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44 Challenging Concepts in Urological Surgery
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some transient pain, to the moribund patient with urosepsis who needs urgent intervention
and time on the critical care unit. Developing a logical approach to the management of these
patients, many of who will pass their stone spontaneously, while trying to avoid complications
of urosepsis and kidney damage is important, and available guidelines help us to do this. There
is no one- size- fits- all approach, however, and management options will be dependent upon
local infrastructure and skill set, and be guided by patient factors such as occupation and social
circumstances. The key in this group of patients is to intervene immediately for those who are
sick and drain the kidney, to intervene early and definitively for those whose symptoms dictate
or who are unlikely to pass their stone, and to manage the remainder of patients expectantly. In
those patients who undergo surgical intervention, reducing the stenting rate and minimizing the
indwell time of a stent if it is placed will help limit the morbidity experienced.
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45Case 4 Ureteric stones
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5
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CASE
Bladder stone management
Siân Allen and Daron Smith
Expert commentary Daron Smith
Case history 1: acute urinary retention, catheter,
and stone
A 67- year- old man with a previous history of ureteric colic developed painful acute
urinary retention secondary to bladder outlet obstruction from an 80 cc benign enlarged prostate. A computed tomography (CT) scan of the kidneys, ureters, and bladder
(KUB) showed a catheter in situ with a 15 × 13 × 11 mm bladder stone (Figure 5.1).
Following a failed trial of voiding and re- catheterization, a transurethral resection of
the prostate (TURP) and cystolitholapaxy with a stone punch was performed; followup showed a good improvement in flow rate and resolution of his lower urinary tract
symptoms.
Figure 5.1 Acute urinary retention, catheter, and stone. This CT KUB scan shows a 15 × 13 × 11 mm
bladder stone with a catheter in situ and an enlarged prostate. There is a tiny residual fragment next to the
catheter on a CT scan performed after mechanical fragmentation with a stone punch followed by TURP.
48 Challenging Concepts in Urological Surgery
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Learning point Clinical features and risk factors
Bladder stones are one of the oldest known diagnoses, and urolithiasis is one of the most common
urological conditions, but bladder stone formation is currently relatively uncommon. In fact, bladder
calculi account for just 5% of urinary calculi, and are more common in men than women (who
represent approximately 5% of bladder stone formers).
Bladder stones can present with haematuria, recurrent urinary tract infections, and/ or voiding
symptoms, and can be formally diagnosed on imaging studies such as KUB X- ray, ultrasound, or
abdominal CT or identified during diagnostic cystoscopy. They may also be asymptomatic, and
detected as an incidental finding during investigations for other conditions.
Risk factors for bladder stone formation include bladder outlet obstruction, neuropathic voiding
dysfunction, bladder augmentation/ reconstructions, recurrent infection and foreign bodies. As such,
adult men with bladder outlet obstruction account for most cases of bladder stones, raising the question
of whether bladder outlet surgery is also needed, and if this should be performed at the time the stones
are treated. In females, the identification of a bladder stone raises the possibility of a foreign body
(sutures, synthetic tapes, or mesh) from previous continence surgery. Considering this from an alternative
perspective, investigations to identify or exclude a bladder stone should be considered in women who
have storage bladder symptoms or recurrent urinary infections following reconstructive pelvic floor
surgery where synthetic material has been used. The same applies to men with similar symptoms who
have undergone radical prostatectomy where a bladder stone may have occurred on a clip.
Learning point Bladder stone treatment options
The treatment of bladder stones has evolved from open surgical removal through blind transurethral
stone crushing to endourological ‘natural orifice’ surgery via the urethra or as ‘minimally invasive
surgery’ via a percutaneous approach. As long ago as 1993, John Wickham noted that ‘nearly all
bladder stones can be treated by transurethral endoscopy’ (at that time using an electrohydraulic
probe) and that ‘only the largest renal tract stones still require open surgery’.
