Anatomical reminder
The bladder is the reservoir in which urine from the kidneys is stored before being evacuated during urination. The neck of the bladder opens during urination, which allows the proper flow of urine. The urethra is the channel through which urine is expelled from the bladder.
Bladder lithiasis refers to the disease related to the formation of stones in the bladder. These calculations (“stones”) which can reach several centimeters are formed from aggregates of various mineral (calcium, phosphates, magnesium, etc.) and organic substances. They may or may not be associated with the presence of other stones in the rest of the urinary tract. eliminates this additional risk.
Most often, in adults, these calculations are formed because:
- Poor bladder emptying, due to a subvesical obstacle or a dysfunction of the bladder of neurological origin.
- More rarely, due to the presence of an intravesical foreign body, anatomical abnormalities or urological surgical history.
- Exceptionally, there is no urological cause and the lithiasis may be due to a metabolic disorder.
Thus, in any patient with no known history of urological disease, your surgeon is always looking for a cause of bladder dysfunction or an obstacle explaining the symptoms. Indeed, if a cause is found (for example an enlarged prostate obstructing the flow of urine) it must also be treated to prevent a recurrence.
Symptoms, when present, are most often urinary tract infections, pain, or episodes of blood in the urine due to irritation of the bladder wall. Voiding disorders such as frequent urges to urinate, sensations of partial or complete blockage of urine are also possible, but intertwined with the causal disease, neurological or not, which can generate the formation of stones.
Principle of the intervention
The surgical treatment of bladder stones is systematic, when the spontaneous expulsion of stones is impossible because of their size. In addition, the presence of stones is the consequence of a pathology (urinary obstacle or neurological disease) that should most often be taken care of.
The principle of the treatment is to remove the stones from the bladder, either in one piece by opening the bladder, or by splitting them through the natural trans-urethral route to then extract the debris. The choice of approach is made according to the context, the size and number of stones and the habits of the surgeon. Large stones are more often extracted by surgical opening, smaller ones by endoscopy.
The treatment of the cause is associated, either by a surgical act (possibly at the same time), or by appropriate medical care.
Are there other possibilities?
Apart from exceptional cases, there is no alternative to endoscopic or surgical removal of stones. In the specific case of the bladder, percutaneous fragmentation techniques (extracorporeal lithotripsy) and medical treatments are generally ineffective.
Preparation for the intervention
Your surgeon asks you to bring all the test results you have. He can perform a bladder fibroscopy to check the integrity of the bladder. In the absence of an obvious cause, further examinations such as a urodynamic assessment can be carried out.
A urine analysis is prescribed before the operation to check for sterility or treat any infection.
An untreated urinary tract infection leads to delaying the date of your operation.
A blood test is carried out before the intervention.
Taking anti-platelet aggregation or anticoagulant must be stopped for several days or possibly continued at a low dose.
Antibiotic prophylaxis is systematic according to the protocol established in the establishment. If the urine was infected before the operation, the antibiotic treatment will be continued for a few days.
Surgical technique
The operation is performed under general or loco-regional anesthesia.
Removal of stones by surgical incision
This operation, formerly called “bladder pruning”, consists of opening the bladder to remove the stones entirely. The treatment of an associated obstacle (eg prostate adenoma) can be carried out at the same time.
The surgeon makes an incision in the abdominal wall. The bladder is open and can thus be fully explored. All calculations are removed. A bladder catheter is inserted; the bladder and then the wall of the abdomen are closed. A through-the-wall drain can be placed outside the bladder. Bladder drainage by urinary catheter is maintained for a few days. It is sometimes necessary to set up an additional drainage of the bladder, through the abdomen (supra pubic catheter).
Lithotripsy and natural extraction
Carried out by endoscopic, trans-urethral route, it consists in fragmenting the calculations, then in extracting the pieces in their entirety.
The surgeon introduces a rigid cystoscope and the identified stones are fragmented with forceps, or by laser, or by percussion, or even by ultrasound. The debris is evacuated by the same route.
The gesture can associate a treatment of the obstacle to the flow of urine (most often trans-urethral resection of the prostate). A urinary catheter is placed during the operation and kept for a few days in case of associated intervention on the prostate.
Post-operative follow-up
The urinary catheter and any drains are kept for several days according to the instructions of your urologist. Analgesics are prescribed if needed. The injection of anticoagulants for the prevention of venous thrombosis can be performed depending on the type of intervention and your risk factors.
The necessary hospitalization is usually a few days. The discharge is made after checking that the consequences of the operation are good: clear urine, good evacuation of the bladder, absence of signs of infection. Oral analgesic treatment, anticoagulant treatment and local care are prescribed upon discharge depending on your situation. The duration of the work stoppage is adapted to the type of intervention.
After the operation, you are advised to avoid heavy exertion. In the event of persistent urinary burns, cloudy urine, fever, significant difficulty in urinating, significant pain or discharge from the surgical site, you should consult your doctor or urologist. The presence of blood in the urine in large quantities or with clots may require the placement of a urinary catheter with declotting and a new hospitalization.
A follow-up consultation is scheduled in the weeks following the operation.
Risks and Complications
The results of this surgery allowing the complete ablation of stones are excellent. In the majority of cases, the intervention which is proposed to you takes place without complication. However, any surgical procedure involves a number of risks and complications described below:
Some complications are related to your general condition and the anesthesia; they will be explained to you during the preoperative consultation with the anesthesiologist or the surgeon and are possible in any surgical procedure.
Your urologist is at your disposal for any information.
Complications directly related to the procedure are rare, but possible:
During the operation:
- Risk of injury and perforation of the bladder wall during an endoscopy procedure.
- Need to interrupt the endoscopic intervention and re-intervene secondarily.
After the procedure:
- Pains: they are generally minimal and limited to a few days following the intervention. A painful pelvic bottom can last for a few weeks.
- Infections: urinary or surgical site infection.
- Pelvic hematoma.
- Lack of healing of the bladder: the wall of the bladder may not be sealed or heal poorly, allowing urine to spill around the bladder, in the small pelvis. These situations require the prolonged maintenance of a urinary catheter and in certain cases, a re-intervention.
- Vesicocutaneous fistula: after open surgery, a communication can form between the bladder and the skin with urine flow, requiring prolonged maintenance of a urinary catheter and in some cases, a re-intervention.
- Voiding disorders: type of urgent need to urinate, most often transient. Their persistence long after the intervention requires a new assessment.
- Urethral stricture: After endoscopic surgery, even minor injuries to the urethral canal can cause the urethra to narrow.
- Sexuality: This operation usually does not affect sexuality.
- To these complications are added those of the act possibly carried out to treat the cause of the disease (adenectomy high route or endoscopic resection of the prostate).
