Bladder Stone Expulsion Therapy for 0.4cm Stone
Medical expulsion therapy (MET) with alpha-blockers is NOT indicated for bladder stones of any size, including 0.4cm stones—this treatment modality is specifically for ureteral stones, not bladder stones. 1
Why MET Does Not Apply to Bladder Stones
Alpha-blockers work by relaxing ureteral smooth muscle to facilitate passage of stones through the ureter, but bladder stones have already reached the bladder and cannot "pass" further through the urethra spontaneously. 1, 2
The European Association of Urology guidelines clearly state that MET is efficacious for ureteral stones >5mm in the ureter, with no mention of applicability to bladder stones. 1
Bladder stones require active removal rather than expectant passage, as they do not spontaneously exit through the urethra regardless of size. 3, 4
Recommended Treatment for 0.4cm Bladder Stone
Transurethral cystolithotripsy (TUCL) using laser or pneumatic lithotripsy is the first-line treatment for bladder stones of this size. 3, 4
Treatment Approach:
Pre-operative urine culture and antimicrobial prophylaxis should be obtained and administered based on local antibiogram patterns before any stone intervention. 3
TUCL offers shorter hospital stay and catheterization time compared to open surgery, with excellent stone-free rates for small stones like 0.4cm. 3, 4
Holmium:YAG laser lithotripsy can be performed under local anesthesia in selected patients, making it particularly attractive for small stones. 5
Alternative Considerations:
Percutaneous cystolithotripsy (PCCL) is an alternative endoscopic approach with similar stone-free rates to TUCL, though it typically requires longer hospital stays. 3, 4
Open cystolithotomy should be reserved for rare cases with very large or complex stones, or anatomic abnormalities requiring reconstruction—not appropriate for a 0.4cm stone. 3
Important Clinical Pitfalls
Do not confuse ureteral stone management with bladder stone management—the treatment algorithms are completely different despite both being urinary tract stones. 1, 3
If purulent urine is encountered during endoscopic intervention, abort the procedure, establish appropriate drainage, and continue antibiotic therapy before reattempting stone removal. 3
Stone analysis should be performed for all first-time stone formers to guide future prevention strategies, particularly to identify infection stones (struvite/carbonate apatite) that may indicate underlying metabolic or infectious issues. 3, 6