What are the treatment options for bladder stones?

Treatment Options for Bladder Stones

The primary treatment for bladder stones is surgical intervention, with transurethral cystolithotripsy (TUCL) being the first-line treatment option for most patients due to its high efficacy and lower morbidity compared to other approaches. 1

Treatment Algorithm Based on Stone Size and Patient Factors

Small to Medium-Sized Stones (<10mm)

• First-line: Transurethral cystolithotripsy (TUCL)
  • Uses endoscopic instruments inserted through the urethra
  • Can utilize laser or pneumatic lithotripsy devices
  • Shorter hospital stays and catheterization time compared to open surgery 1
  • Procedure duration is shorter when using a nephroscope versus a cystoscope 1

Large Stones (>15-20mm)

• First-line options:
  • Percutaneous cystolithotripsy (PCCL)
    • Particularly useful for large stone burden
    • Creates direct access to bladder through a suprapubic approach
    • May require longer catheterization (approximately 72 hours) 2
  • Open cystolithotomy
    • May be considered for extremely large stones or complex cases
    • Longer hospital stay and recovery time 1

Special Populations

Children

• Treatment principles similar to adults, with preference for minimally invasive approaches 2
• TUCL is the intervention of choice where feasible 1
• Endoscopic treatments have shorter catheterization time and convalescence compared to open surgery 1

Women

• Bladder stones represent only about 5% of all bladder stones 3
• Often associated with foreign bodies (sutures, synthetic tapes, or meshes) or urinary stasis 3
• Treatment should address both the stone and underlying cause (e.g., removal of intravesical foreign bodies) 3

Adjunctive Treatments

Medical Management

• Alpha-blockers (e.g., tamsulosin) may be beneficial if stones migrate to the ureter 2, 4
• Oral chemolysis is strongly recommended for uric acid stones
  • Alkalinization with citrate or sodium bicarbonate (pH 7.0-7.2) 5
  • Success rate of 80.5%, with 15.7% requiring further intervention 5

Antibiotic Therapy

• Urine culture should be obtained before stone treatment 5
• Perioperative antibiotic prophylaxis is strongly recommended for all patients undergoing endourological treatment 5
• For most procedures, a single dose of prophylactic antibiotic before the procedure is sufficient 5

Post-Treatment Care and Follow-Up

• Indwelling catheter duration varies by procedure:
  • Endoscopic approaches: ~16 hours
  • PCCL: ~72 hours 2
• Follow-up imaging (ultrasound or KUB radiography) is recommended to confirm stone clearance 2
• Preventive measures should be implemented:
  • Increased fluid intake (2-3 liters per day) 4
  • Dietary modifications (reduced animal protein and salt) 4
  • Treatment of underlying conditions (e.g., prostate hypertrophy, neurogenic bladder) 2, 6

Comparative Efficacy and Complications

• TUCL vs. PCCL: Similar stone-free rates, but hospital stay and procedure duration favor TUCL 1
• Open cystolithotomy vs. endoscopic approaches: Similar stone-free rates, but hospital stay and procedure duration favor endoscopic surgery 1
• Shock wave lithotripsy (SWL) has lower stone-free rates compared to TUCL and is generally not recommended as first-line therapy for bladder stones 1

Potential Complications

• Infection/sepsis
• Urethral or bladder injury
• Bleeding
• Stricture formation 2

For optimal outcomes, the choice of treatment should be based on stone characteristics (size, composition), available equipment, surgeon expertise, and patient-specific factors such as anatomy and comorbidities.