Medical Therapy

The only potentially effective medical treatment for bladder calculi is urinary alkalinization for the dissolution of uric acid stones. Stone dissolution may be possible if the urinary pH can be made greater than or equal to 6.5. Potassium citrate (Polycitra K, Urocit K) at 60 mEq/d is the treatment of choice. However, overly aggressive alkalization may lead to calcium phosphate deposits on the stone surface, making further medical therapy ineffective.[8] Other agents for stone dissolution, such as Suby G or M solution, are rarely used. Renacidin can be used to dissolve phosphate or struvite calculi, but treatment is slow and invasive because it must be used in conjunction with indwelling irrigating catheters. Patients must also be monitored closely for signs of sepsis or hypermagnesemia. Further measures include irrigations of the bladder or continent diversions with saline for a mechanical flushing of debris or with one of the above solutions for preventing stone formation.[6] When underlying errors of metabolism are discovered during 24-hour urine evaluation of stone disease, various treatments are available to prevent further calculus development. However, the discussion of these treatments is beyond the scope of this article.

Surgical Therapy
"Cutting for the stone" is a phrase that has been used since the time of Hippocrates. Historically, stones were removed via the high operation, using a suprapubic incision, or the low operation, using a perineal incision. In the absence of antibiotic therapy and adequate hemostatic techniques, both operations were associated with a high morbidity and mortality rate. Civiale performed the first documented blind transurethral lithotripsy in 1822. Even with the introduction of the cystoscope in 1877, bladder injury was always a risk. The predominant technique in the 1800s and early 1900s was to fill the bladder with 150 mL of fluid, grasp the stone with the lithotrite, rotate it to free the engaged stone from the mucosa, and crush the stone manually. This was repeated until the fragments were small enough to suction out of the bladder with an Ellik evacuator. Common complications included mucosal injury, bladder wall perforation, sepsis, and hemorrhage.[1] Currently, 3 different surgical approaches to this problem are used. Unlike in renal and most ureteral calculi, ESWL has shown little efficacy for bladder calculi in most centers,[30] but some studies suggest that ESWL performed with the patient in the prone position can be considered for treatment.[5] The first approach in adults is transurethral cystolitholapaxy. After cystoscopy is performed to visualize the stone, an energy source is used to fragment it, and the fragments are removed through the cystoscope. The energy sources are mechanical (ie, lithoclast [pneumatic jack hammer]), ultrasonic, electrohydraulic (ie, EHL [spark-induced pressure wave]), manual lithotrite, and laser. The pulsed-dye or other wavelength-specific light sources (eg, holmium) fracture the stone by direct absorption, vaporization, water absorption, and pressure wave generation.[31] Because of recent advancements in instrumentation, the smaller caliber of the

pediatric urethra can be accommodated, allowing these approaches to be applicable in selected children.[32] The second approach in adults (and often primary approach in the pediatric population) is percutaneous suprapubic cystolitholapaxy. The percutaneous route allows the use of shorter- and larger-diameter endoscopic equipment (usually with an ultrasonic lithotripter), which allows rapid fragmentation and evacuation of the calculi.[33] Often, a combined transurethral and percutaneous approach can be used to aid in stone stabilization and to facilitate irrigation of the stone debris. The authors favor the combined approach with the use of the ultrasonic lithotripter or the pneumatic lithoclast. The holmium laser is also effective but is generally slower, even with the 1000-micron fiber.[34] The EHL unit has been associated with a higher incidence of bladder mucosal injury. Options for accessing the bladder may be challenging in certain circumstances, such as in patients who have undergone prior bladder reconstruction or after prior bladder neck procedures for improved continence. Paez et al (2007) described percutaneous removal of bladder stones via ultrasoundassisted access of the bladder through prior suprapubic tube tracts. In one case, they used a Mitrofanoff catheterization channel with a 30F Amplatz sheath. They reported no complications, and percutaneous treatment was judged a safe alternative in this population subset.[35] This same procedure has also been described in continent diversions with urethral closure.[36] First described in 1963 by Barnes et al and supported by numerous subsequent articles, transurethral lithotripsy combined with transurethral resection of the prostate (TURP) or transurethral incision of the prostate (TUIP) can be accomplished easily and safely.[37, 38] Completing the stone ablation prior to these prostatic interventions is advisable, as hemorrhage and excess fluid absorption are potential complications when performed in the reverse order. In a 2009 study by Tugcu et al, 64 patients underwent TURP in addition to concomitant bladder calculi surgery. The participants were divided and treated with either (1) a percutaneous suprapubic approach with a 30F access sheath or (2) transurethral cystolitholapaxy with a 23F sheath and pneumatic lithotripter. The patients who underwent percutaneous stone removal had a statistically significantly larger stone burden, and the mean operative time of the percutaneous approach was nearly half that of the transurethral removal.[39] The third approach, open suprapubic cystotomy, is used to remove the stone or stones intact and can be used with larger and harder stones and when open prostatectomy and/or bladder diverticulectomy are indicated. Open prostatectomy is generally indicated when the prostate volume exceeds 80-100 g. The advantages of suprapubic cystolithotomy include rapidity, easy removal of several calculi at one time, removal of calculi that are adherent to bladder mucosa, and the ability to remove large stones that are too hard or dense to fragment expeditiously via transurethral or percutaneous techniques. The major disadvantages include postoperative pain, longer hospital stay, and longer bladder catheterization times.

