Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel

Transurethral Cystolithotripsy vs Percutaneous Cystolithotomy for Bladder Stones in Children: A Systematic Review and Meta-Analysis Comparing Clinical Outcomes and Complications

Background: The minimally invasive treatment of bladder stones (BS) in children has been demonstrated to be safe and effective by both transurethral cystolithotripsy (TUCL) and percutaneous cystolithotomy (PCCL). The surgical outcomes and potential complications associated with these two treatments remain uncertain. We conducted a meta-analysis to compare TUCL and PCCL in pediatric BS with a focus on long-term stone-free rates (SFR), postoperative complications, and cost-effectiveness. Materials and Methods: PubMed, Embase, Cochrane Library, and Web of Science were last searched on September 12, 2023. Included studies should evaluate at least one of the following outcomes: SFR, operation time, hospital stay, and complications. The quality assessment of the studies was performed using the Cochrane tools and Newcastle-Ottawa Scale system. Results: A total of 397 patients from 7 studies met the inclusion criteria, of which 202 patients underwent TUCL and 195 patients underwent PCCL. The results showed that the PCCL group had shorter operative time (p < 0.00001) and longer hospitalization days (p < 0.00001) than the TUCL group, and other perioperative prognostic differences were not statistically significant. Conclusion: TUCL and PCCL are effective and safe for the treatment of BS in children. Multicenter, large-patient series, and prospective studies are needed to determine the critical value of stone size for selecting the surgical approach.

Multiple Giant Stones in an Augmented Bladder: A Case Report

Bladder stones are a common finding in urology practice although they are less common when compared to kidney and ureteral stones. This case report involves a male patient in his 40s with multiple giant bladder stones. The patient had neurogenic bladder disease due to spina bifida and had a history of bladder augmentation with continent urinary diversion when he was a child. He presented with difficulty in emptying bladder with clean intermittent catheterization. Open cystolithotomy was performed and six giant stones, five pyramid-shaped stones and a cube-shaped stone with a maximum diameter of 7 cm, were removed from the bladder. In our opinion, the rare occurrence of a high stone burden, stone weight and size, and geometric shapes of stones makes this case interesting. The patient was discharged from the hospital on the 10th day after the surgery and there were no postoperative complications.

Emerging Role of Laser Lithotripsy for Bladder Stones: Real-World Outcomes from Two European Endourology Centers with a Systematic Review of Literature

Introduction and Objective: We aimed to look at the evidence for laser lithotripsy for bladder stones (BSs) to provide results from two centers on bladder calculi treatment. In addition, the outcomes of prostatic and other surgical interventions performed in nearly half of all patients. Methods: A retrospective analysis of two large European endourology tertiary centers for patients who underwent laser lithotripsy for BS between 2016 and 2024 (7 years). All patients provided consent and were counseled for the study accordingly, and the studies were registered as an audit in the individual centers. Results: A total of 122 patients were analyzed (mean age of 68.17 ±16.38 years; male:female ratio of 97:25). Thirteen (10.7%) patients had a preoperative long-term catheter. Overall, 42 (34.43%) patients had multiple stones (n = 2.19, ±2.08), with a median stone burden of 32.36 ± 24.13 mm. The mean operative time was 61.6 ± 37.25 minutes, with an overall stone-free rate (SFR) of 95.1% (n = 116). Postoperative complications were noted in nine (7.38%) patients, which included urinary tract infection or sepsis (n = 4, 3%), pain (n = 2, 1.6%), and bleeding/acute urinary retention/urethral stone (n = 1 each, 0.82%). All the complications were Clavien-Dindo I/II and treated conservatively. Six patients (4.9%) with planned concomitant surgical intervention needed a completion (second) intervention at a later date. Sixty patients (49.2%) had concomitant procedure along with their BS treatment. Twenty-two patients (18%) with a mean prostate size of 60.71 cc (±30.50 cc) underwent a transurethral resection of prostate (n = 16, 13.1%) or bladder neck incision (n = 6, 4.9%). Others underwent ureteroscopy (n = 13, 10.7%), transurethral resection of bladder tumor (n = 5, 4.1%), suprapubic catheter repositioning (n = 10, 8.2%), or urethral dilation (n = 10, 8.2%). The mean hospital stay was 1.4 ± 1.33 days. Conclusion: Laser fragmentation of BSs stands out as a safe and efficient choice with a good SFR and low risk of major complications, and perhaps should be considered the new gold standard for BS management. It also allows for concomitant treatment of enlarged prostate and other endourologic procedures with good outcomes.

Semi-closed-circuit vacuum-assisted mini percutaneous cystolithotomy (vamPCL) in the pediatric population: Initial experience of a novel technique in native and augmented bladders

INTRODUCTION

Bladder stones (BS) in children are a rare condition and represent 1-5 % of all urinary tract stones. With advances in miniaturized endoscopes and intracorporeal lithotripters, percutaneous cystolithotomy has been demonstrated to be an effective, safe and quick technique, despite the longer operative time. This limitation may be overcome by a semi-closed-circuit vacuum-assisted technology (vamPCL), characterized by a continuous inflow and a suction-controlled outflow (ClearPetra®).

OBJECTIVES

To assess the safety and efficacy of a vamPCL characterized by continuous inflow and suction-controlled outflow to treat bladder stones in pediatric patients with native or augmented bladder.

STUDY DESIGN

From January 2021 up to December 2023, we prospectively collected variables on consecutive vamPCL procedures (Fig.) The stone-free rate (SFR) was defined as absence of stones or residual fragment <5 mm diagnosed with ultrasound.

RESULTS

Six patients with a median age of 139 months (55-212) were recruited for the study. Three patients (50 %) with the initial diagnosis of extrophy-epispadia complex had an augmented bladder, whereas of the remaining three (50 %) with an initial diagnosis of anorectal malformation two had an augmented bladder. All patients had a Mitrofanoff conduit opening on the right flank, except for one (16 %) with umbilical access. The mean cumulative stone size was 24 mm ± 14,2. The mean operating time was 78,3 min ± 14,7. One procedure was interrupted after 90 min due to the overall size (>50 mm). Stone removal was achieved only via suction in all cases. All vamPCL procedures were completed without intraoperative complications. Fever for 24 h (1/6; 16 %) was the only post-operative complication. The mean stay of the suprapubic catheter was 3.4 days ± 1,5 and of the trans-Mitrofanoff catheter was 9.3 days ± 4,5. The SFR was confirmed in all the cases with US performed after 2 months. Only one male patient (16 %) had recurrent stones after 8 months and he is waiting for second surgery. Mean follow-up was 7.2 months ± 9,4.

