Management of large bladder calculi utilizing dual-action percutaneous lithotripsy via suprapubic tube sheath: a novel technique

Philadelphia, PA

Introduction:

Development of bladder calculi is a common occurrence in patients with poor bladder emptying or retained foreign bodies within the bladder. These calculi cause irritative voiding symptoms and increase the likelihood of refractory urinary tract infections. Many techniques exist to treat bladder calculi, including endoscopic and open-surgical approaches. We present a novel technique to treat exceptionally large or difficult-to-treat bladder calculi.

Methods:

The study included three patients with bladder calculi ranging from 1.3 cm to 6.8 cm. The novel technique involved percutaneous access to the bladder using a suprapubic tube (SPT) trocar and sheath, enabling the use of a dual-action lithotriptor. Sheath insertion and lithotripsy were performed under direct visualization with a rigid cystoscope via the native urethra. The efficacy and safety of the method were assessed based on its ability to achieve complete evacuation of the bladder stones.

Results:

All three patients treated with the technique achieved complete evacuation of their bladder stone burden. There were no postoperative complications.

Case 1: A 60-year-old quadriplegic male with a chronic suprapubic catheter presented with a 6.8 cm bladder calculus. Considering his obese body habitus and difficulty with positioning, our novel technique utilized his existing SPT tract.

Case 2: A 71-year-old male with a history of prostate cancer and incomplete emptying had two bladder calculi (3.8 cm and 1.3 cm). He underwent percutaneous suprapubic cystolithotomy technique through a newly created SPT tract.

Case 3: A 72-year-old male with incomplete bladder emptying had a 3.4 cm bladder calculus. Initially, thulium laser lithotripsy failed due to stone density. Subsequently, percutaneous suprapubic cystolithotomy through a new SPT tract was successful.

Discussion:

In case 1, we removed an exceptionally large bladder calculus in a single operation through an existing tract in a patient with significant comorbidities. In case 3, a thulium laser lithotripsy was attempted but failed due to the hardness of the stone. However, the dual-action lithotriptor efficiently fragmented and evacuated the stone.

Contraindications include bladder cancer, inability to adequately distend the bladder, skin infection, coagulopathy, osteomyelitis of the pubis, and orthopedic hardware in the pubis. Axial imaging before the procedure is needed to confirm the absence of bowel anterior to the bladder.

One limitation of the technique is that it requires two people to perform the procedure. Proper sheath positioning is essential to prevent direct contact of the lithotriptor shaft with the patient’s skin and avoid thermal injury. SPT maintenance for 1-2 weeks allows tract formation and prevents immediate leakage. In patients with intact bladder function, the catheter can be capped at the end of the case, eliminating the need for a urethral catheter. Those with chronic suprapubic catheters can resume regular SPT changes.

The novel technique was effective in treating challenging bladder calculi. It is easy to learn and safe, making it a promising option for patients where alternative methods may pose higher risks. Further research is needed to validate its broader applicability, long-term efficacy, and integration into standard practice.