Stones occur within the urinary bladder due to incomplete bladder emptying, urinary stasis, and/or chronic bladder infections. With time, the urine that is not voided begins to harbor bacteria and contain higher amounts of mucus, sediment and urinary minerals, eventually resulting in a bladder calculus.
Surgical options for patients with symptomatic bladder stones include open cystolithotomy, percutaneous cystolithotomy, or cystoscopic laser lithotripsy with stone extraction (cystolithalopaxy – meaning “a look into the bladder to crush a stone.”). Your bladder/urethral anatomy, your bladder stone size, and body habitus all play major roles in determining outcomes and operative approach. Also, whether or not a prostate procedure is necessary at the time of stone removal is an important consideration for men with enlarged prostates and bladder stones.
The role of cystolithalopaxy over the last ten years has undergone a dramatic evolution, due to the advent of holmium laser. Stone that were routinely removed using an open incision may now be broken into multiple smaller pieces and removed through a natural body opening (the urethra), avoiding both the pain and the recovery of an open incision.
Benjamin K. Canales, MD, MPH
Department of Urology
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Russell S. Terry, MD
Director of MIS Education and New Technologies
Department of Urology
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Prior to the Procedure
What to expect during your initial consultation:
- It is important that prior to your initial clinic consultation that all Xray films and their reports (e.g. CT scans, intravenous pyelogram or IVP, sonogram, or MRI) are compiled and brought to your appointment for careful review by your surgeon. These films can be requested along with the radiology report from the facility that performed the Xray. A review of your medical history and a physical examination will be performed along with blood and urine tests if needed. If your surgeon determines that you are a candidate for cystolithalopaxy, you will then meet with a Surgery Scheduling Coordinator to arrange for the date of your procedure.
What to expect prior to surgery:
- Once your surgery date is secured by one of our Surgery Scheduling Coordinators, the items listed below will be ordered as necessary based upon your age, medical history and risk for surgery. These will be performed through a preoperative anesthesia consultation at the Presurgical Center at UF & Shands that will be arranged for you at your initial visit. During this consultation you will have the opportunity to speak to the anesthesia staff regarding the types of anesthesia available and the risks/benefits.
- Physical exam
- EKG (electrocardiogram)
- CBC (complete blood count)
- PT / PTT (blood coagulation profile)
- Comprehensive Metabolic Panel (blood chemistry profile)Urinalysis
Preparation for surgery
Medications to Avoid Prior to Surgery:
- Patients undergoing cystolithalopaxy are recommended to discontinue all blood thinners prior to surgery, if medically possible. Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery. The following is a list of medications to avoid at least 7-10 days prior to surgery. Many of these medications can alter platelet function or your body’s ability to clot and therefore may contribute to unwanted bleeding during or after surgery. Do not stop any medication without contacting the prescribing doctor to get their approval.
- Aspirin, Motrin, Ibuprofen, Advil, Alka Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox, Celebrex, Voltaren, Vioxx, Plavix
- A formal list of these medications and others will be provided to you by our Surgery Scheduling Coordinators.
There is no bowel preparation needed for cystolithalopaxy, and most patients are asked to be NPO (“nothing by mouth”) after midnight of the night prior to surgery.
Once you are asleep, the surgeon passes a small lighted tube (cystoscope), through the urethra and into the urinary bladder. Once the stone is located, it may be snared with a basket device and removed whole from the urethra. If the stone is large and/or if the diameter of the urethra is narrow, the stone is fragmented into multiple smaller pieces using a laser. These pieces are then irrigated and removed from the bladder through the urethra. In most cases, to ensure proper drainage, a urinary catheter (foley) is left in the bladder after the surgery for several days.
Potential Risks and Complications
As with any major surgery, complications, although rare, may occur with cystolithalopaxy. Potential risks and complications with this operation include but are not limited to the following:
- Bladder spasm/pain: It is widely believed that the bladder heals faster post-operatively when decompressed than when continually filled with urine. Because of this, many patients are asked to keep a plastic urinary tube (foley) within the bladder following the procedure, allowing urine to pass at all times into a bag. The catheter is held in place by means of a plastic balloon, about the size of a ping-pong ball. This balloon “rubs” the lining of the bladder, resulting in bladder spasms (the feeling that one needs to urinate despite an empty bladder) and discomfort. These spasms usually get better with time and bladder decompression, and there are also medications that can be used to treat bladder spasms. Ask your surgeon about the potential need for a catheter following your surgery.
- Secondary procedures: Most patients who undergo cystolithalopaxy have a stone within their bladder for a reason – either chronic stasis of urine (not emptying their bladder well) or chronic infections. Removing a stone does not cure chronic stasis but may help the bladder empty better. Talk to your urologist about the chances of emptying better once the stone is removed and whether or not a procedure is necessary along with your cystolithalopaxy to help the bladder empty better.
- Stone fragments: Residual stones within the bladder is certainly a risk after cystolithalopaxy, and the risk is proportional to the size of the stone being removed. Ask your urologist to give you some idea of success rates for your particular stone size. Large stones may require 2 surgeries, with the potential for 3-4 hours during each surgery.
- Bladder perforation: The bladder is a fairly thick organ, so complete perforation is very rare (0.1%) but mucosal tears and scrapes are inevitable. These all heal with time. Should a large perforation occur, your urologist may chose to stop the procedure and return on another day when the bladder has had time to heal. Should your urologist think the perforation of the bladder is in communication with your abdominal cavity, emergent open bladder surgery will be necessary to close the hole on the bladder using suture material. A catheter would be worn for several weeks until the bladder hole has had time to heal. This catheter temporarily diverts the urine away from the hole and out into a bag until healing can occur and the hole close.
