What is the treatment approach for patients with large bladder stones using Cystolithotripsy (cystoscopic laser lithotripsy)?

Cystolithotripsy for Large Bladder Stones

For large bladder stones, cystoscopic laser lithotripsy using Ho:YAG laser is the gold standard approach, with complete stone removal as the primary goal. 1

Primary Treatment Approach

Laser Selection and Technique

• Ho:YAG laser is the gold standard for cystoscopic lithotripsy, offering safe and effective fragmentation even for stones previously refractory to other modalities. 1, 2
• Thulium fiber laser offers comparable efficacy and represents an acceptable alternative to Ho:YAG. 1
• High-power laser settings reduce operative time but have no proven clinical advantage in terms of stone-free rates or complications. 1
• Complete stone removal should be the goal; the "dust and go" approach should be limited to large renal stones, not bladder stones. 1

Procedural Considerations

• Cystoscopy and flexible cystoscopy are classified as low-risk bleeding procedures, making them suitable for most patients including those on antithrombotic therapy (after appropriate consultation). 1
• The transurethral approach using conventional cystoscopy or nephroscopy with pneumatic lithotripsy achieves complete stone clearance with negligible morbidity, even for very large stones. 3
• For stones >4 cm, Ho:YAG laser fragmentation typically requires an average anesthesia time of approximately 50 minutes with minimal tissue trauma. 2

Alternative Approaches for Very Large Stones

When Transurethral Access is Challenging

• For stones >40 mm or when transurethral manipulation is impractical, percutaneous suprapubic cystolithotripsy through a 30F or 36F tract is effective and safe. 4
• Simultaneous percutaneous suprapubic and transurethral cystolithotripsy can be performed for stones ≥60 mm, shortening total fragmentation time (median 56 minutes) while maintaining complete stone clearance. 5
• This combined approach allows two urologists to work simultaneously using Swiss Lithoclast, holmium laser, and/or ultrasound lithotripsy through both routes. 5

ESWL as Adjunctive Therapy

• Primary transpelvic ESWL followed immediately by endoscopic evacuation can be used for initial stone reduction when stones average >35 mm and primary cystolitholapaxy is judged impractical. 6
• This approach enables subsequent cystolitholapaxy of very large stones that would otherwise require protracted endoscopic manipulation or open surgery. 6

Contraindications and Precautions

Absolute Contraindications

• Untreated urinary tract infection must be excluded or treated before stone removal. 1
• General anesthesia risks in high-risk patients may preclude endoscopic approaches. 1

Bleeding Risk Management

• Patients with bleeding disorders or on antithrombotic therapy should be referred to an internist for appropriate therapeutic measures before proceeding. 1
• Cystoscopic procedures carry low bleeding risk compared to ESWL or PCNL. 1

Perioperative Management

Antibiotic Prophylaxis

• Perioperative antibiotic prophylaxis should be offered to all patients undergoing endourological treatment. 1
• A single dose of prophylactic antibiotic before the procedure is sufficient for routine cases. 1
• Antibiotic choice should be tailored to institutional or regional antimicrobial susceptibility patterns. 1

Postoperative Care

• Medical expulsive therapy (MET) after laser lithotripsy aids stone passage and reduces colic for any residual fragments. 1
• Suprapubic and urethral catheters are typically placed postoperatively when percutaneous access is used, with mean suprapubic catheterization duration of 2-3 days. 4, 5
• Median postoperative hospitalization is approximately 2.7 days for combined approaches. 5

Concomitant Procedures

• Transurethral resection of the prostate can be performed at the completion of stone clearance when bladder outlet obstruction is the underlying cause, without prolonging hospitalization. 5
• Definitive endoscopic treatment of underlying obstructive lesions should be addressed during the same session or follow-on procedure. 6

Common Pitfalls to Avoid

• Do not utilize electrohydraulic lithotripsy (EHL) as first-line modality due to its propensity to damage ureteral mucosa and cause perforation. 1
• Avoid assuming that transurethral approaches are impossible for large stones; even stones occupying the entire bladder lumen can be cleared transurethrally with appropriate equipment and technique. 3
• Do not delay treatment in patients with suspected infection and obstruction, as urgent drainage is required to prevent urosepsis. 1