ORIGINAL ARTICLE
Percutaneous treatment
of bladder lithiasis: comparison of two
surgical techniques
Camacho-Trejo VF1, Aragón-Tovar AR2, Sánchez-Puente JC3, Castillo-González JM1, Vargas-Valtierra P4
• ABSTRACT • RESUMEN
Introduction. Bladder lithiasis is one of the oldest Introducción: La litiasis vesical es una de las patologías
pathologies known to man and its treatment has been a más antiguas que conocemos; y su tratamiento ha sido
subject of discussion throughout history. objeto de múltiples discusiones a lo largo de la historia. La
Percutaneous surgery and the use of shock wave cirugía percutánea y el uso de litotricia por ondas de choque
lithotripsy has been one of the great advances in the han sido uno de los grandes avances en el tratamiento de
treatment of this pathology, eliminating the use of esta patología, ya que al no existir una instrumentación
rigid surgical instruments in the urethra and possible rígida en la uretra, se evitan las complicaciones derivadas
complications from their use. de ésta.
Materials and Methods. Two groups were formed Material y métodos: Se formaron dos grupos con un
from a total of 21 patients who had undergone total de 21 pacientes a los cuales se les realizó tratamiento
percutaneous surgical treatment of bladder lithiasis. percutáneo de la litiasis vesical; en el primero, se
Dilators (Amplatz®) were used in the first group and emplearon dilatadores (Amplatz®), mientras que en el
12mm laparoscopy trocars were used in the second. segundo se utilizó un trocar de laparoscopia de 12 mm.
Both groups were similar with respect to age, sex, Ambos grupos fueron similares con respecto a la edad,
number of fragmented stones, stone size and number of sexo, número de litos fragmentados, tamaño de los litos y
days of hospitalization. días de estancia hospitalaria.
Results. There was significant difference in the time Resultados: La comparación del tiempo quirúrgico fue
in surgery comparison favoring the laparoscopy trocar diferente estadísticamente a favor de la técnica con trocar
technique. de laparoscopia.
Conclusions. Bladder lithiasis percutaneous surgery Conclusiones: El uso de la cirugía percutánea en la
was shown to be a safe, efficient and economic method litiasis vesical ha demostrado ser un método seguro,
with minimal morbidity. eficaz, económico, y con mínima morbilidad.
Key words: Bladder lithiasis, Percutaneous, Lithoclast. Palabras clave: litiasis vesical, percutánea, lithoclast.
1. Urology Service Resident. Unidad Médica de Alta Especialidad Corresponding author: Dr. Víctor F. Camacho Trejo. Servicio de Urología
25. Centro Medico Nacional Noreste, Instituto Mexicano del Seguro Unidad Médica de Alta Especialidad CMNN IMSS. Avenida Fidel
Social, Monterrey NL. 2. Head of Urology Service, CMNN UMAE 25, Velázquez y Abraham Lincoln S/N. Col. Nueva Morelos. CP 64300
IMSS. Monterrey, NL. 3. Urology Service Staff Physician, CMNN Monterrey, NL, México Telephone: (81) 83714100 ext. 41315. e-Mail:
UMAE 25, IMSS. Monterrey, NL. 4. Head of Health Education ixcan77@hotmail.com
Division UMAE 34, IMSS. Monterrey, NL.
318 Rev Mex Urol 2008;68(6):318-323
Camacho-Trejo VF et al. Percutaneous treatment of bladder lithiasis: comparison of two surgical techniques
• INTRODUCTION – Percutaneous cystolithotomy
Bladder lithiasis is a pathology which has been – Cystolithotripsy:
known since ancient times. Egyptian mummies • Ultrasonic ( Lithotriptor )
have been found with calcium oxalate and struvite
• Lithoclast
lithiasis (1).
• Electrohydraulic ( Lithotriptor )
It is most common in men over 50 years of age and
represents 5% of urinary calculi in the western world (2). • YAG laser
Risk factors for developing bladder lithiasis are: – Extracorporeal Shock Wave Lithotripsy (ESWL)
– Urine exit obstruction (benign prostatic hyperplasia
(BPH), urethral stenosis, cystocele, etc.) Cystolithotomy was first described in 1990 by
– Neurogenic bladder Baldani and cols. (7). It was proposed as an alternative
to open surgery in pediatric patients presenting with
– Chronic bacteriuria
narrow urethra, in patients having undergone previous
– Foreign bodies surgery of the urethra or bladder neck and in patients
– Urinary calculi in the upper urinary tract presenting with urethral stenosis.
Treatment contraindications are:
Bladder calculi are commonly diagnosed incidentally Absolute:
during the evaluation of patients presenting with • History of bladder malignancy
obstructive or irritative symptoms of the lower urinary
• Previous pelvic radiotherapy
tract.
