Endoscopic Management of Large Vesical Calculus

By Osama Kalim Shaikh¹, Shakeel Haseeb Uddin Siddique¹, Muhammad Umar¹, Ahsan Rehman¹, Habibullah Muhammad Akbar¹

Doi: https://doi.org/10.36283/ziun-pjmd14-1/023

How to cite: Shaikh OK, Siddique SHU, Umar M, Rehman A, Akbar HUM Endoscopic Management of Large Vesical Calculus. Pak J Med Dent. 2025 Jan ;14(1): 157-160. Doi: https://doi.org/10.36283/ziun-pjmd14-1/023.

Received: Thu, March 14, 2024 Accepted: Fri, December 13, 2024 Published: Fri, January 10, 2025.

Vesical calculi are the most commonly observed lower urinary tract stones. Traditionally, large vesical calculi (>4 cm) have been managed via open surgical procedures like cystolithotomy. However, advancements in urology have introduced minimally invasive techniques, including cystolitholapaxy, percutaneous cystolithotomy, cystolithotripsy, and extracorporeal shock wave lithotripsy (ESWL). This study aimed to share our experience in managing large vesical calculi through endoscopic approaches, particularly in cases where cystolithotomy was not feasible due to prior bladder surgeries. The study included nine patients with vesical calculi exceeding 4 cm. All had a history of open bladder surgery, such as cystolithotomy, with one female patient having undergone vesicovaginal fistula repair twice. Initial fragmentation of stones into 3–4 pieces was achieved using a holmium laser to create smaller, rougher surfaces, facilitating subsequent removal with a lapaxy punch. Complete stone clearance was achieved in all patients without requiring ancillary procedures. Catheters were removed within 24 hours post-procedure. This combined approach using a holmium laser and cystolitholapaxy punch demonstrates an effective, minimally invasive option for managing large vesical calculi in complex cases with prior bladder surgeries.

Key Words: Cystolithotomy, Cystolitholapaxy, Cystolithotripsy.

Human beings have been tormented by vesical calculus since time everlasting, even the signs of stones were found in the pelvis of an old Egyptian skeleton by Archaeologists ¹. Urinary Bladder stones also called vesical calculi are the most widely recognized sort of lower urinary tract stones, depicting roughly 5% of all urinary stones ². Vesical Calculus is subdivided into 2 types: Primary: Most common in children of underdeveloped countries having nutritional deficiency Secondary: Mostly in adults as a result of secondary causes like BOO, Urethral stricture, foreign body, neurogenic bladder, etc³.

Long-standing vesical calculus can induce chronic inflammation, infection, and ulceration which are considered predisposing factors for the formation of bladder tumors. Customarily, treatment of enormous (>4 cm) vesical calculi has been through an open surgical procedure i.e., Cystolithotomy ⁴. In today’s world, different modalities for the treatment of vesical calculus can be utilized which incorporate Cystolitholapaxy, Percutaneous Cystolithotomy, Cystolithotripsy & ESWL ⁵.

Obaid AT et al. regard Percutaneous suprapubic Cystolitholapaxy as a better approach compared to Cystolithotomy in terms of less hospital stay, low incidence of complications, decreased post-operative pain reduced chance of infection, and scar ⁶. Wadhah et al. suggested suprapubic Cystolithotripsy is a superior & better method of treating vesical stones as it carries shorter operative time, less blood loss, and a higher stone-free rate compared to transurethral Cystolithotripsy ⁷.

Open cystolithotomy has the inherent problems of an evident scar, prolonged catheterization, extended hospitalization, and risk of infection. It is still recommended for multiple bladder calculi and even for solitary vesical stones of large size. This study aimed to share our experience of dealing with large vesical calculi by endoscopic approach with challenging conditions where cystolithotomy is not a feasible option.