DISCUSSION

In the present study we demonstrated that vamPCL is safe and feasible in selected cases especially in those with augmented bladder. To our knowledge, this manuscript is the first to present the use of the ClearPetra® for the treatment of bladder stones.

CONCLUSIONS

To our knowledge, this manuscript is the first to present the use of the ClearPetra® for the treatment of bladder stones. The vamPCL seems to be sustainable, safe and feasible for bladder stones treatment in selected children.

High-power versus low-power laser settings during endoscopic stone disease management: a systematic review from the EAU endourology section

PURPOSE

Optimal laser settings during endoscopic stone disease management still represents a debatable issue. The aim of this systematic review is to summarize all existing evidence regarding the comparison of high-power (HP) versus low-power (LP) laser settings during different endoscopic lithotripsy procedures.

METHODS

PubMed, Scopus and Cochrane databases were systematically screened, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. All endoscopic laser lithotripsy surgical approaches were included, including ureteroscopy (URS), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL) and transurethral lithotripsy for bladder stones. Pediatric patients were also included.

RESULTS

In total, 10 studies met the inclusion criteria and were included in final qualitative synthesis. In most studies total operative time (OT) was shorter for the HP group. Mean fragmentation time was homogenously significantly shorter in the HP group. Stone-free rates (SFR) ranged from 59.0% to 100% for the LP group and from 78.9% to 100% for the HP group. Total complication rates were higher for the LP group in six studies, equivalent between the two groups in one study and higher in the HP group in one study.

CONCLUSION

HP laser lithotripsy is a safe and efficient approach for URS, RIRS, PCNL and cystolithotripsy. HP laser settings were associated with significantly shorter total operative time, while some studies reported also better SFR in the HP groups. The implementation of more Randomized Controlled Trials comparing HP and LP laser lithotripsy in different stone settings is of outmost importance, so that better conclusions can be drawn.

Layer upon layer: Imaging techniques of bladder matrix stone: A case report

Matrix lithiasis within the bladder is an extremely rare and diagnostically challenging condition, characterized by its atypical presentation and complex imaging appearance. We report the case of a 69-year-old woman with nonspecific urinary symptoms, including hematuria and abdominal pain. Initial ultrasonography revealed an echogenic lesion on the bladder wall, leading to further investigations using computed tomography (CT) and magnetic resonance imaging (MRI). CT imaging initially delineated the lesion's structure, revealing a complex, multilayered cystic mass. Subsequent MRI provided detailed insights into the internal architecture of the mass, further elucidating its layered structure. Although a parasitic etiology was initially suspected, matrix lithiasis was later confirmed. This case highlights the critical role of a comprehensive imaging strategy in diagnosing rare urological conditions and emphasizes the importance of multimodal imaging in differentiating potential diagnoses.

Safety and efficacy of laser lithotripsy for treatment of bladder calculi: evidence from a systematic literature review

PURPOSE OF REVIEW

Bladder stones account for 5% of all urinary tract calculi. Contributing factors include bladder outflow obstruction, infections, foreign bodies, or neurogenic voiding dysfunction. This necessitates an effective treatment modality, and with advances in medical technology, minimally invasive techniques using lasers are being widely adopted. This systematic review aims to assess the efficacy and safety of laser lithotripsy for treating bladder stones.

RECENT FINDINGS

A thorough literature review (PROSPERO: CRD 42024551910) was conducted using appropriate search terms up to March 2024. Only original studies written in English, with at least 10 patients with bladder stones treated with laser, were considered with inclusion. A total of 8 studies (411 patients) were identified on screening with a mean age of 59.6 ± 8.5 years and a male: female ratio of 326 : 14. These reviews covered a geographical area of Asia, Europe, and the USA. The mean stone size was 3.7 ± 0.7 cm, and an overall stone-free rate (SFR) postlaser lithotripsy was 96%. Mean operation time was calculated to be 76.36 ± 47.10 min and an overall complication rate of 16.5% (n = 68), with the most common being haematuria (n = 22), followed by UTI (n = 18), incontinence (n = 8), urosepsis (n = 6), clot retention (n = 4), mucosal injury (n = 3) and urinary retention (n = 3). All complications were minor and there were no Clavien >II complications.

SUMMARY

Laser lithotripsy for bladder stone achieves an excellent success rate in the form of SFR, combined with a low risk of major complications, and allows concomitant treatment of enlarged prostate, and should be considered in all patients.

International Alliance of Urolithiasis (IAU) guidelines on the management of pediatric urolithiasis

The aim of this study was to construct the sixth in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis (IAU) that by providing a clinical framework for the management of pediatric patients with urolithiasis based on the best available published literature. All recommendations were summarized following a systematic review and assessment of literature in the PubMed database from January 1952 to December 2023. Each generated recommendation was graded using a modified GRADE methodology. Recommendations are agreed upon by Panel Members following review and discussion of the evidence. Guideline recommendations were developed that addressed the following topics: etiology, risk factors, clinical presentation and symptoms, diagnosis, conservative management, surgical interventions, prevention, and follow-up. Similarities in the treatment of primary stone episodes between children and adults, incorporating conservative management and advancements in technology for less invasive stone removal, are evident. Additionally, preventive strategies aiming to reduce recurrence rates, such as ensuring sufficient fluid intake, establishing well-planned dietary adjustments, and selective use pharmacologic therapies will also result in highly successful outcomes in pediatric stone patients. Depending on the severity of metabolic disorders and also anatomical abnormalities, a careful and close follow-up program should inevitably be planned in each pediatric patient to limit the risk of future recurrence rates.

