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