What are the treatment options for bladder stones?

Treatment Options for Bladder Stones

Transurethral cystolithotripsy (TUCL) should be offered as the first-line treatment for bladder stones in adults and children where feasible, as it provides excellent stone-free rates with shorter hospital stays compared to open procedures. 1

Initial Evaluation and Management

• Before any stone intervention, urine microscopy and culture should be obtained to exclude or treat urinary tract infection 2
• Stone analysis should be performed for all first-time stone formers to guide future prevention strategies 2
• Antimicrobial prophylaxis should be administered prior to stone intervention based on prior urine culture results and local antibiogram patterns 2
• If purulent urine is encountered during endoscopic intervention, the procedure should be aborted, appropriate drainage established, and antibiotic therapy continued 2

Treatment Options for Bladder Stones

Endoscopic Procedures

• Transurethral cystolithotripsy (TUCL) is the intervention of choice for bladder stones in both adults and children 1

  • Uses laser or pneumatic lithotripsy to fragment stones
  • Shorter hospital stay and catheterization time compared to open surgery 1
  • Can be performed using either a cystoscope or nephroscope (nephroscope offers shorter procedure duration) 2

• Percutaneous cystolithotripsy (PCCL) is an alternative endoscopic approach 2

  • Similar stone-free rates to TUCL but with longer hospital stays (mean difference 0.82 days) 1
  • May be preferred for larger stone burden when transurethral access is difficult 2

Shock Wave Lithotripsy (SWL)

• Less effective for bladder stones compared to endoscopic procedures 1
• Lower stone-free rates compared to TUCL (risk ratio 0.88) 1
• Contraindicated in pregnancy, bleeding disorders, uncontrolled UTI, and severe obesity 2

Open Surgery

• Open cystolithotomy should not be offered as first-line therapy 2
• Reserved for rare cases with:
  • Very large or complex stones 2
  • Anatomic abnormalities requiring reconstruction 2
  • When endoscopic approaches are not feasible 1

Special Considerations

Patients with Bleeding Disorders

• Ureteroscopy (including TUCL) should be used as first-line therapy in patients with uncorrected bleeding diatheses or those requiring continuous anticoagulation/antiplatelet therapy 2
• SWL and percutaneous procedures are classified as high-risk procedures for bleeding 2

Pediatric Patients

• Endoscopic treatments (TUCL) are preferred over open surgery in children 1
• Similar stone-free rates between endoscopic and open approaches, but with shorter catheterization time and hospital stay for endoscopic procedures 1

Female Patients with Bladder Stones

• Approximately 5% of all bladder stones occur in women 3
• Usually associated with foreign bodies (sutures, synthetic tapes, or meshes) or urinary stasis 3
• Treatment should address both the stone and the underlying cause 3

Prevention Strategies

• Increase fluid intake to achieve daily urine output of 2 liters 4, 5
• Dietary modifications based on stone composition 5
• For calcium stones: maintain normal calcium intake (≥1g/day), moderate salt restriction, and normal-to-low protein intake 5
• For uric acid stones: oral chemolysis with alkalinization using citrate or sodium bicarbonate (pH 7.0-7.2) can dissolve stones with success rates of 80.5% 2, 5

Treatment Algorithm

1. Confirm diagnosis with appropriate imaging (ultrasound, X-ray, or CT scan) 4
2. Obtain urine culture and treat any existing infection before intervention 2
3. Select treatment approach based on:
   • Stone size and composition
   • Patient factors (bleeding risk, anatomical considerations)
   • Available expertise and equipment 2
4. First-line treatment: Transurethral cystolithotripsy for most patients 1
5. Alternative approaches when TUCL is not feasible:
   • PCCL for larger stones or difficult urethral access 2, 1
   • Open cystolithotomy for very large stones or when reconstruction is needed 2, 1
6. Post-treatment: Stone analysis and metabolic evaluation to prevent recurrence 2