Decoding Urinary Stones: Compositional Insights and Recurrence Patterns from a Tertiary Care Hospital in Eastern India

Background and objective Urinary stones are a prevalent medical condition entailing significant health burdens and substantial financial ramifications. Its global prevalence is expected to rise notably, particularly in low-middle-income nations. Understanding the spectrum of diverse urinary stone types is crucial for effective management and prevention. This study aims to elucidate the demographic profiles, clinical types, and recurrence of urinary stone cases at a tertiary care hospital in Eastern India. Methods and materials The clinical data from the electronic medical record of 1,231 patients with urolithiasis who underwent surgery in a tertiary care center in eastern India from January 2015 to November 2022 were retrospectively analyzed. Patient data, including demographic information, clinical records, dietary habits, water intake, and stone recurrence history, were collected. A thorough statistical analysis was conducted to elucidate the associations between patient characteristics, urinary stone composition, and recurrence. Results Among the 1,231 participants, the majority of cases (343 (27.9%)) were in the 31-40 age group, with a higher prevalence in males (876 (71.2%)) than in females (355 (28.8%)). Flank pain or abdominal pain (593 (48.1%)) was the primary complaint, followed by nausea/vomiting (227 (18.5%)). Most stones (922 (74.9%)) were located in the kidney, and calcium oxalate was the predominant stone component (773 (62.8%)). The highest stone recurrence rates were in patients aged between 21-30 years (21 (36.8%)) and 31-40 years (16 (28.0%)). A low non-vegetarian diet and adequate hydration may reduce the likelihood of stone recurrences. Conclusion This study provides insights into the compositional analysis of urinary stones in the eastern Indian population, addressing the causes of their recurrence and management strategies, which are crucial for prevention and effective management. The findings indicate that the early middle-aged group exhibited the highest incidence of urinary stones. We also observed that strict adherence to a low animal protein, along with proper hydration and lifestyle changes, significantly reduced urinary stone recurrence.

Urethral Calculus as an Uncommon Cause of Acute Urinary Retention in Women Diagnosis and Management: A Case Report

Background

Urethral calculi causing acute urinary retention is a highly uncommon condition in women, which poses distinctive difficulties in diagnosis and treatment. This report presents the case of a 52-year-old woman who experienced acute urinary retention caused by a urethral stone. It emphasizes the effective use of minimally invasive methods and underscores the importance of comprehensive multidisciplinary treatment.

Case presentation

A 52-year-old woman patient arrived with acute urinary retention symptoms that lasted 6 hours. She complained of pain in the perineal and periurethral regions. She struggled with poorly managed type 2 diabetes, metabolic syndrome, and frequent cystitis. The examination showed the presence of a 2-cm stone in the urethra. The treatment utilised retrograde propulsion and laser fragmentation. Postoperative magnetic resonance imaging results were normal, and follow-up care involved managing diabetes and adopting lifestyle changes to prevent the recurrence of cystitis and stones for 6 months.

Conclusion

Urethral calculi exceptionally cause acute urinary retention in women. To achieve successful outcomes and prevent recurrence, it is crucial to prioritize prompt, minimally invasive treatment, and comprehensive management.

Big bladder stone accompanied by big posterior urethral stone: A management of rare case report

INTRODUCTION AND IMPORTANCE

Urinary tract stones are a common disease, but concurrent large-size stones in the bladder and urethra are rare. This phenomenon can lead to obstruction, infection, and other complications. We reported the management of a rare case of a giant bladder stone accompanied by a big posterior urethral stone.

CASE PRESENTATION

A 36-year-old man with a chief complaint of not being able to have spontaneous micturition, frequent expulsion of stones from the penis, and a history of hematuria. Bladder examination revealed a giant bladder stone of 1278 Hounsfield Unit (HU) with a size of 4.1 × 7.2 cm, and urethral examination revealed a stone of 1275 Hounsfield Unit (HU) with a length of 4.3 × 4.2 cm, without mass. This patient underwent vesicolithotomy and urethrotomy. The evaluation showed spontaneous micturition and dissolved hydronephrosis.

CLINICAL DISCUSSION

Urinary tract stone management primarily involves endourology or open surgery. For smaller stones (<5-6 mm), medication is sufficient, as they often pass spontaneously. Larger stones may require interventions like vesicolithotomy or urethrotomy. Vesicolithotomy is preferred for complex or large bladder stones, while urethrotomy is performed if the stone location is palpable or seen on imaging. These procedures are practical options for general surgeons in first-level hospitals.

CONCLUSION

Concurrent large bladder and urethral stones are uncommon. Endourology or open surgery is typically employed. Treatment selection should be personalized to individual patient assessment to mitigate potential complications effectively.

The Management of Large Bladder Calculi by Utilizing Dual-Action Percutaneous Lithotripsy via Suprapubic Tube Sheath: A Novel Technique

Bladder calculi commonly develop in patients with poor bladder emptying or those with retained foreign bodies within the bladder, leading to irritative voiding symptoms, hematuria, and an increased likelihood of refractory urinary tract infections. While many techniques exist for the treatment of bladder calculi, including endoscopic and open-surgical approaches, our novel technique may help manage exceptionally large or difficult-to-treat bladder calculi effectively. We present three patients with symptomatic bladder calculi ranging from 1.3 cm to 6.8 cm in size who were successfully treated by using our novel technique. Percutaneous access to the bladder was obtained by using a suprapubic catheter trocar and sheath to enable the utilization of a dual-action lithotriptor. Sheath insertion and lithotripsy were performed under direct visualization with a rigid cystoscope via the native urethra. This technique is easily learned and can be safely employed in patients in whom other methods may pose risks of higher morbidity.

A case report of a giant bladder stone (12 × 8 cm, 610 g)

Bladder lithiasis is common in developing countries. It has become rare in industrialized countries and exceptional in the absence of associated lower tract pathology. usually caused by urinary tract infections, urethral obstruction or the presence of intravesical foreign bodies. Open cystolithotomy was performed on a 45-year-old patient with lower abdominal pain, moderate dysuria, pollakiuria, nocturia, and hematuria for a long time. A stone of 12 × 8cm in size and approximately 620 grams in weight was removed. The cystoscopy was performed without any infravesical obstruction during the operation. The stone analysis showed 21% struvite and 79% carbonate apatite. Bladder lithiasis is common in Morocco. However, giant lithiasis is rare and is the consequence of neglected voiding disorders. Open cystolithotomy remains the most treatment in the management of giant stones.

