What is Cystolithotripsy? - Procedure, Surgery, Risks & Recovery

It is an endoscopic surgery performed to crush a urinary bladder stone into smaller pieces and remove it from the body. It is a safe and quick procedure for treating all types of bladder calculi (stones). 

Anatomy and Physiology of the Urinary System 

The urinary system comprises the following organs:

1. Kidneys
2. Renal Pelvis
3. Ureters
4. Bladder 
5. Urethra

These organs work together to purify the blood by filtering out waste and toxic products to produce urine as the end product. The working of the urine system is explained in the following steps:

1. After metabolism (the process in which the body converts food into energy), the body absorbs all the useful ingredients so that only waste and toxins remain in the blood and the bowel (a tube-shaped organ present in the lower part of the digestive system that goes from the stomach to the anus)
2. The kidneys and the urinary system eliminate the waste and toxins (urea) from the blood to maintain its equilibrium of salt, potassium, and water. 
3. When the kidneys filter the blood, urine is formed as the end product. 
4. Once the urine is formed, it travels down to the bladder through the ureters (tubular structures that the kidneys to the bladder)
5. The bladder walls relax and expand to store urine. When these walls contract, the urine is expelled from the body. 
6. But certain medical conditions may prevent the bladder from emptying completely, and as a result, a small amount of urine remains inside the bladder. 

How Does a Bladder Stone Form? 

Urine contains several salts and minerals the body doesn’t absorb from food. The body expels these minerals with urine. Sometimes, a small amount of urine may be left in the bladder even after peeing. Over time, the minerals in the urine can get concentrated and crystallizes to form a urinary bladder stone.  

Cystolithotripsy is performed to treat almost all types of bladder stones. However, in cases of very large or rigid stones that are resistant to the endoscopic approach, cystolithotripsy may not prove to be effective.

There are several endoscopic procedures that are used to remove urinary bladder stones. Among these, cystolithotripsy is an effective treatment approach, especially for removing small bladder stones. The right candidates for cystolithotripsy can be the individuals who have:

1. A blockage in the urinary tract due to bladder calculi (stone)
2. Urinary tract infection - which may be caused due to a bladder stone
3. Bladder stone symptoms include painful and interrupted urination, small blood in the urine, cloudy urine, etc. 
4. Enlarged prostate and undergoing other obstruction treatments, such as TUR-P or optical urethrotomy. 

Who are not the Right Candidates for Cystolithotripsy? 

Cystolithotripsy may not be effective or can even cause harm to patients who:

1. Are pregnant 
2. Have bleeding disorders or are on blood thinning medications, such as Aspirin (the patient must prevent the use of medications for at least a week before the procedure)
3. Have injured or scarred ureters that may prevent the stone fragments from passing 
4. Have bladder stones composed of cystine and other types of calcium, as these stones may not be broken by lithotripsy

A urologist performs the cystolithotripsy procedure. Usually, it takes about 30 to 45 minutes to remove the bladder stone. However, this procedure can also be completed as soon as five minutes. So, the duration of the procedure may vary depending on the size and location of the stone. The procedure may involve the following steps:

1. At first, the patient is placed in a gynaecological examination position (in a supine position but with knees bent and feet placed at the corners of the table). 
2. The health care providers clean the crotch area and lubricate the urethra. 
3. Once the urethra is lubricated, an instrument called a lithotripter is inserted inside the bladder through the urethra. The lithotripter provides a non-invasive approach (without making an incision) to treat the bladder stone. 
4. During the procedure, ultrasound or fluoroscopy is used to identify the size and location of the stone. 
5. Then a sequence of shock waves is sent through the lithotripter to break the stone into smaller pieces that can be easily removed from the body. 
6. Finally, a catheter is placed inside the bladder to help the stone fragments pass out of the body. 
7. In the case of hematuria (blood in the urine), continuous bladder irrigation is required till the blood clears up from the urine. 
8. If the stone fragments are not small enough to pass from the urinary system, the procedure may be repeated to break them further so they can easily pass. 

The most commonly used lithotripters are: 

1. Ballistic lithotripters use a controlled burst of compressed air to break even the hardest calculi.  
2. Electrohydraulic lithotripters use high electrical voltage sparks to break the stones. 
3. Laser lithotripters use a laser beam to crush the stone located in the urinary tract. 

Before the cystolithoscopy, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Cystolithoscopy 

One can expect the following things before the surgery:

1. The doctor explains the procedure in detail, along with its risks and benefits. The patient can also ask any questions or doubts regarding his or her medical condition or the procedure. 
2. After discussing all the details, the patient signs a consent form to permit the doctors to start the procedure.
3. The patient must tell the doctor about his or her medical history. In addition, the doctor may also perform a physical exam to check if the patient is in good health. 
4. Blood tests, chest X-rays, and other diagnostic tests may also be required before starting the procedure. 
5. If the patient is pregnant, she must inform the doctor about her condition.  
6. If the patient is taking anticoagulants (blood-thinning medications like Aspirin), he or she may need to stop taking these if the doctor instructs.  
7. Fasting before the procedure may be necessary, depending on the anaesthesia used. 

