Cystolitholapaxy

Cystolitholapaxy is the most common surgical procedure to remove bladder stones without external incisions. It is an outpatient procedure where the patient can return home the same day. During a Cystolitholapaxy, the surgeon uses a cystoscope to locate the bladder stone. Next, they use a laser to break the stones into smaller fragments that are cleared from the bladder. However, in some cases, the surgeon may need to make small incisions in the lower abdomen and bladder to remove stones.

 

1. The bladder is a muscular, hollow sac in the pelvic cavity located behind and above the pubic bone. 
2. The urinary bladder’s shape and size change with the amount of urine it holds and the pressure it receives from the surrounding organs. 
3. When empty, it is about the size and shape of a pear. 
4. Urine is produced in the kidneys, which travels down the two tubes called ureters to the bladder. 

The urinary bladder plays two main roles, which include:-

1. The temporary storage of urine: The bladder is a hollow organ that stores urine, allowing infrequent and controlled urination. It has a folded internal lining called rugae that stretches to hold about 400-600 mL of urine in a healthy adult. 
2. Allows the exit of urine: The bladder muscles squeeze during urination, opening the two valves or sphincters and allowing the urine to flow out into the urethra. The urethra then carries urine out of the body. 

Cystolitholapaxy is performed to treat urinary bladder stones that may not pass by drinking extra water. It is a procedure that requires no external incisions.

Patients unable to pass stones naturally by drinking lots of water may require Cystolitholapaxy. The candidates for this procedure include patients who:-

1. Do not want to have an invasive procedure with surgical incisions
2. Have stones less than 3 cm in size
3. Need another procedure simultaneously to treat prostate

Percutaneous suprapubic Cystolitholapaxy (a type of Cystolitholapaxy) is also preferred for children with urinary bladder stones to prevent damaging their urethra.

 

Those who have the following conditions are not the ideal candidate for Cystolitholapaxy:-

1. Untreated UTIs (urinary tract infections)
2. Very large or too many bladder stones
3. Prostate volume above 80 mL (if surgical treatment of benign prostate hyperplasia is required)

Cystolitholapaxy is an outpatient procedure, i.e., the patient can return home on the same day of their surgery. Depending on the stone size, the procedure can take 30-60 minutes. The steps involved in the surgery include:-

Preparation for the Final Surgery

1. In the OT, the patient will be made to relax in a dorsal lithotomy position (lying at the back with legs flexed 90 degrees at the hip) on the operating table.
2. The team will start an IV line in the patient’s arms or hands for fluids and medications. 
3. The anaesthesiologist will administer general or local anaesthesia. While local anaesthesia will be inserted into the urethra to numb the area, general anaesthesia administered through the IV line will make him/her unconscious during the procedure. 
4. In the case of general anaesthesia, the anaesthesiologist will insert a breathing tube in the patient’s mouth and down the windpipe once he/she is asleep. 
5. The nursing team will clean the surgical site with an antiseptic solution. 
6. The anaesthesiologist will monitor the vitals throughout the procedure, including heart rate, breathing, and blood pressure. 

The Final Surgery

1. The surgeon will place a cystoscope (a small tube with a camera at the end) through the urethra and into the bladder. The camera in the cystoscope will allow the surgeon to locate the stone. 
2. A laser or ultrasonic wave will be passed through the cystoscope to fragment the stone. 
3. The surgeon will use fluids to flush the stone fragments out through the urethra. 
4. The cystoscope will be removed, and a catheter will be inserted into the bladder. 

Types of Cystolitholapaxy

There are two types of Cystolitholapaxy procedures:-

1. Transurethral Cystolitholapaxy: The procedure is commonly performed to treat bladder stones in adults under general or local anaesthesia to prevent pain during the procedure. The surgeon inserts a cystoscope in the bladder that helps locate and remove the bladder stones. 
2. Percutaneous suprapubic Cystolitholapaxy: The procedure is performed in situations where the transurethral Cystolitholapaxy may not be effective. It is a preferred method for treating bladder stones in children or adults with large bladder stones. Instead of inserting a cystoscope into the urethra, the surgeon makes small incisions in the lower abdomen and bladder to place a hollow tube. The surgeon inserts the cystoscope through this tube and removes the bladder stones. It is performed under general anaesthesia. 

But why is percutaneous suprapubic Cystolitholapaxy preferred over transurethral Cystolitholapaxy for children? Because children have a narrower urethra, making the insertion of cystoscopes more difficult. 

The following table compares transurethral and percutaneous suprapubic Cystolitholapaxy:-

 

Before the bladder stone removal surgery, the doctor will perform a physical test and evaluate the patient’s medical history. During the physical test, he/she will feel the lower abdomen to check for an enlarged bladder or perform a rectal exam to check for enlarged prostate. He/she will perform a series of tests before the surgery, which includes:-

1. ECG tests: to check the electrical activity of the heart before surgery
2. CT scan: to locate the urinary bladder stone
3. Ultrasound: to identify the bladder stone
4. Blood tests: to check haemoglobin levels and liver and kidney function 
5. Urine test: to check the presence of blood in the urine. It also determines the levels of minerals and crystals that cause stone formation. Furthermore, the test must be performed before the surgery to rule out urinary tract infections. 

Here’s what the patient can expect in preparation for surgery:-

1. A visit to the anaesthesiologist for a pre-anaesthetic checkup (PAC). 
2. Must quit smoking several weeks before the surgery. 
3. May need to stop taking certain blood-thinning medications like aspirin and ibuprofen, herbs, and supplements one week before the surgery. 
4. Will be required to fast six hours before the procedure. 
5. Inform the provider if he/she has any of the following:-
   1. A coronary artery stent
   2. An artificial heart valve
   3. A heart pacemaker
   4. A neurosurgical shunt
   5. An artificial joint
   6. An artificial blood-vessel graft
   7. Other implanted foreign bodies
6. After receiving clearance for the surgery, the doctor will appoint a date for the surgery. 
7. Based on the PAC results and surgery, the anaesthesiologist will decide the type of anaesthesia to be administered during the procedure. 
8. The doctor will explain the procedure, duration, estimated cost, and insurance formalities. 