The aim of bladder stone treatment is to achieve a completely stone- free bladder with a short hospital
stay and minimal risk of postoperative complications. The treatment options are extracorporeal
shockwave lithotripsy (SWL), transurethral cystolitholapaxy (TUCL), percutaneous cystolitholapaxy
(PCCL), and open surgical removal by cystolithotomy. The endourological treatments use a variety of
energy sources to fragment/ disintegrate the stones including mechanical cystolitholapaxy with a ‘stone
punch’, ultrasound, electrohydraulic lithotripsy, pneumatic/ ballistic LithoClast®, and holmium:yttrium
aluminium- garnet (HoYAG) laser. Each treatment option has advantages and disadvantages; as such,
the characteristics of the stone (size, number, consistency), ease of access to the bladder, and the
general health of the patient need to be considered before determining the best choice of treatment.
In addition, the likely underlying cause for the stone formation should be borne in mind, such that
relieving bladder outlet obstruction, eliminating infection, and removing foreign bodies are important
in bladder stone management, particularly for reducing the likelihood of recurrent stone formation.
Clinical tip SWL
SWL is an easy, simple, and
well- tolerated procedure for
bladder stones, but has the
lowest stone clearance rate
of the treatment options. It is
therefore generally reserved to
avoid anaesthesia in high- risk
patients with small- volume stones,
and without significant bladder
outflow obstruction such that the
stone fragments can be passed
satisfactorily.
Expert comment Benign prostate hyperplasia and stones
While it has long been recognized that bladder stones are associated with bladder outlet obstruction
secondary to benign prostatic enlargement, for many years it was considered high risk to combine
cystolitholapaxy and TURP in a single operation. This created a conflicting treatment rationale that
lower urinary tract symptoms due to bladder stones are due to bladder outlet obstruction and
therefore an outflow procedure is also needed, while recommending that bladder stone treatment
and relief of outflow obstruction should not be performed at the same time due to increased surgical
morbidity, including of postoperative infection.
However, as technology has developed, so has the feasibility of combining these procedures safely and
effectively. Over the last 30 years, simultaneous treatment has evolved from SWL therapy with a Dornier
HM3 lithotripter in patients with small stones undergoing TURP for small to medium prostates through
pneumatic lithotripsy and TURP for larger stones and prostates to laser cystolitholapaxy combined with
holmium laser enucleation of the prostate for those with still larger stone burdens and prostate sizes.
The key to a successful outcome is to complete the stone treatment in reasonable time before
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the prostate surgery. If stone treatment via the urethra would add too much time to the overall
operation, it is possible to combine percutaneous stone surgery with TURP, either as sequential or
even simultaneous procedures. In the sequential approach, the suprapubic sheath can be left in situ
following PCCL to provide continuous drainage during TURP, followed by a suprapubic catheter for
additional postoperative drainage/ monitoring. A simultaneous approach has also been described
whereby PCCL can be performed on the stone(s) in a laparoscopic entrapment bag while the TURP is
performed concurrently by a second surgeon.
49Case 5 Bladder stone management
Case history 2: stone on mesh
A 67- year- old lady who had undergone a transvaginal tape procedure 10 years previously
had recurrent bladder stones treated three times over a 4- year period in another hospital.
Further stones were identified at CT KUB— a larger oval stone measuring 30 × 28 ×
18 mm and a smaller spherical 10 mm stone that appeared adherent to the right anterolateral bladder wall (Figure 5.2a). At cystoscopy, during which both stones were treated by
laser cystolitholapaxy, the 10 mm stone was adherent to eroded mesh, which was lasered
to just beneath the urothelium. A follow- up CT a year and a half postoperatively showed
a curvilinear calcification where the adherent stone had been previously (Figure 5.2b).
A cystoscopy showed some eroded mesh with surface calcification. A transvaginal/
laparoscopic mesh excision was scheduled, but a repeat cystoscopy prior to that procedure 4 months later showed no stone or eroded mesh, and she has remained stone
free at further follow- up CT imaging 2 years after the cystolitholapaxy and mesh lasering.
Figure 5.2 Stone on mesh. (a) This CT KUB scan shows a free- floating 30 × 28 × 18 mm and a 10 mm
stone adherent to eroded mesh. An initial 22 Fr cystoscopy was followed by laser cystolitholapaxy and laser
to intravesical mesh using a resectoscope to allow larger fragments to be washed out than possible via a
cystoscope. (b) A follow- up CT scan 18 months after her cystolitholapaxy/ showed curvilinear calcification
where the adherent stone had been previously, which had fully resolved at further follow- up after 2 years.
