V. Surgical Procedures: Lithalopaxy

 

Bladder Stone Treatment

I will not cut for stone, even for patients in whom the disease is manifest;
I will leave this operation to be performed by practitioners.
-Hippocratic Oath

Before the advent of modern surgical techniques, treatment of bladder stones was a very risky venture. The most common approach to removing bladder stones, known as lithotomy, involved removal of the stone through a perineal incision in an awake patient after a metal sound was placed through the urethra to secure the stone's position in the inferior portion of bladder. Indeed, Hippocrates considered the procedure so risky that in his oath he advised that only the skilled professional attempt the feat. Some believe that Hippocrates' recommendation is the first designation of a surgical subspecialty.

Urinary stasis (whether from bladder outlet obstruction or neurogenic dysfunction), infection, and presence of a foreign body are the primary culprits for bladder stone formation.

Video 1: Classic "jack" stone in an elderly patient with bladder outlet obstruction (click to watch video)

 

Modern surgical armamentarium for treatment of bladder stones includes open surgery (suprapubic approach), manual cystoscopic lithalopaxy (crushing of stone with forceps), ultrasonic lithotripsy, pneumatic lithotripsy, electrodydralulic lithotripsy (EHL), holmium:YAG laser, and rarely extracorporeal shock wave lithotripsy.

Surgical Tips:

• Pre-Operative considerations:
  • Does the patient need concominant bladder outlet obstruction procedure?
  • If bladder outlet reduction is required, decide between benign suprapubic prostatectomy with bladder stone removal vs cystoscopic lithalopaxy combined with TURP.
  • Large portion of bladder stones have infectious components, pre-operative broad-specturm antiobiotic prophylaxis is a must.
  • Screen for upper tract urolithiasis.
• Intra-Operative considerations:
  • It is quite easy to stir up major bleeding during a lithalopaxy procedure
    • Keep the lithotripsy device away from the prostate and bladder walls
    • Continuous flow is your friend -- use a resectoscope with an adapter for a bridge to introduce instruments
    • Poor visualization can easily lead to bladder perforation -- be careful.
  • When treating hard stones with a lithotripsy probe, it is sometimes useful to trap the stone in a fold of a partially deflated bladder (however, take care not to damage the bladder wall).
  • Always treat lithalopaxy forceps with respect -- this is a deadly weapon. When using lithalopaxy forecepts, it is best to crush the stone in the middle of a fully filled bladder after the stone is grasped. This greatly reduces the chance of damaging the bladder.
• Post-Operative considerations:
  • Monitor patients for bleeding and infection.
  • Prophylactic antibiosis is advisable.