Guidelines
Guidelines Summary
In 2019, the European Association of Urology (EAU) and/or cystoscopy are the optimum imaging modalities for detection of bladder stones.
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Asymptomatic migratory bladder stones in adults may be left untreated, especially if stones are small.
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Primary and secondary bladder stones are usually symptomatic and unlikely to pass spontaneously. Active treatment of such stones is usually indicated.
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Stones composed of uric acid or struvite can be dissolved by chemolysis. Uric acid stones can be dissolved by oral urinary alkalinization when a pH > 6.5 is consistently achieved, typically using an alkaline citrate or sodium bicarbonate. Careful monitoring is required during therapy. Irrigation chemolysis is possible for struvite or uric acid stones; a two-way or three-way Foley catheter can be used.
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Bladder stones can be treated with open, laparoscopic, robotic assisted laparoscopic, or endoscopic (transurethral or percutaneous) surgery or extracorporeal shock wave lithotripsy (SWL).
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Open suprapubic cystolithotomy is successful, but is associated with a need for catheterization and longer hospital stay in both adults and children, compared with all other stone removal modalities.
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In both adults and children, transurethral cystolithotripsy provides similar, high stone-free rates (SFR) and appears to be safe.
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Bladder stones in men aged over 40 years are typically related to benign prostatic hyperplasia (BPH), the management of which should also be considered.
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Bladder stones formed after bladder augmentation may be removed via open cystolithotomy or endoscopically. Daily bladder irrigation with 250 mL of saline solution significantly reduces the incidence of recurrent stone formation and bacterial colonization compared with lower- volume bladder irrigations.
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For bladder stones formed after urinary diversion, a percutaneous approach or open procedure may be required if the caliber of the nipple is too small to allow the safe insertion of an appropriately sized endoscopic instrument without risking damage to the continence apparatus.
Specific EAU treatment recommendations are as follows [24] :
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Offer adults and children transurethral cystolithotripsy where feasible.
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In adult men with bladder outlet obstruction (BOO) and bladder stones, preferably treat the underlying BOO simultaneously with stone removal.
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Offer adults and children percutaneous cystolithotripsy where transurethral is not possible or is associated with a high risk of urethral stricture (eg, young children, patients with previous urethral reconstruction, patients with spinal cord injury).
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Discuss open cystolithotomy for very large bladder stones (there is no evidence to suggest a size cut-off).
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Open, laparoscopic, robotic, and extracorporeal shock wave lithotripsy are alternatives where endoscopic treatment is not feasible.
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Perform transurethral cystolithotripsy with a continuous flow instrument (eg, nephroscope or resectoscope) where possible in adults.
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In children with primary stones, perform open cystolithotomy preferably without placing a catheter or drain in uncomplicated cases (ie, those with no prior infection, surgery, or bladder dysfunction).
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Recommend regular irrigation therapy with saline solution to patients with a bladder augmentation or continent cutaneous urinary reservoirs.
Media Gallery
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Multiple laminated bladder calculi in patient with neurogenic bladder.
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Endoscopic view of spiculated "jack" stone with erythematous bladder mucosa in background.
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Large calculus visible on plain film of intravenous pyelogram performed for hematuria.
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Ex vivo photograph of bladder stone.
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Two delicate "jack" stones removed before open prostatectomy.
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Bladder stone accretion on matrix. Patient had history of urinary tract infections and presented with irritative voiding symptoms and microscopic hematuria. Upper-tract evaluation findings were normal, but cystoscopy demonstrated calculus. Upon laser treatment of stone, soft matrix core was encountered beneath glistening outer core. Exposed matrix core is visible in crevices.
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Bladder stone accretion on matrix. Patient had history of urinary tract infections and presented with irritative voiding symptoms and microscopic hematuria. Upper-tract evaluation findings were normal, but cystoscopy demonstrated calculus. Upon laser treatment of stone, soft matrix core was encountered beneath glistening outer core. Exposed matrix core is visible in crevices.
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Laser destruction of stone. Note small lacuna generated in stone as result of laser energy. At lower power settings, stone can be quickly reduced to dust.
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Layered nature of bladder calculus exposed as laser strips away surface.
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