Preoperative Details

After diagnosis and treatment planning have been completed, the usual preoperative evaluation, including urine culture and sensitivity, CBC count, comprehensive metabolic panel (ie, serum chemistries), coagulation studies, chest radiography, and ECG, is completed. When a sterile urine culture is not attainable preoperatively, appropriate antibiotic therapy should be started a minimum of 24 hours in advance of the anticipated procedure.
y

y y

Anesthesia: Regional or general anesthesia can be used depending on the patient's comorbidities and the anesthesiologist's preference. Performance under local anesthesia (eg, urethral and intravesical lidocaine, tetracaine, dicyclomine) can be accomplished in certain patients harboring a low stone burden. The procedure requires pain tolerance similar to that for rigid cystoscopy with a 17F sheath.[40] Positioning: The preferred position is the dorsal lithotomy, although supine positioning also can work well if flexible cystoscopes and/or percutaneous access are used. Antibiotics: Appropriate oral or intravenous antibiotics are administered prior to the start of the operation based on the findings of the preoperative urine culture and sensitivity. When the urine culture is sterile, an oral fluoroquinolone generally provides adequate prophylaxis. Preparation: The lower abdomen and perineum are shaved, prepared using Betadine or another antiseptic solution, and draped in the usual sterile fashion. The irrigant of choice is isotonic sodium chloride solution, although sterile water or sorbitol can be substituted for short procedures. Significant absorption of a hypotonic solution may be a problem if bleeding is encountered.

Intraoperative Details
The most commonly used contemporary treatment for bladder calculi is transurethral cystolitholapaxy. This can be performed using rigid or flexible cystoscopes; larger-caliber, rigid, continuous-flow scopes provide better visualization.

Procedural details
A cystoscope with a camera to provide video imaging is used to identify the stone under direct vision. If previous gross hematuria was noted, careful removal of all clots is necessary to ensure identification of all stone material. The bladder mucosa and bladder neck must also be fully assessed. Lithotripsy is performed, and the small remnant fragments are removed with one of several commercially available evacuators. Once inspection reveals no residual fragments in the bladder or any diverticula, attention can be paid to the bladder outlet or diverticula for further management of obstruction. For TUIP and TURP, the irrigant is changed to 3% sorbitol, and the operation is completed in the usual fashion. If percutaneous access to the bladder has been established, the access sheath or a large-bore catheter can be left in place to assist with continuous irrigation during TURP. If the bladder is not obstructed but a diverticulum needs to be addressed, sterile water or sorbitol can be used for diverticular fulguration and incision of the diverticular neck. While generally safe if performed expeditiously, reports have indicated that combined operations are associated with significantly increased complication rates (ie, 20%-30%). A catheter is generally left in place

overnight if TURP or TUIP has been performed. Incision of a diverticular neck may require that a catheter be left for a few days to protect against urinary extravasation.

Lithotripsy instrumentation
Energy sources used to fragment the stone vary. A commonly used type of energy source is EHL. Other sources include the pulse-dye laser, the holmium laser, ultrasound, and the lithoclast (pneumatic jackhammer).[41] The EHL probe was first introduced in 1959; since then, it has been widely used with excellent results. The EHL probe (5F-9F) can be inserted through the working port of the cystoscope and advanced 1 cm beyond the lens. The probe must remain at least 1 cm away from the bladder mucosa to prevent injury and perforation of the bladder. The probe is then positioned 1-2 mm away from the stone, and fragmentation is initiated under direct vision to avoid bladder injury. Pinning the stone against the bladder wall may reduce the duration of the procedure, but take care not to involve the ureteral orifices. Fragmentation of the stone is initiated by cracking the outer layers until the stone is reduced to a size suitable for evacuation. A manual suction evacuator (eg, Microvasive, Ellik) is commonly used to remove the fragments, although grasping forceps can also be used. Frequent drainage of the bladder or low-pressure continuous irrigation during the procedure is important to prevent bladder rupture. The success rate of EHL is 92%100% for stone sizes of 3-6 cm. Relative contraindications to EHL include small-capacity bladder, possibly pregnancy, and the presence of a cardiac-pacing or defibrillation devices. The lithoclast and laser (holmium) lithotripters are used for calculi in all locations throughout the urinary tract, and they have largely supplanted the EHL unit when available. Ultrasonic lithotripsy is also commonly used for renal and bladder calculi.[8]