Types of Anaesthesia Used in Cystolithotripsy 

Cystolithotripsy can be performed under local, spinal, or general anaesthesia, depending on the size and location of the stone. 

1. Local anaesthesia is induced to numb a part or region of the body where the operation is performed. 
2. Spinal anaesthesia is induced in the lower back (intrathecal space), where the cerebrospinal fluid is present. This fluid surrounds the spinal cord and is used to numb the lower abdominal region. 
3. General Anaesthesia is given to render the patient unconscious or sleepy so that they don’t feel any pain during the operation.

On the day of Cystolithoscopy 

One can expect the following things on the day of surgery:

1. The patient is asked to remove jewellery or any other accessories that may interfere with the procedure. 
2. He or she is made to change into a hospital gown and be taken to the operating room. An IV line is started in the patient's arm to supply medications and IV fluids. 
3. After placing the patient in a gynaecological examination position, shockwaves are sent to break the stone into fragments so that it can easily pass through the urinary system.
4. Finally, a catheter is placed inside the bladder to remove the residual stone fragments from the bladder. 

Cystolithotripsy may be an inpatient or outpatient procedure, depending on the patient’s health condition after the process. He or she may expect the following things after the procedure: 

The recovery process at the hospital

1. The patient is shifted to the recovery or hospital room.
2. The catheter inserted during the procedure is removed as soon as the blood clears up from the urine (usually, it is removed after 6 to 8 hours of the procedure).
3. If they are stable after the procedure, the doctor allows the patient to go home. If not, the patient may need to stay in the hospital for 1 to 2 days until recovery. 
4. The doctor may prescribe pain-relieving medications and give instructions to drink more water and fluids to pass the urine without discomfort. 

Recovery process/expectation after hospital discharge

1. The patient may notice a small amount of blood in the urine for a few days after the procedure.
2. Pain and burning sensation in the urethra is also standard. The patient must take prescribed medications only to manage the pain. Aspirin and other pain relievers may increase the chance of bleeding.  
3. If small fragments of stones were left in the bladder, they might pass out with urine the following days after the procedure. The doctor may also instruct to strain the urine to collect the stones for examination. 
4. The patient may feel pain and discomfort while peeing for a few days after the procedure. But may recover from the pain and resume work within 2-3 days following the process. 
5. If the catheter is not removed, the patient may experience intense pain and bladder spasms that last for a few seconds but return regularly. These symptoms can be improved with prescribed medicines till the catheter is removed. 

Restrictions:

1. Don’t engage in strenuous physical activities till the doctor allows it.
2. Smoking, drinking coffee, and alcohol must be avoided, as these may irritate the bladder. 

First follow-up appointment

1. The first follow-up appointment is scheduled a few weeks after the procedure. During the visit, the doctor examines the patient’s health condition. If a catheter is still placed inside the bladder, it is removed during the visit. 
2. After removing the catheter, the doctor may check the urination mechanism of the patient with an ultrasound to ensure that the bladder empties after peeing. 

Cystolithotripsy is a non-surgical means to treat urinary bladder stones. It has the following benefits:

1. Cystolithotripsy is considered a highly effective treatment approach with a success rate of 60 to 100%, depending on the size of the stone. 
2. It is considered safe as no cuts or incisions are required to carry out the procedure. 

Although cystolithotripsy is a safe procedure for bladder stone removal, it may have a risk of the following complications:

1. Urinary tract infection 
2. Blockage in the urine flow if the stone fragments obstruct the urinary tract 
3. Residues of stone fragments remaining after the surgery, requiring another cystolithotripsy

When is consultation with the doctor needed?

The patient must immediately consult their doctor if he/she is experiencing the following symptoms:

1. Fever or chills
2. Increased pain, redness, and swelling around the incision site
3. Bleeding or drainage from the incision site

If a bladder stone remains untreated for a long time,

1. It may grow large by accumulating more minerals over time. Endoscopic procedures may not effectively treat large stones, so the patient may require open surgery to get relief. 
2. Small untreated stones can move from the bladder and obstruct the passage of urine flow. This can lead to the risk of repeated urinary tract infections.
3. Blockage in the urine flow may also cause urine to pool inside the bladder leading to the risk of developing more bladder stones. 

The estimated cost of cystolithotripsy in India is ₹1,10,000 to ₹2,40,000. However, the prices may be different depending on the chosen city and the patient’s medical condition. The cost varies based on the following factors:

1. Age of the patient
2. The type of technique used
3. The medical condition of the patient
4. The type of hospital facility availed - individual room or shared.

Procedure Name	Cost Value
Cystolithotripsy	₹1,10,000 to ₹2,40,000