On the Day of Cystolitholapaxy Surgery

Generally, the patient is admitted to the hospital on the same day of the surgery. Here’s what he/she can expect on the day of surgery:-

1. The doctor will ask to sign the consent formalities before the procedure. 
2. The patient will be made to change into a hospital gown and remove all jewellery. 
3. Someone from the nursing team will shave the excess hair at the surgical site. 
4. The provider will record the patient’s last meal and give medicine to be taken with a sip of water. 
5. The anaesthesiologist will monitor the vital signs. 
6. The patient will be moved to the OT room.

 

For 24 hours to one week after the procedure, the patient may:-

1. Feel burning during urination
2. Witness blood in the urine
3. Have a catheter in the bladder

Cystolitholapaxy is an outpatient procedure, so the patient may not need to stay overnight in the hospital. However, he/she will be under anaesthetic effect after the procedure and may expect the following in the hospital:-

1. The patient will be moved to the recovery room, where the anaesthesiologist will monitor the vitals and anaesthesia effect.
2. The catheter will remain inside the urethra, usually removed 24-48 hours after the surgery. 
3. He/she will be encouraged to move around as much as possible to prevent chest infections and blood clots. 
4. The provider will prescribe antibiotics to prevent infections and pain relievers for managing post-operative pain. 
5. The patient will get discharged from the hospital once his/her vitals stabilise and the effect of anaesthesia wears off. 
6. The doctor will provide specific home care and follow-up instructions.

Recovery at Home

1. The patient may recover from the surgery about a week after the procedure. Home care instructions after Cystolitholapaxy include:-
2. Showering
3. May shower on the day of the surgery.
4. Take a bath only when the catheter has been removed. 

Diet

1. Drink plenty of clear liquids for the first 24 hours after Cystolitholapaxy. 
2. May resume his/her normal diet, as tolerated, the next day. 
3. Vegetables, fruits, and other high-fibre food can help prevent constipation. 
4. Drink about six to eight glasses (1.5-2 litres) of water daily. 

Activity

1. Walk at least six times daily to prevent blood clots in the legs.
2. May climb up and down the stairs. 
3. Can resume normal activities 5-7 days after the procedure. 

Work

1. Can resume work 2-3 days after surgery if it is a desk job. 
2. If the job requires strenuous activities or heavy lifting, the patient may need to avoid resuming work for 1-2 weeks post-surgery. 

Restrictions

1. Avoid engaging in heavy lifting, strenuous, or sexual activities for 2-5 days or until the doctor approves. 
2. Avoid driving for 24 hours after leaving the hospital. 

Medicine

1. The doctor will prescribe antibiotics to prevent infections. 
2. He/she may also prescribe stool softeners to help sluggish bowel movements. 
3. The patient may take pain medications if he/she experiences post-operative discomfort. 

Catheter

1. The patient will return with a catheter attached to a urine drainage bag. 
2. The tube will be removed 24-48 hours after the surgery. 
3. If he/she has difficulty urinating after catheter removal, it may need to be reinserted for emptying the bladder. 

 

First Follow-Up Appointment

The doctor will schedule a follow-up appointment 4-6 weeks after the procedure or earlier in case of complications. During the visit, the doctor will perform X-rays or a CT scan to check whether the bladder stones have been removed completely. He/she will provide further follow-up instructions if required. 

 

There are several benefits of Cystolitholapaxy compared to other stone treatments:-

1. Cystolitholapaxy can treat most bladder stones. 
2. It avoids the need for surgical incisions. 
3. It offers faster recovery. 
4. The risk of bladder infections and pain is reduced. 
5. It lowers urinary tract symptoms.

Though rare, Cystolitholapaxy has some potential complications like any other procedure. The side effects of the procedure include:-

1. Fever
2. Blood clot formation in lungs or legs
3. Infections
4. Reaction to anaesthesia

Complications specific to Cystolitholapaxy include:-

1. Common (almost all patients)
2. A burning sensation while urinating

Occasional (approximately 1 in 10)

1. Urinary tract infection (requires antibiotic treatment)
2. Failure to remove all stones or stone fragments
3. Bleeding for a few days 
4. Difficulty passing urine or frequent urination

Rare (1 in 100 or 1 in 250)

1. Urethral injury leading to scar formation (may require another surgery)
2. Urinary bladder perforation (may require open surgical repair)

Sequelae of Complications If Not Treated in Time

Complications like urethral injury and bladder perforation may require additional surgery. If left untreated, it may have the following sequelae:-

1. Urethral injury can lead to stricture, impotence, or incontinence.
2. Bladder perforation may cause complications like infection, haemorrhage, transurethral resection syndrome, or death. 

When to Consult a Doctor?

The patient should call the healthcare professional if he/she experiences:-

1. Fever higher than 101℉
2. Nausea and vomiting
3. Pain that does not get better with prescribed medications
4. Burning or discomfort while urination
5. Bleeding in urine for more than three days
6. Bright red urine
7. Blood clots in the urine
8. Inability to pass urine

Risks of Delaying Cystolitholapaxy

1. Most urinary bladder stones pass on their own. However, some may require surgical intervention. 
2. If left untreated or delayed, bladder stones can lead to long-term urinary complications like the frequent need for urination and pain. 
3. Bladder stones can cause repeated infections in the urinary tract, resulting in permanent damage to the bladder or kidneys.