Special situations
Percutaneous lithotripsy has become the treatment of choice in the pediatric population because it prevents potential injury to the small-caliber urethra while providing an approach that is less invasive than open surgery, thus reducing pain and hospital stay. Access is obtained in a fashion similar to renal access. A rigid nephroscope, graspers, the ultrasonic lithotripter, and suction are used for rapid stone fragmentation and evacuation. Contraindications include prior lower abdominal surgery, prior pelvic surgery, and small-capacity noncompliant bladders.[42, 43, 44] A report by Isen et al (2008) studied the use of a semirigid ureteroscope with holmium laser lithotripsy for bladder stones in 27 boys aged 3-14 years. At 2 weeks postsurgery, all patients were stone-free, and only two had required repeat intervention owing to obstruction by stone fragments. This treatment was recommended as an alternative approach to bladder stones in children with stones smaller than 2 cm.[45]

Postoperative Details
The usual postoperative course includes a short duration of catheterization, until the effects of anesthesia abate. The antibiotic coverage is continued according to preoperative findings and

discontinued after the appropriate length of treatment, usually 5-7 days for an active preoperative infection or until the drains and catheters are removed. Hospitalization is unnecessary unless secondary procedures have been performed or the open surgical approach was used. Anticoagulants should be avoided until any hematuria has resolved.

Follow-up
Typical follow-up is 3-4 weeks postoperatively with KUB or bladder ultrasonography to document clearing of all the fragments. Thereafter, metabolic evaluation may be pursued as indicated and periodic KUB at approximately 6- to 12-month intervals is warranted. A metabolic stone profile analysis is indicated in patients with uric acid stones, concurrent upper tract calculi, a strong family history of stone disease, calculi without obstruction, and recurrent calculi.

Complications
Transurethral litholapaxy is, by far, the most common general modality used to treat bladder calculi and has been associated with relatively few minor complications. Common complications include urinary infection (11%), fever (9%), bladder perforation (2%), hyponatremia (2%), and hemorrhage (1%). Fever and urinary tract infection are clinical diagnoses marked by fever, dysuria, elevated WBC count, and positive findings on urinalysis and cultures. Treatment involves intravenous antibiotics and good bladder drainage. Gross hematuria is not uncommon and, when present, usually self-limiting. In severe cases, 3-way catheter irrigation and blood transfusions may be necessary. Bladder perforation is usually diagnosed intraoperatively when irrigating solution suddenly does not return during the procedure. Intraoperative cystography is used to confirm the diagnosis. Extraperitoneal perforation is managed with a Foley catheter, while intraperitoneal perforation usually requires retrieval of extravasated stone debris, open surgical repair of the bladder wall, and placement of a Foley catheter. The catheter is left for 5-7 days, and, prior to removal of the catheter, cystography may be performed to rule out leakage. Hyponatremia can be a consequence of cystolitholapaxy in combination with TURP. Low serum sodium levels with mental status changes and lethargy confirm the diagnosis. The treatment involves termination of the procedure and administration of intravenous furosemide, isotonic sodium chloride solution or other iso-osmotic intravenous fluids postoperatively, and, occasionally, short-term use of 3% hypertonic sodium chloride solution if the patient is acutely symptomatic and not otherwise responding. Symptoms generally develop as the serum sodium level falls below 125 mg/dL.[46]

Future and Controversies

The incidence of bladder stones in children is slowly declining, even in endemic areas. This is mostly due to improved nutrition, better prenatal and postnatal care, and improved awareness of the problem in the endemic areas. In the 21st century, the incidence of this disease in children will probably continue to decline and the disease will largely become a disease of adults.

The aggressive treatment of lower urinary tract symptoms with alpha-blockers and 5-alphareductase inhibitors should further decrease the overall incidence of bladder stones because of improved bladder emptying. The removal of bladder stones will continue to progress toward minimally invasive techniques, thus decreasing hospital stay and recovery times. Continued advancement of surgical equipment and the ability to downsize, without the sacrifice of effectiveness, could eventually make open surgery for stones obsolete. Additionally, continued aggressive management of neurogenic bladder, specifically in the pediatric neurogenic bladder population, may lead to a rise in both the incidence of struvite stones as well as the development of creative and minimally invasive surgical techniques in augmented bladders.