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Cystolitholapaxy: Transurethral or Percutaneous Technique

Indications for Cystolitholapaxy

Bladder stones are treated surgically by endoscopic cystolitholapaxy or open surgery. The decision between endoscopic or open surgery depends on the size of the stones, number of stones, and size of the prostate if simultaneous treatment of benign prostatic hyperplasia is sought.

Contraindications for Cystolitholapaxy

• Untreated urinary tract infection
• Coagulation disorders
• Further contraindications depend on the surgical risk due to the patient's comorbidity. 

Surgical Technique of Cystolitholapaxy

For patient preparation, anesthesia, and perioperative antibiotic prophylaxis, see the section on Transurethral Resection of the Prostate.

Mechanical lithotripsy with a Stone Punch:

A stone punch is resembles a resectoscope, it is equiped with a crushing blade and a 5-degree optical lens. The stone is desintegrated (like with a nutcracker) into large fragments, which can be retrieved via the sheath [fig. cystolitholapaxy with a stone punsh]. The fragments in patients with a significant stone burden may be removed with the Ellik evacuator or bladder glass syringe.

Transurethral cystolitholapaxy: bladder stones as seen with the stone punch (left). Grasping the bladder stone with the stone punch (center). Fragmented bladder stones (right).

Electrohydraulic Lithotripsy (EHL):

The electric discharge triggered by a probe results in a pressure wave in the vicinity of the bladder stone, which leads to disintegration [fig. electrohydraulic lithotripsy]. The fragments are removed with the Ellik evacuator or bladder glass syringe.

Electrohydraulic lithotripsy: positioning of the probe in the vicinity of a bladder stone (left). The result after several shock waves (right).

Pneumatic Lithotripsy:

Pneumatic lithotripsy transmits mechanical energy via a rigid probe on the stone. 8 CH probes are available for bladder stones. The fragments are removed with the Ellik evacuator or bladder glass syringe.

Laser Cystolithotomy

Modern laser systems generate sufficient power to disintegrate even larger bladder stones in a reasonable time. The small sand-like disintegrates can be easily flushed out. Laser lithotripsy is very simple and less dangerous than the above-mentioned procedures. It is also possible via a suprapubic approach using PNL equipment. Percutaneous suprapubic laser lithotripsy spares the urethra and is the method of first choice in children.

Postoperative Care

Quick removal of the bladder catheter is possible after an uneventful procedure (no bleeding or fever, no additional procedure) after one day.

Complications of Cystolitholapaxy

Perforation of the bladder is a typical complication. Beware of using electrohydraulic lithotripsy near the bladder wall, and exercise caution not to grasp the bladder wall with the stone punch. Further complications are bleeding, infection, and urethral injury resulting in urethral strictures. Conversion to open surgery is an option if the stone burden is too significant.

References

  Deutsche Version: Harnblasensteinlithotripsie