Calculi encountered in the lower urinary tract typically reside within the bladder, less often in the urethra. In this video, we present a minimally invasive endoscopic approach for removal of the largest total stone volume in the lower urinary tract reported in the literature to date.
A 25-year-old male (BMI 61 kg/m2) with neurogenic bladder presented with urosepsis and acute kidney injury secondary to obstructive uropathy. Computerized tomography (CT) of the abdomen and pelvis demonstrated bilateral severe hydroureteronephrosis, a 4.2 cm bladder stone, and three urethral stones, including a 7.7 cm prostatic urethral stone and two membranous urethral stones (Fig. 1). Urgent bilateral percutaneous nephrostomy tubes were placed. The patient elected for endoscopic management.
The patient was placed in the supine lithotomy position. His buried penis and narrow urethra only accommodated a 16 French flexible cystoscope. Multiple stones were encountered in the membranous urethra. A 60W SuperPulse Thulium Fiber laser at 2 joules and 30 hertz was utilized to dust the urethral stones efficiently. Simultaneous ultrasound guided percutaneous access into the bladder was obtained and ultrasonic lithotripsy via shockpulse was used to clear the bladder stone and prostatic stone from above. Total stone treatment time was 240 minutes. Suprapubic and urethral catheters were placed at the conclusion. Post-operative day (POD) 1 CT scan confirmed stone free status and he was discharged POD 2. Outpatient nephrostogram demonstrated patency of bilateral ureters and nephrostomy tubes were removed.
Higher morbidity procedures including open or laparoscopic approaches have been described for management of large lower urinary tract stones. In this video, we demonstrate a minimally invasive approach of combined simultaneous antegrade and retrograde lithotripsy to achieve a stone free status in this morbidly obese and complicated patient.
Urology. 2020 Jul 24 [Epub ahead of print]
Jonathan Maldonado, Ruth E Belay, Mohamed Keheila, Akin Amasyali, Jason Groegler, D Duane Baldwin, Mohammad Hajiha
Department of Urology, Loma Linda University Health, Loma Linda, CA. Electronic address: ., Department of Urology, Loma Linda University Health, Loma Linda, CA.