• Active infection of the abdominal wall
Characteristic symptoms are:
Relative:
• Dysuria
• Previous abdominal surgery
• Macro and microscopic hematuria
• Pelvic prosthesis
• Suprapubic pain
• Acute urine retention
There are reports in the literature about
percutaneous treatment of bladder lithiasis that use the
Diagnosis is generally made with echography, same techniques as those employed in percutaneous
observing a mobile, hyperechogenic bladder mass that nephrolithotomy (5,6,8,9). A puncture is made, a
projects an acoustic shadow. guidewire is placed and dilatation with Amplatz is
Excretory urography will show a filling defect in carried out, leaving a 26 to 30F caliber sheath in the
the cystographic phase and it has been reported as an tract. Rigid instrumentation is then employed as well as
incidental finding in computerized tomography. intracorporeal lithotriptors.
Bladder lithiasis treatment has been controversial In Mexico Rodríguez-Esqueda and cols. (3,4) used
at different points in history. Starting with the first the percutaneous technique creating a tract with
bladder cuts in Egypt and India (1) techniques were a 10-12 mm laparoscopic trocar but only placing a
perfected over time leading to the procedure of open cystostomy catheter (22 or 24F Foley catheter) and
cystolithotomy. Instruments were then designed for letting the tract mature for 3 to 4 weeks before the
endoscopic stone extraction and today intra and surgical procedure.
extracorporeal lithotriptors are used. Based on this information the decision was made to
The goal of bladder lithiasis treatment is for the carry out a comparison of both percutaneous surgical
patient to be calculi-free. Nevertheless, relief from techniques, but instead of letting the tract made with
lower urinary tract obstruction, infection treatment and the laparoscopic trocar mature, it was used as a sheath
correction of urinary stasis should also be considered for inserting the nephroscope to perform the definitive
important treatment aspects. procedure.
Conservative management is prolonged and not
very effective. Today various modalities for bladder • OBJECTIVE
lithiasis treatment are available:
The objective of the present study was to compare
2 percutaneous surgical approach techniques for
– Open cystolithotomy resolving bladder lithiasis using Amplatz dilators and 12
– Cystolitholapaxy mm laparoscopic trocar.
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Camacho-Trejo VF et al. Percutaneous treatment of bladder lithiasis: comparison of two surgical techniques
Table 1. General data.
Patient Group Age Sex Stone mm* Qx time Days Hosp. Other Proc.
2 A 33 male 1 18 10 | Yes Ureteroscopy
3 A 53 male 1 20 18 1 Yes Urethrotomy
5 A 52 male 1 19 20 1 Yes Urethrotomy
6 A 67 male 1 24 20 2 Yes TURP
8 A 66 male 1 22 23 2 Yes TURP
9 A 72 male 1 30 25 1 No
11 A 62 male 1 25, 22 33 1 Yes Urethrotomy
14 A 72 male 2 28,26 40 2 Yes TURP
18 A 70 male 2 30, 22 45 2 Yes TURP
19 A 18 male 1 38 55 1 No
21 A 69 male 4 22,24,30,28 90 1 No
1 B 87 male 1 21 7 2 Yes TURP
4 B 38 male 1 24 8 1 No
7 B 72 male 1 28 13 2 Yes TURP
10 B 47 male 1 30, 14 14 1 Yes Urethrotomy
12 B 56 male 1 28 15 1 Yes TURP
13 B 31 male 2 30, 29 15 1 No
15 B 72 male 1 32 15 2 Yes TURP
16 B 50 male 1 40 16 1 Yes Urethrotomy
17 B 62 male 1 40 20 1 Yes Urethrotomy
20 B 78 male 3 22, 26, 32 30 1 Yes Urethrotomy
Size in mm of each stone; Group A: Amplatz; Group B: 12 mm laparoscopic trocar.
• MATERIALS AND METHODS Group A: Amplatz
A total of 21 patients were included in the study that Group B: 12 mm laparoscopic trocar
had been seen by the urology service of the Centro A 24F Wolf Rigid Nephroscope, Swiss Lithoclast
Medico Nacional Noreste UMAE 25 IMSS in Monterrey, intracorporeal lithotripter with 0.8, 1.0 and 2.0 mm
NL, Mexico between January and August 2007. rods and 5F trident tweezer were used in both groups.
Patients presented with clinical and radiological All patients were given local anesthesia. A 16F Foley
diagnosis of multiple or simple bladder lithiasis. Age transurethral catheter was placed in each patient
and sex were not taken into consideration. Some for gravity filling of the bladder with physiological
of these patients underwent transurethral resection of solution prior to puncture. The catheter remained
the prostate (TURP) or urethrotomy to resolve their closed during the entire procedure. Stones were
obstructive problem at the same time as the lithiasis completely removed in 100% of patients (Photos 1
surgery. and 2).