50 Challenging Concepts in Urological Surgery
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Figure 5.2 Continued
Cystoscopic treatment
A standard 22 French (Fr) cystoscope allows an initial assessment of the urethra, prostate/ bladder
neck, as well as the bladder urothelium and the stone burden itself. After treating the stone with an
energy source (most commonly a laser), the fragments and dust can be washed out using an Ellik
evacuator. Small fragments can also be retrieved directly via the cystoscope sheath using biopsy/ stent
removal forceps. A short- term postoperative catheter may be inserted, including the use of a ‘threeway’ catheter to irrigate stone dust and tiny fragments, and avoid the potential for clot formation from
associated bleeding from a prominent prostate middle lobe.
Learning point TUCL
Nephroscopic treatment
After an initial diagnostic cystoscopy, a rigid nephroscope can be used as an alternative to a cystoscope
Expert comment
Mesh/ synthetic material
Suture or synthetic mesh associated
with bladder stone formation
can be laser ablated until just
below the bladder mucosa to
reduce the risk of recurrent
stone formation. Preoperative
cross- sectional imaging should be
reviewed to assess the proximity
of neighbouring structures which
may have become tethered to the
bladder to avoid inadvertent fistula
creation following lasering. If this
technique fails, surgical resection of
the mesh should be considered.
for treating the stone. Having a wider lumen than a cystoscope, a nephroscope offers better irrigation,
and therefore improved vision, as well as the opportunity to use larger calibre lithotripters, such as a
combined pneumatic/ ultrasound lithotripsy device. This has the advantage over laser fragmentation as
stone dust and small fragments can be actively suctioned via the probe, improving vision and reducing
the time required to wash out or remove small fragments with forceps. When the stones have been
fully treated, the cystoscope can be re- inserted to identify and remove any small remaining fragments,
whereas larger fragments may require re- insertion of the nephroscope and further disintegration with the
energy source. As for cystoscopic treatment, a postoperative urethral catheter will usually be required.
Case history 3: stone and urethral stricture
A 24- year- old male, who had a 2 year- history of prior urethral stricture disease requiring regular urethral dilatations, was referred for a urethroplasty. A large bladder
stone was identified on the urethrogram, for which a non- contrast CT KUB was
Figure 5.3 Stone and urethral stricture. This CT scan shows a 38 × 37 × 21 mm bladder stone with
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intraoperative PCCL images showing a guidewire in the bladder to safely negotiate a 22 Fr cystoscope via
a narrow urethra to the bladder. An Amplatz sheath is seen ‘end on’ via which the stone was fragmented
and cleared.
51Case 5 Bladder stone management
performed, confirming a 38 × 37 × 21 mm bladder stone. To avoid exacerbating his
urethral stricture, this was treated percutaneously, and was confirmed to be stone free
on postoperative CT KUB. His lower urinary tract symptoms improved such that he did
not keep further urological follow- up appointments and the anticipated urethroplasty
has not been required (Figure 5.3).
Case history 4: small- volume neobladder
A 53- year- old man who had undergone a radical cystectomy with an orthotopic
neobladder formation 3 years previously reported increasing difficulty performing
clean intermittent self- catheterization and recurrent urinary tract infections. He was
diagnosed with two rapidly enlarging bladder stones (17 × 14 × 13 mm and 14 × 13
× 13 mm) on CT abdomen and pelvis imaging performed as part of his oncological
follow- up (Figure 5.4). A laser cystolitholapaxy was scheduled, including the possibility of percutaneous access to the right kidney to pass an antegrade guidewire to
help identify the Studer extension of his neobladder to facilitate accessing that part of
the neobladder with a flexible cystoscope. Following a urethral dilatation, both stones
were successfully identified and cleared; the biochemistry was pure calcium magnesium ammonium phosphate with a positive bacterial culture of both Escherichia coli
and Proteus mirabilis. The rapid stone growth was therefore likely to have been the
consequence of urinary stasis and recurrent infections, as opposed to the cause of
them, with an increase in the urinary pH causing increased calcium phosphate and
magnesium ammonium phosphate crystalluria and stone formation.
