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Bladder stones

5 % of all stones.

Classification

  • Migrant
    • 3 – 17 % migrate from upper tract
  • Primary
    • Associated with nutritional deficiency, often in children
    • Decreased urine output (dehydration secondary to poor intake and diarrhoea), pH change and other metabolic abnormalities
    • Low dietary phosphate and low animal protein -> hypophosphaturia, promoting calcium oxalate and ammonium acid urate
    • Usually boys under 10
  • Secondary
    • Classically men over 60, associated with lower urinary tract obstruction
      • BOO associated with 45 – 80 % of secondary bladder stones
    • Foreign bodies
      • Catheters (2.2 % long term IDC), mesh, IUDs, stents,
    • Urinary stasis or incomplete emptying
      • Obstruction – BPH, stricture
      • Neurogenic bladder (15 – 30 % neuropaths)
      • Urinary diversion

EAU – 42 % calcium based, 33 % magnesium ammonium phosphate, 14 % urate, 10 % mixed

Presentation

  • Terminal haematuria (most common)
  • Varied LUTS
  • Urinary retention
  • Bladder pain and spasms (classically terminal pain)
  • Recurrent UTIs
  • In children – pulling at penis and passage of sand
  • Incidental

 

Work-up

  • History – including fitness for GA, co-morbidities, previous surgeries, LUTS, excluding of neuropathy
  • Examination including scars, obesity, genitals, DRE
  • Urine microscopy and culture, haematuria
  • Imaging – CT KUB +/- prone, ultrasound, can often be seen on XR
  • Flow rate and PVR
  • Consider urodynamics

 

 

Management

Cystoscopic management (cystolitholapaxy):

  • Safe, usually feasible to remove in one operation.
  • No incision. Minimal recovery time.
  • Stone punch / lithotrite – risks of bladder injury.
  • Holmium laser – can use large fibre with continuous flow (23 fr greenlight sheath) – nephroscope use also well described
  • Con – potential urethral injury / stricturing

 

Percutaneous cystolithotripsy:

  • Avoid urethra
  • Small risk of ongoing urine leak
  • Useful if continent diversion, no urethral access
  • Allows bigger scopes and instruments cf. urethra
  • Techniques – Amplatz sheath, or 2 x laparoscopic ports with a scope in one and grasper or endocatch bag through the other under vision

 

Open cystolithotomy:

  • Can be done extraperitoneal through Pfannenstiel or lower midline
  • Need for catheter (+ ?drain) afterwards
  • Useful for very large stones
  • Can be done in conjunction with transvesical prostatectomy
  • Could be offered lap or robot

 

ESWL – described for patients with prosthetics in attempt to avoid instrumentation. Needs to be done prone.

Chemolysis – not well described or often done – bladder irrigations with potassium citrate, sodium bicarbonate – time consuming and impractical.

 

Finding stones within neobladders cystoscopically may be tricky – can use II to help. Mucus may need to be washed out or evacuated.

 

 

Men with concomitant bladder outlet obstruction and bladder stone

  • Classically an indication for surgical management of BOO
  • TURP + removal of bladder stone can be combined in same operation – although risk of infection may be higher
  • Alternative is medical management with 5-ARIs