What is the appropriate management for a post-operative bladder stone?

Post-Operative Bladder Stone Management

Transurethral cystolithotripsy (TUCL) is the recommended first-line treatment for post-operative bladder stones, offering superior outcomes with shorter hospital stays and procedure duration compared to other approaches. 1

Diagnostic Evaluation

• CT scan is the gold standard for detecting urinary stones with approximately 97% sensitivity 2
• Alternative imaging options:
  • Ultrasound (75% overall sensitivity, 38% for ureteral stones)
  • KUB radiography for monitoring stone position and size

Treatment Options Based on Stone Size

Small Stones (<10mm)

• Endourological management is strongly recommended 2
  • Holmium:YAG laser lithotripsy offers advantages including:
    • Most cost-effective option
    • Shorter hospital stays
    • Minimal invasiveness

Medium Stones (10-15mm)

• Either endourological approach or percutaneous cystolithotripsy (PCCL)
• Selection depends on:
  • Stone characteristics
  • Surgeon expertise
  • Patient-specific factors (anatomy, prior surgeries)

Large Stones (>15-20mm)

• Robotic cystolithotomy or PCCL 2
  • Robotic approaches allow removal of large stones without crushing
  • Facilitates precise bladder wall closure
  • PCCL effective but may require longer catheterization and hospital stays

Comparative Effectiveness of Treatment Options

1. Transurethral Cystolithotripsy (TUCL)

   • Preferred first-line treatment 1
   • Shorter hospital stay compared to PCCL (mean difference 0.82 days) 1
   • Shorter procedure duration than PCCL 1
   • Using a nephroscope rather than cystoscope reduces procedure time by approximately 23 minutes 1

2. Percutaneous Cystolithotripsy (PCCL)

   • Similar stone-free rates to TUCL 1
   • Longer hospital stay and procedure duration than TUCL 1
   • May be preferred for larger stone burden

3. Open Cystolithotomy

   • Similar stone-free rates to endoscopic procedures 1
   • Longer hospital stay and catheterization time 1
   • Consider only when endoscopic approaches not feasible or for very large stones

4. Shock Wave Lithotripsy (SWL)

   • Lower stone-free rates than TUCL 1
   • Not recommended as first-line therapy for bladder stones

Perioperative Management

Safety Measures

• Use a safety guidewire for most endoscopic procedures 3
  • Facilitates rapid re-access to collecting system if primary wire is lost
  • Provides access in cases of ureteric or collecting system injury

Antibiotic Prophylaxis

• Administer antimicrobial prophylaxis prior to stone intervention 3
  • Base selection on prior urine culture results and local antibiogram
  • Single dose of antibiotic covering gram-positive and gram-negative uropathogens

Stone Analysis

• Send stone material for analysis 3
  • Exception: patients with multiple recurrent stones of documented similar composition

Special Considerations

Post-Augmentation Bladder Stones

• High recurrence rate (47.7% at median 9.5 years) 4
• Recurrence risk highest in first 2 years post-operatively (12.1% per patient per year) 4
• Yearly KUB X-ray and ultrasound recommended for surveillance 4

Stones Associated with Foreign Bodies

• Common in women with previous pelvic floor surgery using synthetic materials 5
• Remove or cut flush any associated suture or synthetic mesh with the bladder mucosa 5
• Consider partial resection of mesh with cystotomy if transurethral treatment fails 5

Follow-up and Prevention

• Confirm stone clearance with follow-up imaging (ultrasound or KUB radiography) 2
• Evaluate for predisposing factors:
  • Congenital urological abnormalities
  • Neurogenic bladder
  • Metabolic disorders (hypercalciuria, hyperoxaluria, cystinuria)
  • Recurrent urinary tract infections
• Increase fluid intake to more than 2L/day to help prevent recurrence 2

Pitfalls and Caveats

• In cases of sepsis with an obstructed kidney, urgent decompression via percutaneous nephrostomy or ureteral stenting is required before definitive stone treatment 3
• Abort stone removal procedures if infection is suspected 3
• Open/laparoscopic/robotic surgery should not be offered as first-line therapy except in rare cases with anatomic abnormalities, large/complex stones, or those requiring reconstruction 3