit with abdominal pain. He had
sudden onset of right loin and abdominal pain. He described the pain as excruciatingly
severe, radiating from the loin to groin and was unable to gain comfort. There were
no associated lower urinary tract symptoms. He felt nauseous, with no vomiting and
no other gastrointestinal symptoms. There was no previous history of kidney stones
or urinary tract infections. Interestingly, in the past, he had suffered with intermittent
right loin pain exacerbated with alcohol intake. Regarding his general health, there
was no previous significant medical or surgical history. He had no known drug allergies or prescription medication. There was a strong family history of kidney stones
(maternal and paternal family). He worked as a full- time chef.
On examination, he appeared to be in discomfort. He had mild pyrexia of 37.9˚C,
pulse rate of 88 beats per minute, blood pressure of 140/ 75 mmHg, pulse oximetry of
96%, and respiratory rate of 18 breaths per minute. Abdominal examination demonstrated tenderness but no guarding in the right periumbilical region and loin. There
were no palpable abdominal masses. Genital examination was unremarkable.
He was given pain relief with per rectal diclofenac (a non- steroidal anti- inflammatory
drug). His blood tests revealed a haemoglobin level of 164 g/ L (normal range: 131–
166 g/ L) and white cell count of 14 × 109/ L (normal range: 3.5– 9.5 × 109/ L); his
serum calcium and uric acid levels were normal. Urine dipstick was positive for red
and white cells but negative for nitrites. Clinically, the differential diagnoses included
right ureteric calculi or pyelonephritis. He underwent a low- dose, non- contrast computed tomography (CT) scan of the abdomen and pelvis. The CT scan was reported
as a horseshoe kidney with bilateral, multiple renal calculi but no ureteric calculi,
and there was inflammation of the right peri- pelvicalyceal system and hydronephrosis
(Figure 6.1). He was transferred to the urology team. Initially, he was treated with
intravenous antibiotics and, subsequently, discharged home with an oral course of coamoxiclav. His urine and blood cultures were negative for bacterial growth.
Learning point Epidemiology of UPJO
● Congenital UPJO: incidence 1 in 2000 live births screened by routine antenatal ultrasound.
● Males are more commonly affected than females (2:1).
● Aetiology:
– Functional obstruction: results from impaired smooth muscle differentiation in the upper ureter
and renal pelvis.
6
Clinical tip Salient history
Classical symptoms of acute
ureteric colic:
● Sudden onset of severe colicky
pain.
● Radiation loin to groin.
● Associated fever and
elevated white cell count
raises possibility of infected,
obstructed kidney.
Classical presentation of ureteropelvic
junction obstruction (UPJO):
● Onset and exacerbation of pain
with alcohol and caffeinated
drinks.
● Onset and exacerbation of pain
with diuretics.
● Asymptomatic UPJO may result
in irreversible ‘silent renal loss’.
Learning point
Epidemiology of renal stones
Risk factors for developing stones:
● Sex: three times more likely
● Family history of kidney stones:
● Occupation: increased risk in
● Incidence of renal stones
1,2
in men.
increased risk of 30% in firstdegree relative.
cooks/ chefs.
in patients with UPJO and
horseshoe kidney is 20%.
Patients with UPJO and
concurrent renal calculi carry
the same metabolic risk as other
stone formers in the general
population.
5
3,4
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