Exclusion criteria were:
– Indicated adenomectomy AMPLATZ USE:
– Previous history of abdominal surgery involving Once the bladder was filled with physiological solution,
the pelvis a 4 cm suprapubic puncture was made above the
– Previous history of oncological pelvic disease superior pubic ramus with a 14 G needle. When the
– Pelvic radiation exit of physiological solution was observed, a 0.35 inch
Bentson guidewire was inserted through the needle
The surgical procedures were explained to all
opening. A 1 cm incision in the skin and fascia was made
patients and they signed informed consent forms.
and Amplatz dilators up to number 30F were inserted,
Patients were randomly assigned to 2 groups leaving the sheath and safety guidewire in place during
(Table 1). the procedure.
320 Rev Mex Urol 2008;68(6):318-323
Camacho-Trejo VF et al. Percutaneous treatment of bladder lithiasis: comparison of two surgical techniques
Photo 1. Equipment used Photo 2. Bladder gravity filling and catheter pinching
Photo 4. Nephroscope inside the laparoscopic trocar and use of Swiss
Photo 3. Insertion of 12 mm laparoscopic trocar
Lithoclast.
12 MM LAPAROSCOPIC TROCAR USE: Foley catheters were left in place (Photos 4, 5
After bladder gravity filling, a 1 cm in diameter and 6).
suprapubic incision was made 4 cm above the superior
branch of the pubic bone. Blunt dissection was carried STATISTICAL ANALYSIS:
out up to the fascia which was opened. The trocar
was inserted and puncture was made, noting the Data analysis was carried out using descriptive
exit of a small quantity of physiological solution. statistics and central tendency and dispersion
The nephroscope was inserted in order to verify measurements which were evaluated with the SPSS
bladder permanence (Photo 3). 12.0 Statistics Program (Table 2).
Stone fragmentation and removal was carried Quantitative variables between both groups were
out in both groups. Cystostomy and transurethral compared by means of the Student t test with a 95%
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Camacho-Trejo VF et al. Percutaneous treatment of bladder lithiasis: comparison of two surgical techniques
Photo 5. Extracted stone fragments. Photo 6. 20 F cystostomy catheter placement after the procedure was
finished.
Table 2. Descriptive statistics for each group and their total. Table 3. Student t test with a 95% CI.
Group A Group B Total Size Time in Days
Age Stone Stone Surgery of Hospitalization
Age Mean 57.36 59.00 59.36
Standard Deviation 18.10 17.78 18.02 p .606 .748 .128 .006 .809
Stones Mean 1.45 1.30 1.36
Standard Deviation .934 .674 .789
Stone Size Mean 25.17 28.14 26.51
Standard Deviation 5.06 6.71 5.95
left in place for 7 days, regardless of whether or not another
Time in Surgery Mean 34.45 15.80 25.57
surgery was performed.
Standard Deviation 22.71 6.56 19.19
Another procedure was carried out on 16 patients (76%)
Days of Mean 1.36 1.30 1.33 at the same surgery time: TURP in 4 patients from Group
Hospitalization Standard Deviation .504 .483 .480 A and 4 patients from Group B; Urethrotomy in 3 patients
from Group A and 4 patients from Group B; and Rigid
Ureteroscopy in 1 patient from Group A.
• CONCLUSIONS
Confidence Interval. There was statistical significance when
An important aspect of both surgeries evaluated is that
P = < 0.05 (Table 3).
undesirable urethral injury is avoided, whether caused by
surgical instruments or stone fragment removal. It is safe
• RESULTS to carry out other surgical procedures such as TURP or
Both groups were homogeneous regarding age, number urethrotomy during the same surgical time.
of days of hospitalization, and size and number of stones. Both techniques are reproducible in any urology
There was a favorable difference in the time in surgery for service.
the laparoscopic trocar group in which P = .006. Statistically demonstrable advantages were found
Complete stone extraction was achieved in 100% of with the laparoscopic trocar technique compared with the
patients. Amplatz technique. Time in surgery is shorter and better
The majority of patients presented with immediate bladder distension is achieved because there is no irrigation
hematuria which disappeared in less than 24 hours with the fluid leakage.
help of a cystostomy catheter. The catheter was removed in In the present study, there was no morbidity associated
all patients after 24 hours. The transurethral catheter was with the procedures and none of the cases presented with
322 Rev Mex Urol 2008;68(6):318-323
Camacho-Trejo VF et al. Percutaneous treatment of bladder lithiasis: comparison of two surgical techniques
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