52 Challenging Concepts in Urological Surgery
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Figure 5.4 Small- volume neobladder. This CT KUB scan shows a 17 × 14 × 13 mm and 14 × 13 ×
13 mm stone in a Studer neobladder reconstruction. The first stone was treated straightforwardly with a
laser via a 22 Fr cystoscope. A flexible cystoscope was used to direct a wire and ureteric catheter to the
Studer extension of the neobladder, where the second stone was identified, grasped in a Nitinol basket,
and retrieved to the main bladder lumen, where it was treated using the rigid cystoscope.
Case history 5: small- volume neobladder and
artificial urinary sphincter
A 23- year- old woman with spina bifida, requiring a wheelchair to mobilize, had an
augmentation cystoplasty and Mitrofanoff channel for neuropathic detrusor overactivity and incontinence. She had formed bladder stones previously, and although
she still had urethral access to her bladder, there was an artificial urinary sphincter
in situ, such that these were treated percutaneously. Follow- up imaging 2 years later
showed two new spiculated bladder stones measuring 20 × 16 × 16 mm and 10 × 9
× 9 mm for which a further PCCL was performed. The stone biochemistry was 75%
magnesium ammonium phosphate/ 25% ammonium urate, with a positive culture of
Corynebacterium, which is a urease- producing organism generating an alkaline urine
consistent with the stone biochemistry (Figure 5.5).
Learning point PCCL
A percutaneous suprapubic approach to the bladder offers a minimally invasive option for larger
bladder calculi, or where the urethral approach would be challenging or impossible. As stones enlarge,
the time taken to treat them and the number of fragments generated increase (see ‘Expert comment’
box on stone size). The percutaneous approach allows high flow rates via a nephroscope, with efflux
of irrigation fluid and stone dust via the Amplatz sheath offering excellent visualization during stone
fragmentation. Furthermore, it avoids prolonged urethral instrumentation and thereby reduces the risk
of a subsequent urethral stricture.
53Case 5 Bladder stone management
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Figure 5.5 Small- volume neobladder and artificial urinary sphincter. This CT KUB scan and
rendered reconstruction image shows two spiculated bladder stones measuring 20 × 16 × 16 mm
and 10 × 9 × 9 mm with an artificial urinary sphincter in situ (reservoir, pump, cuff and tubing). The
stones were treated with a nephroscope via a 30 Fr Amplatz sheath.
The bladder/ neobladder is filled with saline though a catheter or endoscope via the urethra or
Mitrofanoff catheterizable stoma. When adequately distended, guidewire access can be achieved
via a needle puncture or through an existing suprapubic catheter tract with any combination of
cystoscopic, ultrasound, or fluoroscopic guidance. A tract is dilated over the wire, often using a
balloon dilator, to allow insertion of an Amplatz sheath via which a nephroscope is placed and the
stone fragmented and retrieved percutaneously through the sheath.
Access can also be obtained directly via a Mitrofanoff channel, although care has to be taken to
make sure that this does not affect the continence mechanism or ease for the patient to catheterize
postoperatively. For this reason, it is often advisable to gain separate percutaneous access away from
the Mitrofanoff stoma.
Postoperatively, the patient may be left with both a suprapubic and urethral catheter; the former can
be used for irrigation and the latter for drainage.
Expert comment PCCL technical tweaks
● A bladder evacuator can be attached to the Amplatz sheath to wash out large quantities of stone
fragments more rapidly than they can be aspirated through the nephroscope probe, or removed under
vision with forceps (Figure 5.6). This should be performed with the bladder underfilled to avoid high
intravesical pressures, especially in reconstructed bladders, where there is a risk of bladder rupture.
● The use of a 12 mm self- retaining laparoscopic trocar has been described to allow the use of
large- calibre nephroscopes for rapid stone fragmentation and extraction.
● Laparoscopic entrapment sacs have also been used to manipulate calculi into for ease of
subsequent fragmentation. After the initial laparoscopic trocar has been removed over the
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