Suprapubic Cystolithotomy

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Opening, removal of stone and closure of urinary bladder.

 

Primary stone—stone formed in the sterile urine

Secondary stone—stone formed in infected urine

 

Presentation of urinary bladder stone—

1.     Patient will have pain in the suprapubic region which is exacerbate at the end of the micturation (due to irritation of the bladder wall, when the bladder collapses it contracts over the stone surface)

2.     Terminal haematuria—when the bladder is empty, it contracts over the stone surface, irritation and ulceration of mucosa causing bleeding at the end of micturation.

3.     Dysuria—due to superadded infection.

4.     In children—history given by the mother that baby pulls the penis and cries.

 

Investigation—plain X-ray of KUB region

 

Treatment—

1.     Suprapubic cystolithotomy

2.     Lithotripsy—ultrasonic lithotripter used to crush stone by sound wave, electrohydrolic—electric wave to crush stone, ESWL (Extracorporeal Shockwave Lithotripsy)—to crush stone from outside the body by shock wave.

3.     Litholapaxy—crush the stone by Lithotrite, which may be introduced through cystoscope.

 

Contraindication of Lithotripsy and Litholapaxy—

1.     Too big/too small stone—may cause injury to the bladder mucosa due to repeated attempt of holding the stone.

2.     Too hard/too soft stone—if too hard then cannot break and if too soft then becomes flattened.

3.     Infection in the bladder.

4.     Congenital anomalies of bladder, like diverticulum. (dust particles may enter into the diverticulum)

5.     Specialized surgeons and costly machineries are needed.

 

Procedure of Suprapubic Cystolithotomy—

Anaesthesia, preparation of the patient (painting and draping) like suprapubic cystostomy.

Insert a penile catheter and insert water or normal saline to distend the bladder.

 

Steps—

1.     Cut these layers—skin, subcutaneous tissue, superficial fascia, anterior rectus sheath.

2.     Anterior rectus sheath is flapped upwards and downwards.

3.     Separate the Rectus abdominis muscle and Pyramidalis muscle carefully and retract them laterally.

4.     Clean the loose areolar tissue in the extra-peritoneal space with gauge.

5.     We do not go to the peritoneal cavity, we reflect the peritoneal cavity as a whole with blunt dissection go retroperitoneal to expose the anterior surface of the urinary bladder.

6.     The bladder will be seen as a shiny, whitish, fish belly appearance structure. (to be sure we can insert a needle and urine will come out)

7.     Apply 2 stay sutures by 1.0 catgut on the anterior wall of the bladder.

8.     Pull the suture, there will be tenting of the bladder.

9.     Stab incision vertically on the tenting part, use suction if urine comes out.

10. Enlarge the opening in relation to the size of the stone.

11. Hold the margin by Ali’s tissue forceps.

12. Cystolithotomy forceps introduced, hold the stone and bring it out.

13. Check for any other pathology in the bladder.

14. Close the bladder, repair by 1.0 chromic catgut. Repair the muscle coat excluding the mucosa, suture material cannot be in contact with urine because it may lead to stone formation. Interrupted suture followed by continuous suture.

15. Keep the penile urethra. Keep a drainage tube at the recto-pubic space because leakage of urine occurs which may lead to recto-pubic abscess.

16. Closure of the wound.

 

*** remove the penile catheter after 8-10 days until the bladder heals.

*** remove the drainage tube 2 days after removal of the catheter if nothing comes out.