Urological Guidelines for Kidney Stones: Overview and Comprehensive Update

BACKGROUND

Evidence-based guidelines are published by urological organisations for various conditions, including urolithiasis. In this paper, we provide guidance on the management of kidney stone disease (KSD) and compare the American Urological Association (AUA) and European Association of Urologists (EAU) guidelines.

METHODS

We evaluate and appraise the evidence and grade of recommendation provided by the AUA and EAU guidelines on urolithiasis (both surgical and medical management).

RESULTS

Both the AUA and EAU guidelines provide guidance on the type of imaging, treatment options, and medical therapies and advice on specific patient groups, such as in paediatrics and pregnancy. While the guidelines are generally aligned and based on evidence, some subtle differences exist in the recommendations, but both are generally unanimous for the majority of the principles of management.

CONCLUSIONS

We recommend that the guidelines should undergo regular updates based on recently published material, and while these guidelines provide a framework, treatment plans should still be personalised, respecting patient preferences, surgical expertise, and various other individual factors, to offer the best outcome for kidney stone patients.

Thulium fiber laser cystolithotripsy under local anesthesia: A day care procedure

INTRODUCTION

Bladder stones account for 5% of all urolithiasis. Patients present with LUTS or acute urinary retention. Thus, warranting an early intervention. Minimally invasive approach with laser lithotripsy is the present gold standard to treat bladder stones.

AIMS AND OBJECTIVES

To evaluate the outcomes of TFL (60 W) for bladder stones performed under local anesthesia as a day-care procedure.

MATERIALS AND METHODS

This was a retrospective single-center study conducted after obtaining IRB approval. Study period was between June 2021 and June 2022 were included. All patients were operated under local anesthesia as a day care procedure. The procedure was carried out using an 18 Fr laser sheath and calculus dusted using TFL energy (15-30 W). Parameters including operative time in minutes, complications were recorded. Patients were encouraged oral and normal voiding in the immediate post-op period.

RESULTS

A total of 47 patients with bladder stones presented during this period. Of these, 30 underwent laser lithotripsy (TFL) for bladder calculi. The clinical presentation of patients was LUTS in 28 (93%) and 5 (16%) patients had AUR. The average size of the stone in this series was 15 ± 2.8 mm. The mean duration of laser lithotripsy was 15 ± 5.4 min. Energy to dust the stone was variable with mean LASER energy of 18.23 ± 10 W. All patients tolerated the procedure well and none required conversion to conventional anesthesia. One patient failed to void in the post-op period. 100% clearance rate was documented in all patients.

CONCLUSION

Thulium fiber laser for transurethral cystolithotripsy of bladder stones under local anesthesia is a feasible technique with minimal morbidity and good outcome.

Which Laser System Is Optimal for Cystolithotripsy of Large Bladder Calculi?

Introduction and Objective: A variety of laser sources are available to treat bladder stones. The aim of this study was to compare time and cost efficiency of the thulium fiber laser (TFL) to four holmium lasers (HLs) with different powers or technologies, including MOSES™ during simulated cystolithotripsy. Materials and Methods: In a benchtop simulation of laser cystolithotripsy, 25 identical 4-cm BegoStones (calcium oxalate monohydrate consistency) were placed on a grid within a 3D-printed bladder model. Lasers were operated at maximal energy, using a 550 μm fiber. Lasers compared were as follows: 60 W TFL, 120 W HL with MOSES, and conventional 120, 100, and 30 W HLs. Five trials were performed for each laser with endpoints of laser time, total time, number of fiber strippings, and total energy. Cost-effectiveness was modeled using laser purchase price, fiber, and operating room (OR) time cost. ANOVA with Tukey's B post hoc was performed to compare outcomes. Spearman's test was used to assess correlation between laser power and procedure time. Results: The laser and total operating times were significantly different between the five systems (p < 0.001). The 120 W HL with MOSES was the fastest with 60.9 minutes of laser and 68.3 minutes of procedure times, while the 30 W HL was the slowest with 281.2 minutes of laser and 297.5 minutes of procedure times. The 60 W TFL was faster than the 30 W HL, but slower than the higher power HLs. Higher laser power was associated with shorter procedure time (Rs = -0.98; p = 0.002). When estimating cost per procedure, the MOSES HL was the cheapest, but had the highest purchase cost. The TFL was not cost-effective for large bladder stones compared with the 100 W HL. Conclusions: When treating large bladder stones, total laser power was highly correlated with laser and procedure times and the TFL was limited by its total power. The most cost-effective laser for use will depend on the case volume.

Extraprostatic incidental findings on prostate mpMRI: A pictorial review from the ESUR junior network

The role of multiparametric MRI (mpMRI) in prostate cancer setting is increasingly consolidated and, as a result, its usage in clinical practice is in exponential growth. However, beyond the prostate gland, several key structures are included in the field of view of mpMRI scans. Consequently, various extra-prostatic incidental findings (IFs) belonging to different anatomical systems can be accidentally recognized. Therefore, it is mandatory for a radiologist to be familiar with the wide range of pathologies potentially encountered, to guide management and avoid patient anxiety and costs due to additional work-up prompted by clinically insignificant extra-prostatic findings. With this pictorial review, we aim to illustrate a wide range of IFs that can be detected when performing mpMRI of the prostate, focusing on their imaging characteristics, differential diagnosis, and clinical relevance. Additionally, we propose the CheckDEEP, the Checklist for DEtection of ExtraProstatic findings, to be used for a thorough evaluation of target areas within each anatomical system.

14F Super-Mini Percutaneous Cystolitholapaxy: A Novel Technique in the Treatment of Bladder Stones

Introduction: This single-center experience describes the indications, novel technique, and outcomes of performing 14F super-mini percutaneous cystolitholapaxy (14F-SMPCCL). Materials and Methods: Cases between 2019 and 2022 were retrospectively identified with surgical outcomes recorded. Using percutaneous access to the bladder, an endoscope was inserted through the ClearPetra 14F super-mini sheath and laser lithotripsy completed with stone fragments suctioned out. Results: Sixteen cases were included in the study and all patients were adults. Average conglomerate stone size was 28.1 mm (range = 10-50 mm). Average operative time was 60.0 minutes (range = 23-110 minutes). Visual stone-free rate was 91.7%, radiologic stone-free rate was 81.3%, and average postoperative length of stay was 1 day. One patient developed urosepsis postoperatively and there were no other complications. Conclusion: The novel technique of 14F-SMPCCL is safe and feasible for treating large burdens of bladder stones with a conglomerate size of ∼2.5 to 5 cm. Active suction allows for efficient removal of stone fragments.

