Percutaneous Cystolithotomy in Augmented Bladders.

AIMS: Incidence and recurrence of bladder stone in augmented exstrophy bladder rate is high. So, recurrent open cystolithotomy is not a preferred procedure; particularly through scarred tissues, consequence of previous surgeries. Percutaneous cystolithotomy (PCCL) is an old but standard procedure for retrieval of bladder stones in adults. We extrapolated PCCL for bladder stone in augmented bladders in children. PATIENTS AND METHODS: In three patients, we made suprapubic (SP) needle track with initial puncture (IP) needle under cystoscopic guidance. Following that laparoscopic cannula was placed through dilated SP track that was crafted with Alken's dilators and bladder stones were removed with grasper.
RESULTS: On cystoscopy, we also observed the patches of skin tissues in native bladders. Continence and bladder capacity were not affected following PCCL.
CONCLUSION: PCCL in augmented bladder showed good outcome. High recurrence of bladder stone is possibly due to presence of keratin in dermal tissue; invaded mucosa in open bladder plate. It seems shaving or fulguration of those dermal elements during bladder reconstruction might decrease incidence of stone formation. However, we haven't attempted fulguration during PCCL. Copyright:

INTRODUCTION

Lifetime prevalence of urinary stone is estimated to be around 3.8%.[1] Out of that, bladder stone has got least incidence, particularly in hygienic environments. However, the incidence of bladder stone in augmented exstrophy bladder [Figure 1] is around 15%–50% and recurrence rate is also high: which is around 39%.[24] It is thus exasperation, particularly after achievement of continent bladder of small children. In this situation, considering the incidence of recurrence, transurethral lithotripsy through narrow urethra is not chosen with an apprehension of spoil of reconstructed continent bladder neck.

Figure 1

Stone in augmented bladder

Percutaneous cystolithotomy (PCCL) is a standard procedure for retrieval of bladder stones in adult.[5] We did cystoscope-guided PCCL and used the laparoscopic cannula and grasper for removal of bladder stone.

PATIENTS AND METHODS

Three patients, two female and one male, aged 4–6 year [Table 1], were treated with this PCCL. All three patients had bladder neck reconstruction, pubic osteotomy minimal procedure,[6] and augmented ileal bladder for the reconstruction of exstrophy. All three patients were continent either with clean intermittent catheterization via naturalis or by normal void. They were not advised for regular bladder wash.

Table 1

Patients with stones profile

Patients	Age of the patients (years)	Timing of bladder augmentations (years)	Timings of stone formation (years)	Number of stones	Size of stones
IR (male)	4	1.5	After 2.5	Single stone	7mm
SN (female)	4.5	1	After 3.5	Two stone	8 mm and 6 mm
IP (female)	6	1.5	At 4.5	Had two stone. Smaller 6 mm came out spontaneously	We removed another 8 mm calculus

Under general anesthesia and in “frog position,” we did cystoscopy and identified stone. Size of stones was within 6–8 mm. Following that, puncture of the bladder at the suprapubic region was made using 18-G puncture needle [Figure 2a] under endoscopic guidance and guide wire was threaded through the lumen of that needle to place portion of guide wire in the bladder. Guide rod of Alken's dilator [Figure 2b] was then threaded on that guide wire and passed into the bladder through the ileal wall of the augmented bladder under endovision guidance. Following that, track for PCCL was made and dilated with Alken's dilator up to 30f [Figures Figure 2c, 3a]. Laparoscopic cannula was then pushed into bladder threading on Alkenes dilator [Figure 3b]. The stone was then grasped under guidance of cystoscope for removal [Figure 3c]. At the end, we did cystopanendoscopy to check residual stone or any residual stitches. During cystopanendoscopy, we found few dermal elements near the bladder neck and trigone.

Figure 2

Puncture with needle and guide wire is threaded (a). Guide rod is threaded over guide wire (b). Alken's telescopic dilators are threaded over guide rod (c)

Figure 3

Alken's telescopic dilators are threaded over guide rod (a). Laparoscopic cannula is threaded over Alken's dilators (b). Stone retrieved with grasper (c)

Few stitches were made to close the PCCL track and urethral catheter kept for 7 days.

RESULTS

No fistula was there in PCCL track. One patient had recurrence of stone after 3 years. Continence and bladder capacity were not affected following PCCL unlike open cystolithotomy.

DISCUSSION

Open cystolithotomy in an augmented bladder is not desirable for the apprehension of dehiscence of the abdominal wall or indolent fistula. Minimally invasive endoscopic procedure, i.e., PCCL, is preferable. In 1999, a boy of 13 years was treated by Talic[7] for prostatovesical calculus by the same procedure through the suprapubic tract. In the same year, Agrawal et al. described similar procedure[8] for vesical calculus in children. Following that, Salah et al.[9] also did PCCL for children. However, all those procedures were done for the stone of native bladder with the help of nephroscope.

Pediatric cystoscope, laparoscopic cannula, and graspers are available in most of pediatric surgical setup for endoscopic procedure. Only the Alken's dilator set, cost of which is around five thousand only, is necessary for this modified PCCL procedure, which might turn aside further investment for costlier equipments, i.e., nephroscope, LASER, etc. Eletrohydraulic/LASER is simpler and better alternative and may make the stone extraction simpler but dictates costlier investment.

In this modified PCCL, we have discussed the access of bladder cavity through gradual dilation with Alken's dilators.[10] However, access of the bladder through puncture with laparoscopic trocar–cannula [Figure 4a] under endoscopic guidance [Figure 4b] is also a possibility. PCCL with laparoscopic trocar–cannula was described by Barber et al.[11] and Khullar et al.[12] for retrieval of bladder stone and knotted feeding tube, respectively.

Figure 4

Direct puncture with laparoscopic trocar–cannula (a). Tip of trocar visible through mucosa (b)

Most authors claim that the urinary stasis, bacterial colonization, infection with urea-splitting organisms, retained mucus, and foreign bodies all can contribute to the formation of bladder stones[34] in an augmented ileal bladder. However, incidence of bladder stones in orthotopic neo-ileal-bladder following radical cystectomy is not high compared to augmented exstrophy bladder and it is only around 7%[13] and that is not at all comparable to the incidence of bladder stones in augmented ileal bladder. Now, the question arises: why this outlandish higher incidence of stone in augmented bladder in exstrophy, compared to neobladder, when both ileal bladders have got similar milieu in their cavity! We found few dermal elements near neck and trigone during cystopanendoscopy at the end of PCCL. Those are due to migrated epidermal tissue in the bladder mucosa often seen in post neonatal bladder plate. Possibly prior invaded epidermal tissues were enclosed without shaving during bladder reconstruction. Shedding of insoluble keratin protein[14] from the dermal tissue in augmented bladder might be the nidus for bladder stone formation along with other factors and makes the incidence higher.

CONCLUSIONS

This modified PCCL seems to be a simple minimal invasive procedure for the stones in augmented bladder, without further costly investment.

'Philosophically, nothing is new, and technically innovation is a mutation; sometimes might be a new colossal'

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.