Management of a Massive Bladder Stone Burden in an Elderly Comorbid Woman via a Transurethral Approach

Abstract

Here we present the case of a 78-year-old medically comorbid woman with an extremely large bladder stone burden treated by cystolithalopaxy performed using a Swiss LithoClast^® Trilogy Lithotripter (Boston Scientific, Marlborough, MA, USA) through a nephroscope traversing a transurethral Amplatz sheath.

Introduction

Bladder stones are an uncommon pathology in women, with females accounting for ∼5% of cases.¹ Often, the development of bladder calculi in women is related to the presence of a foreign body or urinary stasis.¹ Although smaller stones are commonly managed through a cystoscopic approach, larger stones may be managed through a percutaneous approach or through open extraction. In this study, we present the case of a medically comorbid elderly woman with an extremely large bladder stone burden treated effectively by cystolithalopaxy using a Swiss LithoClast^® Trilogy Lithotripter (Boston Scientific, Marlborough, MA, USA) through a nephroscope traversing a transurethral Amplatz sheath.

Case Presentation

A 78-year-old woman with a history of an abdominal aortic aneurism, recurrent urinary tract infections, diabetes mellitus, and uterine prolapse repaired 1 year prior presented to our hospital's emergency room with altered mental status and signs of sepsis. A noncontrast CT scan of the abdomen and pelvis was obtained that revealed several large bladder stones occupying nearly the entirety of the urinary bladder with associated bilateral hydroureteronephrosis (Fig. 1). Physical examination was notable for a large cystocele, and the patient's creatinine on presentation was acutely elevated to 1.8 mg/dL. The patient was admitted for intravenous antibiotics and resuscitation. After resolution of her septic episode and medical optimization, the patient was taken to the operating room for definitive management of her bladder stones. Of note, given the patient's abdominal aortic aneurism, aspirin was continued through the perioperative period. Furthermore, the patient was noted to have poor exercise tolerance by the anesthesia team on preoperative evaluation. In light of these comorbid factors, the decision was made to perform cystolithalopaxy through a transurethral approach.

FIG. 1.

Noncontrast CT images showing our patient's extremely large bladder stone burden and associated bilateral hydroureteronephrosis.

The patient was placed in dorsal lithotomy position and examination under anesthesia revealed a patulous urethra. Given the patulous appearance of the patient's urethra, a 24F Amplatz sheath was able to be easily passed transurethrally into the bladder. Alternatively, had the patient's urethra not readily accommodated the Amplatz sheath, we would have placed a wire into the bladder cystoscopically and proceed with serial wire-guided dilation of the urethra, ultimately passing an Amplatz sheath over the 24F dilator. With transurethral access established, we proceeded to use the Swiss LithoClast Trilogy Lithotripter through a nephroscope to fragment and suction the bladder stone. Our operative setup is shown in Figure 2 and endoscopic images are shown in Figure 3. We used settings of 8–10 Hz, suction 50%, impact 100%, and ultrasound 100%. Despite the impressive stone burden, we did not experience any intraoperative issues related to our lithotripter overheating or becoming clogged. At the conclusion of the procedure, the patient was stone free (Fig. 4). Total operative time was 193 minutes.

FIG. 2.

(A) Shows our operative setup with the Swiss LithoClast^® Trilogy Lithotripter inside of a nephroscope traversing a transurethral Amplatz sheath. (B) Shows the totality of the stone burden removed from the patient's bladder.

FIG. 3.

Endoscopic images showing the use of the Swiss LithoClast Trilogy Lithotripter for transurethral cystolithalopaxy.

FIG. 4.

Comparison of preoperative preoperative CT-scout image (A) with postoperative abdominal X-ray (B) showing resolution of patient's bladder stone burden.

Discussion

Bladder stones predominantly occur in male patients, and although small stones can be managed cystoscopically, larger stones are often managed through an open approach or a percutaneous endoscopic approach.¹ However, in a comorbid patient on antiplatelet medication, a transurethral approach to a large stone burden may be preferred as it is less invasive than percutaneous or open extraction. The use of a transurethral Amplatz sheath allows for surgeon utilization of a nephroscope and a combined ultrasonic/pneumatic lithotripter in the bladder and may expedite transurethral cystolithalopaxy.² Although this technique has been studied in men,^2,3 the literature on the use of combined ultrasonic/pneumatic transurethral cystolithalopaxy in women has been limited since Maheshwari originally described the technique in two female patients in 1998.⁴ Since that time, novel lithotripters have been developed and this is to our knowledge the first report on the use of the novel Swiss LithoClast Trilogy Lithotripter for transurethral cystolithalopaxy in a woman. Although long-term safety data on the Swiss LithoClast Trilogy Lithotripter for cystolithalopaxy are lacking, our clinical experience has been that it is less traumatic than prior combined ultrasonic/pneumatic lithotripters. Indeed, here we have demonstrated the effective use of this technique and technology in a female patient with a massive bladder stone burden. Thus, although there are multiple acceptable operative approaches for the treatment of women with large bladder stone burdens, we have shown, similar to the prior study of Maheshwari,⁴ that the use of a contemporary combined mechanical/pneumatic lithotripter through a transurethral Amplatz sheath is a viable addition to the endourologist's armamentarium when treating a comorbid patient.

Conclusion

Women with large bladder stone burdens can be effectively treated with cystolithalopaxy using a contemporary combined ultrasonic/pneumatic lithotripter through a nephroscope traversing a transurethral Amplatz sheath. This technique may serve as a viable alternative to percutaneous and open approaches for the treatment of extremely large bladder stones in comorbid women.

Abbreviation Used

CT

computed tomography

Disclosure Statement

None of the authors have any direct conflicts of interest regarding this research project. However, of note, as a general financial disclosure, Dr. Mantu Gupta is compensated for educational training for Cook Urological, Inc., Boston Scientific, Inc., Olympus, Inc., Lumenis, Inc., and Retrophin, Inc., In addition, Dr. Gupta is the editor in chief of Videourology. None of the other authors have relevant financial disclosures.

Funding Information

No funding was received for this article.

Cite this article as: Khusid JA, Sadiq AS, Gupta M, Atallah WM (2020) Management of a massive bladder stone burden in an elderly comorbid woman via a transurethral approach, Journal of Endourology Case Reports 6:4, 509–511, DOI: 10.1089/cren.2020.0190.