Do men with bladder stones benefit from treatment of benign prostatic obstruction?

OBJECTIVE

To identify whether men aged ≥40 years with bladder stones (BS) benefit from treatment of benign prostatic obstruction (BPO).

PATIENTS AND METHODS

A regional, retrospective study of patients undergoing BS surgery between January 2011 and December 2018 was performed using a prospectively collected database. The primary outcome was BS recurrence after successful removal. Kruskal-Wallis and chi-squared statistical tests were used.

RESULTS

A total of 174 patients underwent BS removal and 71 (40.8%) were excluded due to BS formation secondary to causes other than BPO. Hence, 103 men aged ≥40 years had BS successfully removed, of which 40% had a history of upper tract urolithiasis. These men were divided into three groups: those undergoing contemporaneous medical, surgical, or no BPO treatment. Age, diabetes, previous urolithiasis and previous BPO surgery were well matched between the BPO treatment groups. In all, 18 of these men (17%) had BS recurrence after 46 months follow-up. Recurrences were significantly lower following BPO surgery; one of 34 (3%) men versus five of 28 (18%) with no BPO treatment (P = 0.048) and 12 of 41 (29%) with medical BPO treatment (P = 0.003). Recurrences after medical and no BPO treatment were similar (P = 0.280). In all, 34 men (33%) had BPO complications that were similar between groups (P = 0.378).

CONCLUSION

This is the largest reported cohort of men, with the longest follow-up after BS removal. Most men aged ≥40 years with BS benefit from BPO surgery. However, the study findings also support a multifactorial aetiology for BS, which questions the dogma that BS are an 'absolute indication' for BPO surgery, as is stated in the Non-neurogenic Male Lower Urinary Tract Symptoms European Association of Urology Guideline. Assessment and management of all causative factors is likely to enable selection of which men will benefit from BPO surgery and to reduce BS recurrence rates.

A methodologic survey on use of the GRADE approach in evidence syntheses published in high-impact factor urology and nephrology journals

Background

To identify and describe the use of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for rating the certainty of systematic reviews (SRs) evidence published in urology and nephrology journals.

Methods

SRs that were published in the top ten "urology and nephrology" journals with the highest impact factor according to the 2020 Journal Citation Reports (covering 2016–2020) were systematically searched and evaluated using the GRADE approach.

Results

A total of 445 SRs were researched. Sixty SRs of randomized control trials (RCTs) and/or non-randomized studies (NRSs) were evaluated using the GRADE approach. Forty-nine SRs (11%) rated the outcome-specific certainty of evidence (n = 29 in 2019–2020). We identified 811 certainty of evidence outcome ratings (n = 544 RCT ratings) as follows: very low (33.0%); low (32.1%); moderate (24.5%); and high (10.4%). Very low and high certainty of evidence ratings accounted for 55.0% and 0.4% of ratings in SRs of NRSs compared to 23.0% and 15.3% in SRs of RCTs. The certainty of evidence for RCTs and NRSs was downgraded most often for risk of bias and imprecision.

Conclusions

We recommend increased emphasis on acceptance of the GRADE approach, as well as optimal use of the GRADE approach, in the synthesis of urinary tract evidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01701-x.

Treatment outcomes of bladder stones in children with intact bladders in developing countries: A systematic review of >1000 cases on behalf of the European Association of Urology Bladder Stones Guideline panel

INTRODUCTION

Bladder stones (BS) are still endemic in children in developing nations and account for a high volume of paediatric urology workload in these areas. The aim of this systematic review is to comparatively assess the benefits and risks of minimally invasive and open surgical interventions for the treatment of bladder stones in children.

METHODS

This systematic review was conducted in accordance with Cochrane Guidance. Database searches (January 1970- March 2021) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and non-randomised studies (NRSs) with >10 patients per group. Open cystolithotomy (CL), transurethral cystolithotripsy (TUCL), percutaneous cystolithotripsy (PCCL), extracorporeal shock wave lithotripsy (ESWL) and laparoscopic cystolithotomy (LapCL) were evaluated.

RESULTS

In total, 3040 abstracts were screened, and 8 studies were included. There were 7 retrospective non-randomised studies (NRS's) and 1 quasi-RCT with 1034 eligible patients (CL: n=637, TUCL: n=196, PCCL: n=138, ESWL: n=63, LapCL n=0). Stone free rate (SFR) was given in 7 studies and measured 100%, 86.6%-100%, and 100% for CL, TUCL and PCCL respectively. CL was associated with a longer duration of inpatient stay than PCCL and TUCL (p<0.05). One NRS showed that SFR was significantly lower after 1 session with outpatient ESWL (47.6%) compared to TUCL (93.5%) and CL (100%) (p<0.01 and p<0.01 respectively). One RCT compared TUCL with laser versus TUCL with pneumatic lithotripsy and found that procedure duration was shorter with laser for stones <1.5cm (n=25, p=0.04).

CONCLUSION

In conclusion, CL, TUCL and PCCL have comparable SFRs but ESWL is less effective for treating stones in paediatric patients. CL has the longest duration of inpatient stay. Information gathered from this systematic review will enable paediatric urologists to comparatively assess the risks and benefits of all urological modalities when considering surgical intervention for bladder stones.

Case report. Geschokt door de wachttijd: ESWL bij blaasstenen

De behandeling van eerste keuze voor vesicale stenen is de transurethrale cystolithotripsie (TUCL). Door de COVID-19-pandemie kampen ziekenhuizen echter met lange wachttijden voor – onder meer – deze operaties. Daarnaast komen sommige patiënten niet in aanmerking voor een operatie door hun comorbiditeit. In de jaren negentig van de vorige eeuw was extracorporele shockwave lithotripsie (ESWL) een veel gebruikte, veilige behandelmethode voor blaasstenen. Toen TUCL effectiever bleek, is ESWL voor blaasstenen echter in de vergetelheid geraakt. ESWL is poliklinisch uit te voeren, waardoor wachttijden korter zijn dan die voor operatieve ingrepen. Gedurende de COVID-19-pandemie hebben we enkele patiënten met blaasstenen behandeld met ESWL. We concluderen dat ESWL een geschikt alternatief is voor de TUCL bij geselecteerde patiënten, maar dat voor een effectieve behandeling meerdere ESWL-procedures nodig zijn.

