VESICOLITHOTOMY

Most bladder stones are asymptomatic

and are found incidentally.
In adults, bladder stones rarely occur
spontaneously; usually a predisposing
factor promotes stone formation.
Bladder outlet obstruction
neurogenic voiding dysfunction
Infection
Foreign bodies
 In children
uncorrected anatomic
abnormalities
posterior urethral valves
voiding dysfunction
vesicoureteral reflux
are predisposing factors for bladder
calculi formation
 Plain radiographs or an intravenous
pyelogram can be used to diagnose a
bladder stone, but a significant
number of stones can be missed due
to either radiolucency of the stone or
bowel gas
 Cystolithotomy is indicated for patients
with a
large stone burden (i.e., greater than 6
cm), hard stones, abnormal anatomy,
failure of an endoscopic approach, and
concomitant open prostatectomy or
diverticulectomy.
Patient comorbidities, previous surgery,
and available instrumentation also guide
treatment decisions
 TECHNIQUE
1. Place the patient in the
supine position with the
buttocks over the
kidney rest. Prep and
drape the penis/urethra
into the field. Insert a
22-French balloon
catheter and partially fill
the bladder. Cover the
penis/urethra and
catheter with a towel.
2. Make a lower midline
extraperitoneal incision
3. Incise the linea
alba and enter the
abdomen between
the recti and
separate them.
Divide the
transversalis fascia
with scissors and
move laterally.
4. Push the peritoneal
fold upward, revealing
the perivesical fat.
Through the Foley
catheter, fill the
bladder to capacity
with sterile water.
Develop the
retropubic space and
place a retractor if
needed.
5. Place two stay sutures in
the detrusor well above
the pubic symphysis.
Ensure that there is
adequate suction in hand.
Incise the detrusor muscle
in a vertical fashion
between the stay sutures
using electrocautery. Open
the bladder enough to
visualize the stones. The
entire bladder need not be
incised. Use the suction to
remove excess irrigation
6. Using the ring
forceps, grasp the
stone and remove
it from the bladder
7. When a large incision has been made, place
a suprapubic tube through a small cystotomy
in the bladder and through the abdominal
wall. Suture in place at the bladder with a
purse string suture and with a nonabsorbable
suture at the skin. If a smaller incision has
been made and adequate drainage can be
maintained through a large Foley catheter, it
is possible to forego the suprapubic tube at
the discretion of the surgeon.
8. Close the bladder in two layers
using 3-0 Vicryl on the mucosa and
2-0 Vicryl on the detrusor layer. The
mucosal layer is closed first with a
running suture. Close the detrusor/
serosals layer also using a running
suture. Test the closure by filling the
bladder with sterile water.
9. Place a Penrose or closed suction drain near
the bladder closure, exiting next to the
wound. Stitch in place to the skin with
nonabsorbable suture to prevent inadvertent
removal.
10. Leave the catheter for drainage for 8 to 10
days. Obtain a cystogram before catheter
removal.
11. Close the fascia with zero polydioxanone
suture. Skin closure is by surgeon preference.