What is the best course of treatment for an older adult with a large bladder calculus, benign prostatic hyperplasia, and potential urinary tract infection?

Management of Large Bladder Calculus with BPH

For an older adult with a large bladder calculus and BPH, surgical removal of the stone combined with treatment of bladder outlet obstruction is the definitive approach, as bladder stones secondary to BPH require both stone removal and correction of the underlying obstruction to prevent recurrence.

Immediate Management Priority

Surgery is mandatory for bladder stones clearly due to BPH, as this represents a complication requiring definitive intervention. 1 The presence of bladder calculi indicates significant bladder outlet obstruction that has allowed stone formation, and medical management alone is insufficient. 1

If Concurrent UTI is Present

• Urgent treatment is required if the patient shows signs of sepsis or infection. 1
• Obtain urine culture and initiate appropriate antibiotics based on local resistance patterns 1
• If the patient has obstructive symptoms with infection, consider temporary urinary drainage (either percutaneous nephrostomy or ureteral stent) until infection clears before definitive stone treatment 1
• Complete the full course of antimicrobial therapy before proceeding with elective stone removal 1

Surgical Approach for Stone Removal

For Large Bladder Calculi (>3-4 cm)

Percutaneous suprapubic cystolithotripsy is the preferred minimally invasive approach for large bladder stones, as it avoids urethral injury, allows rapid stone clearance, and can be combined with BPH treatment in a single procedure. 2, 3

• Percutaneous approach through 30F or 36F suprapubic tract using pneumatic lithotripsy (Swiss Lithoclast) achieves complete stone clearance in a single procedure 2
• Mean operative time approximately 56 minutes for stones 40-80mm 3
• Hospital stay typically 2-3 days with suprapubic catheter removal in 1-5 days 2
• Simultaneous percutaneous and transurethral approach can shorten fragmentation time for very large stones 3

Alternative: Open Suprapubic Cystolithotomy

• Consider for extremely large stones (>6 cm) or when endoscopic equipment unavailable 4, 5
• Allows direct visualization and complete stone removal 4
• Can be combined with open prostatectomy if prostate is very large (>80-100g) 1

Mandatory Treatment of Underlying BPH

Bladder outlet obstruction must be addressed simultaneously or immediately after stone removal to prevent stone recurrence. 1, 5, 6 Failure to treat the underlying BPH results in high recurrence rates. 5, 6

Surgical Options for BPH (Based on Prostate Size)

For prostates <60-80g:

• TURP (transurethral resection of prostate) should be performed, either during the same procedure as stone removal or as a staged procedure. 1
• Monopolar or bipolar TURP are equally effective for symptom relief 1
• Bipolar TURP preferred for longer resection times and larger glands due to lower risk of TUR syndrome 1
• Can be safely combined with percutaneous cystolithotripsy without prolonging hospitalization 3

For prostates >60-80g:

• Consider open, laparoscopic, or robotic simple prostatectomy depending on surgical expertise. 1
• Open simple prostatectomy can be combined with open cystolithotomy for very large stones and prostates 1

For small prostates ≤30g:

• TUIP (transurethral incision of prostate) is an option with lower rates of retrograde ejaculation (18.2% vs 65.4% with TURP) 1

Recommended Surgical Algorithm

1. Preoperative evaluation: Obtain urine culture, renal function tests, imaging (CT or ultrasound) to assess stone size/number and upper tract status 1

2. If active UTI present: Treat infection first, consider temporary drainage if obstructed 1

3. Stone removal approach:

   • Stones >3-4 cm: Percutaneous suprapubic cystolithotripsy 2, 3
   • Extremely large stones (>6 cm): Consider open cystolithotomy 4, 5

4. Simultaneous or staged BPH treatment:

   • Prostate <60-80g: TURP (can be done same procedure) 1, 3
   • Prostate >60-80g: Simple prostatectomy 1

5. Postoperative: Suprapubic and urethral catheter drainage for 2-5 days 2, 3

Critical Pitfalls to Avoid

• Never treat bladder stones with medical therapy alone or stone removal without addressing BPH - this guarantees stone recurrence due to persistent outlet obstruction 1, 5, 6
• Do not attempt transurethral cystolithotripsy alone for stones >3 cm - this is time-consuming and risks urethral injury 2
• Do not delay treatment in patients with renal insufficiency, recurrent UTIs, or gross hematuria - these are absolute indications for surgery 1
• Avoid performing surgery on asymptomatic bladder diverticulum alone - assess for bladder outlet obstruction and treat the obstruction, not just the diverticulum 1

Expected Outcomes

• Complete stone clearance achieved in >95% of cases with percutaneous approach 2, 3
• Low complication rates with modern endoscopic techniques 2, 3
• Close follow-up is mandatory as recurrence risk remains elevated even after BPH treatment in patients with history of stones and recurrent infections 5, 6