Comparison of nephroscopy and cystoscopy used in the treatment of bladder stones: a systematic review and meta-analysis of randomized controlled trials

Background

A systematic review and meta-analysis was conducted to compare the safety and efficiency of nephroscopy and cystoscopy in transurethral cystolithotripsy (TUCL) for bladder stones (BS).

Methods

The PubMed, Web of Science, Embase, EBSCO, and Cochrane Library databases were searched up to January 2021 for studies assessing the effect of different types of endoscopes among patients who underwent TUCL. The search strategy and study selection process were in accordance with the PRISMA statement.

Results

Five randomized controlled trials were included in the meta-analysis. The results showed no difference in stone-free rate (RR = 1.00, CI = 0.98–1.02, p = 1.00) between the two groups and nonsignificant heterogeneity (I² = 0%, p = 1.00), and all patients were rendered stone free. Use of the nephroscope significantly shortened the operative time compared with the cystoscope group (RR= − 26.26, CI = − 35.84 to − 16.68, p < 0.00001), and there was significant heterogeneity (I²= 87%, p < 0.00001). There was no significant difference in mean urethral entries (RR = 0.66, CI = − 0.71 to − 2.04, p = 0.35), hospitalization (MD = 0.08, 95% CI = − 0.07 to 0.23, p = 0.31) or total complication rate (RR=1.37, 95% CI = 0.47–4.00, p = 0.56) between the two groups.

Conclusions

In conclusion, this systematic review demonstrates that both nephroscopy and cystoscopy have high stone clearance efficiency, low rates of complications and short hospitalizations. The mean urethral entries depend on the treatment method for large stone fragments. However, the use of nephroscopy can significantly reduce the operative time.

Minimally Invasive Robotic-Assisted Cystolithotomy in a Complicated Urinary Diversion: A Feasible and Safe Approach

Urinary diversion following radical cystectomy and neoadjuvant chemotherapy is the gold standard for the management of muscle-invasive bladder cancer. Urinary diversions are at an increased risk of urolithiasis as a result of various factors. Traditional surgical intervention has included open cystolithotomy which has given way to minimally invasive techniques as of late. We describe a case of a robotic-assisted cystolithotomy from a neobladder in a 54-year-old female patient with muscle-invasive bladder cancer. This is the first description of a robotic-assisted removal of a stone in an orthotopic neobladder. This approach has many advantages, especially in the removal of larger stones. Further study is needed to investigate the efficacy and success of this approach.

Assess the safety and effectiveness of a novel approach during transurethral pneumatic cystolithotripsy in large urinary bladder stone: quasi-clinical trial

To assess the safety and efficacy of using continuous irrigation-modified hysteroscopy during transurethral pneumatic cystolithotripsy for large bladder calculi. A prospective study was carried out from May 2016 until March 2020. All patients with solitary or multiple bladder stones > 2.5 cm were subjected to Transurethral pneumatic cystolithotripsy using a modified continuous irrigation hysteroscopy, the stone fragments were removed by Ellik Evacuator, the safety and effectiveness of the procedures were evaluated, stone-free rate (SFR), stone recurrence and stricture urethra disease during follow-up. 55 patients with a mean age of 57.36 (22-82) years were included, the male: female ratio was 4:1, single stone in 74.5% and the mean stone size was 52 mm. Lithotripsy time and an operative time were (20.39 ± 3.06 and 32.00 ± 3.57) minutes, respectively. Mean hospital stay was 10 ± 3.6 h. This endoscopic technique succeeded with a 100% SFR. During the 22 months of follow-up, no urethral stricture or stone recurrence was documented. The mean visual analog pain score (VAS) was 4.2 ± 2.1 and 1.4 ± 0.6, respectively, during and after the operation. The use of the modified hysteroscopy sheath during transurethral pneumatic cystolithotripsy is safe and effective for the management of large urinary bladder stones, an alternative to holmium laser in developing countries when laser equipment is unavailable. Comparable to other transurethral maneuvers, with a decrease in the risk of urethral stricture disease due to the small caliber of the device, as there is no urethral dilatation is required.

Lost and forgotten: A case of intravesical migration of an intrauterine device

In this report we explore the clinical journey of a female patient that presented with a history of failed contraception and more recently recurrent urinary tract infection (UTI). Renal tract ultrasound was done to investigate the cause of UTI and a bladder calculus was seen. During cystolithotripsy an intrauterine device (IUD) was seen embedded in the calculus. The risk factors for intravesical migration of an IUD are discussed.

Which Endoscopic Methods in Prepubertal Patients with 10-20 mm Bladder Stones: Transurethral Cystolithotripsy or Percutaneous Cystolithotripsy?

BACKGROUND

The aim of this study was to evaluate the efficacy and safety of transurethral cystolithotripsy(TUC) and percutaneous cystolithotripsy(PCC) in prepubertal patients with 10-20 mm bladder stones.

MATERIALS AND METHODS

The files of patients the age of 12 and under who were admitted our clinic for bladder stones from January 2007 to January 2021 were reviewed retrospectively. Inclusion criteria were patients who were 12 years of age and under with 10-20 mm bladder stones, and who underwent endoscopic surgery(TUC or PCC). None of the patients had prior bladder or stone surgery. The patients were divided into two groups(Group 1:PCC group, and Group 2:TUC group) and collected data(preoperative, intraoperative, and postoperative characteristics) were compared between the groups.

RESULTS

This present study was enrolled 51 patients(21 patients in Group 1 and 30 patients in Group 2).The mean ages of the groups were similar (Group 1:4.7±3.6; Group 2:4.6±3.2; p:0.936). The mean stone size was 15.8±3.5 in Group 1, and 12.1±2.4 mm in Group 2. It was higher in the PCC group than TUC group(p<0.001). The operative time was lower in Group 1 than Group 2(36.4±12.9 min vs. 42.7±16.3 min, respectively), but there was no statistically significance difference between the groups (p:0.117).We achieved SFR for all the patients in both groups. Complications were observed in four (7.7%) cases. One female patient was in Group 1 and three male patients were in Group 2. There was no difference for complication rates between the groups(p:0.634).