This Retrospective case series was performed at the Department of Urology, The Kidney Centre, Karachi after administrative permission from the concerned authorities and the Ethical review committee and it lasted for a year approx. (Reference No. 142-URO-042022). In this case series, data comprises of 09 patients. Of the patients which are included, all of them had large vesical calculus of more than 4cm and among them, 07 were adult males who previously had a history of open bladder surgery i.e., Cystolithotomy and 02 patients were female with an earlier history of Vesicovaginal fistula repair twice in one case and cystolithotomy in other case. In all the cases, the stone was initially fragmented with the assistance of a holmium laser using a 21fr cystoscope and it was done to make the surface of the stone small, rough, and irregular enough so that lapaxy punch could easily be used to fragment it and removal of stone later on. This strategy was employed to avoid the overutilization of lasers as well as to reduce operative time. Operative time, Stone clearance, post-operative complications like fever, Infection, Hematuria & length of hospital stay, and catheterization time remain the primary focal point of the study. The data was collected reviewed and analyzed by SPSS Version 26.

In our series, the mean age was 52.1 years, and the mean BMI was found 24.5kg/m2. The mean stone size was 4.7cm. And mean operative time was 44.4 minutes. All patients were discharged on the following day after the procedure. None of the patients had any post-operative complications, all patients had complete clearance of stone and none of the cases required any ancillary procedure, and the catheter was removed in all patients after 24 hours.

Table 1: Clinical Profile and Characteristics of Patients Undergoing Endoscopic Management of Large Vesical Calculi

The incidence of vesical calculus is higher in developing countries, particularly among children with diets low in animal protein, inadequate hydration, and a history of recurrent diarrhea.⁸. Luckily, the rate of vesical calculi has declined altogether in developed countries ⁹. Various treatment choices and modalities are available for the treatment of vesical calculus which highly rely on the size and number of stones but nowadays these techniques are often used together for better results ⁵. Cystolithotomy is associated with extended scars, long hospital stays, prolonged catheterization, and greater chances of infection ⁶. Bhatia et al. study results showed the effectiveness of open Cystolithotomy with complete stone clearance but longer hospital stay compared to endoscopic Cystolitholapaxy with higher complication rate like bladder perforation, intraoperative bleeding, and urethral stricture but lesser hospital stay compared to open procedure ¹⁰. On the contrary, our study also did not report any bladder trauma or perforation by Cystolitholapaxy as well as from laser Cystolithotripsy, and no stricture was found in any cases in long-term follow-up of three years.

Jang et al. reported Ultrasonic lithotripsy is deemed an advantageous and safe methodology as it offers fragmentation and clearance of stone at the same time hence limiting injury and shortening the procedure time. He presented the data of Cystolithotripsy performed by cystoscope as well as Nephroscope but we only used a 21FR cystoscope with a laser to make the surface of the stone rough and uneven, later on used a Cystolitholapaxy punch for stone clearance. In our study, we reported similar operative time but shorter hospital stays of one day compared to two days hospital stay in his study ¹¹. Sathaye et al also favored the endoscopic management of large vesical stones up to 10cm with the use of pneumatic lithotripsy via a Nephroscope through the urethra and found sufficient enough for complete clearance of stone without any sort of complication. He reported a catheterization time of 24 to 48 hours ¹². In our study, the catheter was removed on the first post-operative day within 24 hours. Emphasized on reliability and cost-effectiveness of this modality. Another study demonstrated the efficacy of percutaneous removal of vesical stones in children as it lowers the chances of iatrogenic urethral stricture with the sole disadvantage of increased post-operative hospital stay due to Suprapubic catheterization ¹³. In contrast to his study, we also reported complete clearance of stone without the need for suprapubic intervention and catheter with a shorter hospital stay.

In light of the above discussion, we conclude that large-size urinary bladder stones in the previously operated urinary bladder can be treated with an endoscopic combined approach using holmium laser as well as Cystolitholapaxy punch safely with reduced operative time, reduced morbidity & lesser hospital stay.

The author declared no conflict of interest.

Ethical approval for the study was obtained from the Ethical Review Committee of The Kidney Centre (Reference No. 142-URO-042022).

OKS: Contributed to the writing of this manuscript, including the conception and design, data acquisition, analysis, interpretation, and drafting of the manuscript. HUS: Contributed to the conception and design, Supervision & Critical review of the manuscript for important intellectual content.MU: Contributed to the writing of this manuscript also data acquisition & analysis.AR: Contributed to data acquisition & analysis. MA: Contributed to the supervision & critical review of the manuscript for important intellectual content.

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