What are the management options for bladder stones?

Management of Bladder Stones

Transurethral cystolithotripsy (TUCL) is the first-line treatment for bladder stones in adults and children when feasible, offering the best balance of efficacy and reduced morbidity. 1

Diagnostic Approach

• Imaging studies to determine stone size, number, and composition
• Evaluation for underlying causes (bladder outlet obstruction, neurogenic bladder, foreign bodies)
• Assessment of renal function to identify potential kidney injury

Treatment Algorithm Based on Stone Characteristics

Small to Medium-Sized Stones (<2 cm)

1. Transurethral cystolithotripsy (TUCL)

   • First-line treatment with highest stone-free rates
   • Shorter hospital stay compared to open surgery
   • Can be performed with either cystoscope or nephroscope (nephroscope offers shorter procedure time) 1
   • Various energy sources can be used:
     • Laser lithotripsy
     • Pneumatic lithotripsy
     • Ultrasonic lithotripsy

2. Shock wave lithotripsy (SWL)

   • Less effective than TUCL (lower stone-free rates) 1
   • Consider only when TUCL is contraindicated or unavailable
   • Limited efficacy for larger or harder stones

Large Stones (>2 cm)

1. Percutaneous cystolithotripsy (PCCL)

   • Effective for larger stones
   • Similar stone-free rates to TUCL
   • Longer hospital stay and procedure duration compared to TUCL 1

2. Open cystolithotomy (CL)

   • Reserved for very large stones (>4-5 cm)
   • Consider when endoscopic approaches are not feasible
   • Longer hospitalization and recovery time
   • Similar stone-free rates to endoscopic approaches 1

Special Considerations

Patients with Bleeding Disorders

• Ureteroscopy (URS) is recommended as first-line therapy in patients with uncorrected bleeding diatheses or those requiring continuous anticoagulation/antiplatelet therapy 2
• Consider deferring treatment until anticoagulation can be safely interrupted for non-urgent cases

Pediatric Patients

• TUCL is the intervention of choice where feasible 1
• Open cystolithotomy may be necessary for very large stones
• Shorter catheterization time and hospital stay with endoscopic treatments compared to open surgery 1

Concomitant Conditions

• Bladder outlet obstruction: Consider addressing the underlying cause (e.g., prostate surgery for BPH) during the same procedure
• Neurogenic bladder: Requires comprehensive management plan to prevent recurrence
• Foreign body: Remove the nidus for stone formation

Prevention of Recurrence

• Treatment of underlying causes (bladder outlet obstruction, neurogenic bladder)
• Regular bladder emptying for patients with retention
• Increased fluid intake
• Treatment of urinary tract infections
• Dietary modifications based on stone composition

Potential Complications to Monitor

• Urethral injury during TUCL (especially with larger stones)
• Bladder perforation
• Post-operative urinary tract infection
• Hematuria
• Incomplete stone clearance
• Acute kidney injury in cases of bilateral obstruction 3

Key Pitfalls to Avoid

1. Failing to identify and treat the underlying cause, leading to stone recurrence
2. Using SWL as first-line treatment (lower efficacy compared to endoscopic approaches)
3. Neglecting to evaluate renal function before intervention
4. Attempting TUCL for very large stones that might be better managed with PCCL or open surgery
5. Overlooking the need for follow-up imaging to confirm complete stone clearance

By following this algorithmic approach based on stone characteristics and patient factors, clinicians can optimize outcomes while minimizing morbidity in the management of bladder stones.