CONCLUSIONS

Endoscopic surgeries have almost become a routine method in the treatment of bladder stones. Despite larger stone size, PCC provides similar SFR compared with TUC along with a tendency of shorter operative time. However, the use of the TUC method in toddler males could increase the risk of postoperative urinary retention. Hence, stone size and patient age should be considered in the selection of a surgical approach.

Comparison of three different modalities for the treatment of bladder calculi by size

PURPOSE

Treatment recommendations for kidney or ureteral stones are based on stone size; however, this is uncertain for bladder stones. This study aims to determine the best approach to bladder stones based on their size.

MATERIALS AND METHODS

We retrospectively analyzed 401 patients with bladder stones. Patients were divided into three different groups according to stone size (11-20 mm, 21-30 mm, 31-40 mm as groups 1, 2, and 3 respectively). Patients had transurethral cystolithotripsy (TUCL), percutaneous cystolithotripsy (PCCL), and open cystolithotomy (OCL) performed.

RESULTS

Stone fragments were removed completely in all patients. When catheter time, postoperative stay, and hematocrit decrease values were compared, the results were significantly higher for OCL in all three groups (p: 0.001). When the relationship between stone sizes and operation time is evaluated, TUCL had shorter operation times (34.1 ± 10.6 min) in group 1. However, TUCL had longer operation times in group 2 and group 3 compared to OCL and PCCL.

CONCLUSION

TUCL may be preferable due to better postoperative outcomes and shorter operative time for ⩽2 cm stones. As the stone size increases, PCCL is more favorable in terms of operation time.

A prospective evaluation of high- and low-power holmium laser settings for transurethral lithotripsy in the management of adults with large bladder calculi

PURPOSE

To prospectively investigate the efficacy and safety of high-power (100 W) vs low-power (20 W) laser settings for transurethral laser lithotripsy in the management large vesical calculi (> 4 cm).

METHODS

All patients with vesical calculi > 4 cm in the maximum dimension and scheduled for transurethral holmium laser lithotripsy were invited to participate in the study. Every alternate patient was treated with either the low- or high-power laser settings. We used a continuous irrigation resectoscope with laser bridge or a laser working element (Karl Storz) for laser lithotripsy of bladder stones. We compared the operative time, intra-operative/post-operative complications (up to 1 year), and stone-free rates between the treatment groups using IBM SPSS Statistics 24 software. Comparisons between treatment groups for continuous variables were assessed using the Welch test, while categorical variables were compared with either the Chi-square or Fisher's exact test. A p value < 0.05 was considered statistically significant.

RESULTS

Twenty patients with ten in each cohort were recruited. Preoperative data and mean bladder stone size were comparable in both groups. The duration of surgery was significantly reduced from 70.80 ± 25.28 min in low-power cohort to 40.90 ± 15.01 min in the high-power group (p = 0.005). There were no significant intra-operative complications in either group. All patients were stone-free following the procedure.

CONCLUSION

High-power laser setting of up to 100 W results in a significant reduction in duration of surgery without any increase in the complication rate for treatment of large bladder stones.

Flexible cystoscopy and laser stone fragmentation via Mitrofanoff stoma: A case series

Objective:

This case series aimed to demonstrate that flexible cystoscopy and laser stone fragmentation via a Mitrofanoff stoma is possible and an effective treatment for symptomatic bladder stones in complex patients with inaccessible urethras and challenging anatomy.

Patients and methods:

We present three cases which were managed in a tertiary centre. The procedure involved using a flexible cystoscope via the Mitrofanoff stoma and laser stone fragmentation without the need for an access sheath.

Results:

This technique was performed safely and demonstrated successful bladder stone clearance on follow-up, with no postoperative complications.

Conclusion:

Our case series illustrates a technique that can be performed in this select group of patients in specialist centres with the relevant surgical exposure and expertise.

Level of evidence

Level 4.

Simple Solution to a Difficult Problem: Removal of Large Bladder Calculi Using a Laparoscopic Entrapment Sac

Introduction and Objectives: Percutaneous management of large bladder calculi with the use of a laparoscopic entrapment sac is a minimally invasive procedure that may have advantages over open cystolithotomy and transurethral cystolithotripsy, as well as standard percutaneous cystolithotomy. We first performed this procedure in 2008, and refined it after our initial publication in 2013 by changing the position from lithotomy to supine by using a urethral catheter postoperatively instead of a suprapubic (SP) catheter, by using ultrasound guidance for access, and by changing the procedure from being inpatient to outpatient. Our objective is to assess the continued feasibility of percutaneous entrapment sac cystolithotomy (PESC) and describe modifications that simplify the technique (mPESC), comparing outcomes and complications. Methods: Forty seven male patients underwent PESC from 2008 to 2019, 16 who had PESC and 31 who had mPESC. After extraction of calculi, either an SP catheter was placed, or the wound was closed and a urethral catheter was placed. Operative and follow-up parameters were compared between the two cohorts. Results: All patients were rendered stone free. Procedure time and length of stay were both significantly shorter in the mPESC cohort. Stone burden and estimated blood loss were equivalent between cohorts. There were no complications of urethral trauma in either cohort. The PESC cohort had higher rates of leakage from the SP site (25% vs 0%), increased need for catheter over 5 days (18.8% vs 0%), and greater likelihood of recurrent retention (12.5% vs 6%). Conclusions: Modifications of PESC, mPESC, leads to fewer complications and reduced length of stay compared with the original PESC procedure. This safe and efficacious technique can reduce morbidity during the management of large bladder calculi and is well suited for an outpatient procedure.

Mini-percutaneous cystolithotripsy (mPCCL) versus transurethral cystolithotripsy (TUC) in pre-school children: Prospective comparative non-randomized outcomes over 8 years

INTRODUCTION

Bladder stones in children can often be challenging to manage. We present our experience of minimally invasive percutaneous cystolithotripsy using 'mini-perc' instruments in the treatment of the bladder stones in pre-school children. The study also compares the outcomes of mini-percutaneous cystolithotripsy (mPCCL) and transurethral cystolithotripsy (TUC).