- Urethral or ureteral injury: During stone fragment removal, stone fragments may cut or tear the urethra. This is usually self-limiting but may occasionally result in urethral strictures (scar tissue within the urethra) or bleeding. Within the bladder are two opening that bring urine down from the kidney (ureter). Although unlikely, it is possible to injure the ureter by direct laser firing or by scope trauma. This rare event usually requires a ureteral stent to facilitate ureteral healing.
- Hematuria and infection: Almost all patients see blood in the urine for several days after stone surgery. Urinary tract infection is also certainly possible when the stone is broken as bacteria are released from the stone surface. These complications are usually self-limiting and resolve with hydration and antibiotics, respectively.
What to Expect After Surgery
- Immediate post-operative period: After the surgery you will be taken to the recovery room. If a urinary catheter (foley) was placed during surgery, it will likely stay in place for several days until its removal in clinic. Once your pain is controlled, you may be discharged from the recovery room to home. Expect blood in the urine for several days. With time and hydration, the urine should slowly turn from a watermelon red color to pink to clear. You may have foley balloon pain or bladder spasms (see complications of cystolithalopaxy above) that can be helped by overactive bladder. Due to instrumentation, most patients will receive 4-5 days of oral antibiotics to prevent a urinary tract infection.
- Postoperative Pain: Most patients after cystolithalopaxy experience mild to moderate pain in the suprapubic area. This is generally well controlled by use of oral narcotics (pain medication) such as Percocet or Vicodin. As you get further out from your surgery, you may be able to decrease the strength of the medication to Extra Strength Tylenol or Motrin, as narcotics may cause constipation and sedation.
- Nausea: Nausea is fairly common following any surgery especially related to general anesthesia. This is usually transient and is self-limiting. Should you have excessive nausea and vomiting, you should contact your surgeon for advice.
- Showering: Patients can shower immediately upon discharge from the hospital
- Activity: Patients may begin driving once they are off all narcotic pain medication. Most patients are able to perform normal, daily activities within 5-7 days after cystolithalopaxy. However, many patients describe more fatigue and discomfort with a foley catheter in the bladder. This may limit the amount of activities that you can perform.
- Diet: Most patients only desire clear liquids for the first 24 hours following cystolithalopaxy, as your intestinal function may be sluggish due to the effects of surgery and general anesthesia. Following this period, patients may resume a regular diet as tolerated.
- Fatigue: Fatigue is quite common following surgery and should subside in several days following surgery.
- Constipation/Gas Cramps: You may experience sluggish bowels for several days following your cystolithalopaxy as a result of the anesthesia. Suppositories and stool softeners are usually given to help with this problem. Taking a teaspoon of mineral oil daily at home will also help to prevent constipation. Narcotic pain medication can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.
- Follow-up Appointment: Patients should make a follow-up appointment with their surgeon by contacting the UF Health Medical Plaza Urology Clinic at 352.265.8240. Your surgeon will let you know the timing and schedule of clinic visits following surgery.
Frequently Asked Questions (FAQs)
What are the advantages of cystolithalopaxy compared to other stone treatments?
- Cystolithalopaxy can treat most stones with the bladder, avoiding the incision of open surgery as well as the prolonged wearing of an indwelling catheter. Because it uses a natural body opening, the healing time is sooner and the risk of infection is lessened.
Who is not a good candidate for cystolithalopaxy?
- Because cystolithalopaxy requires actively removing all stone fragments, the treatment of very large stones may yield so many fragments that complete removal becomes impractical or impossible. Also, remember that every piece of bladder stone must be broken and come through the urethra, causing a potential for urethral strictures or scar tissue. Speak to your urologist about when to perform a cystolithalopaxy versus an open/percutaneous bladder stone removal.
What are the success rates of cystolithalopaxy?
- Depending on stone size, success rates vary anywhere from 60% – 100%. Ask your surgeon to discuss success rates tailored to your particular stone disease.
Do I need a prostate procedure in addition to my bladder stone removal?
- Many times, the presence of a bladder stone is a surrogate marker for bladder neck dysfunction, chronic infections, metabolic disorders, or prostate obstruction. For modern urologists, a wide array of prostate medications is available to help patients empty after bladder stone removal. However, many studies have documented the safety and efficacy of a combined prostate and bladder stone surgery. Ask your doctor to discuss with you their experience with this type of combined procedure.
How long will my catheter stay in place?
- The length of time the catheter remains in your bladder is variable. Your doctor will probably request it to be removed somewhere between 2 – 10 days after your procedure.
Following cystolithapaxy, when might it be necessary to call a doctor?
- You should contact your urologist if the catheter is causing you constant, unrelenting pain, if you have symptoms of a urinary tract infection (fever, rigours, feeling unwell and pain passing urine), or if your urine is dark red, similar to the color of tomato basil soup.
What alternatives are there to a foley catheter?
- Occasionally, it may be possible to place a tube externally that drains the bladder. This tube is placed directly through the skin and into the bladder, called a “suprapubic catheter.” This is placed under direct vision using fluoroscopic Xray guidance at the time of your surgery. As the tube remains outside the body, it is slightly more inconvenient, has higher infection rates, and can sometimes get pulled out by accident. The advantage of a suprapubic tube is better drainage, less urethral irritation, and ability to place contrast into the bladder to evaluate for obstruction or leakage. Also, should there be any question of urination after surgery, one may clamp the suprapubic tube for several days and allow the bladder to cycle/urinate during this time. After each urination, the tube may be unclamped and the amount of “post-void” residual can be measured (similar to a pop-off valve). If it appears that the bladder is emptying, then the suprapubic tube can be removed in clinic.