OBJECTIVE

We hypothesized that mPCCL is a new minimally invasive technique with comparable outcomes to TUC.

STUDY DESIGN

After parental consent and institutional review board approval, consecutive pre-school children with bladder stones were included from January 2011-December 2018. We shifted from the TUC to mPCCL in 2014, with mPCCL introduced as a new technique. Outcomes including stone free rate (SFR) and complication rates were compared for patients aged between 1 and 5 years of age who underwent mPCCL or TUC.

RESULTS

A total of 31 patients (16 patients in Group 1 (mPCCL) and 15 patients in Group 2 (TUC) underwent the procedure. The mean age, stone size and operative times were 2.4 ± 0.96 years and 3.8 ± 0.77 years; 1.86 ± 0.65 cm and 1.34 ± 0.52 cm; and 33.5 ± 8.42 min and 38.2 ± 6.76 min for groups 1 and 2 respectively. While there were no intra or post-operative complications in group 1, in group 2 one patient required conversion to mPCCL due to difficulty in fragment removal per urethra and one with residual fragment needed repeat cystoscopy and fragment removal (Clavien IIIb). All patients in both groups were discharged the following day after catheter removal and remained stone free at 1- and 6-month follow-up.

DISCUSSION

Our study shows good outcomes in managing bladder stones with the use of both TUC and mPCCL. We shifted from the former to mPCCL in 2014 during which there was an overlap of both these techniques, while mPCCL was being introduced. Subsequently, all stones have been managed with mPCCL without the need to revert back to TUC. In Group 1, we performed mPCCL, where the puncture was performed under ultrasound-guidance and fragment retrieval was accomplished with the vacuum-cleaner effect through the operating sheath. Complete stone clearance was achieved in all cases with no complications or need for secondary procedures. Limitations of our study include small sample size, single-centre experience, and lack of randomization. Further prospective randomized multicenter studies may be required to validate our results.

CONCLUSION

The technique of percutaneous suprapubic cystolithotripsy using mini-nephroscope is an alternate to transurethral cystolithotripsy. While both these techniques are suitable for smaller bladder stones, PCCL may be considered as the preferred management option of especially large bladder calculus in preschool children.

Efficacy of transurethral cystolithotripsy assisted by percutaneous evacuation and the benefit of genetic analysis in a pediatric cystinuria patient with a large bladder stone

Cystinuria is an inherited disease, and the defective reabsorption of cysteine causes often requires operations for large urinary stones from childhood. It is rare to be diagnosed only with bladder stones and essential to select an operative procedure according to the age of the patient and the size of the stone.

We report the case of a 2-year-old boy with cystinuria diagnosed with a large bladder stone and investigate the efficacy of transurethral cystolithotripsy assisted by percutaneous evacuation. Additional genetic analysis for the entire family revealed benefit for the life-span treatment of cystinuria.

<p>Transurethral Resection of Prostate (TURP) and Vesicolithotomy for Large Bladder Stone in Single Session: The Third World Perspective</p>

Objective

Methods

Results

Conclusion

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Guideline of guidelines for kidney and bladder stones

Urological organizations publish detailed evidence-based guidelines to support the urologists in the management of urolithiasis. Our objective was to provide clear guidance on the management of urolithiasis, compare the American Urological Association (AUA) and European Association of Urologists (EAU) guidelines, and present an algorithm for different clinical scenarios. The latest AUA and EAU guidelines on urolithiasis were evaluated for the level of evidence and grade of recommendation. All recommendations on management of urolithiasis (surgical and medical management) were reviewed and included. Both the organizations provide guidance for initial patient assessment, imaging requirements, and therapeutic options, including surgical intervention and medical therapy. In addition, these guidelines provide advice for managing specific patient groups, including pediatric patients and pregnant patients. Although there is a general concordance between both the groups, differences exist particularly for recommended modality of surgical intervention depending on stone location and size. Although both the guidelines were broadly similar, we also highlighted the variations in the level of evidence and grade of recommendation. Although these guidelines provide a valuable evidence-based framework to support the management of urinary tract stones, their implementation must be tailored to individual patient needs and available resources.

Minimally Invasive Management of Bladder Stones in Children

Background: Bladder stones (BS) are rare in children. Minimally invasive surgery (MIS) seems to be nowadays the procedure of choice to treat pediatric patients with BS. This study aimed to analyze retrospectively our experience with percutaneous cystolithotomy, endourological treatment with Holmium laser and robotic cystolithotomy in children with BS. Methods: We retrospectively analyzed the data of 13 children (eight boys and five girls) with BS who were treated at our centers between July 2013 and July 2020. The patients received three different MIS procedures for stones removal: five underwent robotic cystolithotomy, five underwent endourological treatment and three received percutaneous cystolithotomy (PCCL). We preferentially adopted endourological approach for stones <10 mm, percutaneous approach between 2014 and 2016 and robotic approach since 2016 for larger stones. Results: Mean patients' age at the time of diagnosis was 13 years (range 5-18). Ten/13 patients (76.9%) had primary BS and 3/13 patients (23.1%) had secondary BS. Mean stone size was 18.8 mm (range 7-50). In all cases the stones were removed successfully. One Clavien II post-operative complication occurred following PCCL (33.3%). All the procedures were completed without conversions. Operative time ranged between 40 and 90 min (mean 66) with no significant difference between the three methods (p = 0.8). Indwelling bladder catheter duration was significantly longer after PCCL (mean 72 h) compared with robotic and endourological approaches (mean 15.6 h) (p = 0.001). Hospitalization was significantly longer after PCCL (mean 7.6 days) compared with the other two approaches (mean 4.7 days) (p = 0.001). The endourological approach was the most cost-effective method compared with the other two approaches (p = 0.001). Conclusions: Minimally invasive management of bladder stones in children was safe and effective. Endourological management was the most cost-effective method, allowing a shorter hospital stay compared with the other procedures but it was mainly indicated for smaller stones with a diameter < 10 mm. Based upon our preliminary results, robotic surgery seemed to be a feasible treatment option for BS larger than 15-20 mm. It allowed to remove the big stones without crushing them with a safe and easy closure of the bladder wall thanks to the easy suturing provided by the Robot technology.