Operation to remove stones from the bladder: methods and rehabilitation

Cystolithiasis or the presence of stones in the bladder, conservative treatment in most cases is not amenable. To date, there are no medicines that are guaranteed to dissolve calculous deposits or prevent their formation.

Modern methods of removing stones from the bladder are less traumatic than traditional cavitary surgery. Open surgical intervention is very rarely used nowadays, only in cases when the use of minimally invasive methods will be recognized as ineffective. Basically, transurethral cystectomy using endoscopic equipment is used.

Stones can form directly in the bladder, and can fall there from the kidneys. In any case, their removal is the first stage of treatment of urinary tract pathologies, which led to the formation of concrements.

[1], [2], [3], [4], [5], [6]

Indications for the procedure

If the ineffectiveness of conservative treatment, chronic periodically exacerbated bladder infections, regular pain in the lower abdomen, impurity of blood in the urine, or acute delay, resort to the removal of stones from the bladder.

Transurethral methods of extraction of stones are shown when they are visualized by the instrumental method and there are no obstacles to the extraction or independent release of small particles of fractured formations.

The indication for an open surgical operation is the detection of a purulent inflammatory process or urethral stricture in the patient, the impossibility of visualizing stones, and also the presence of large concrements that can not be crushed.

[7], [8], [9], [10], [11], [12], [13]

Preparation

With the use of ultrasound and / or cystoscopy, visualization of concrements, assessment of their size, location, condition of the organ, probability of complications is performed. The method of operative treatment is determined.

The patient's blood and urine are examined. The method of anesthesia (local, spinal, general) is chosen by an anesthesiologist, taking into account the type of surgical intervention and concomitant pathologies of the patient.

Beforehand, the patient must clean the intestines from the stool with enema or special preparations.

Before open cystolithotomy, the scalp is removed from the pubic area.

[14], [15], [16], [17], [18]

Technique of the removal of stones from the bladder

Operative removal of stones from the bladder in men who suffer from urolithiasis due to the anatomical features of the urethra is much more likely than women to be the most reliable way to get rid of these formations.

The most common method of removal in people of both sexes today is  transurethral cystolitholapaxy  (endoscopic removal of the stone from the bladder through the natural openings of the body). Through the urethra, a thin fiber-optic (flexible) or metal (rigid) cystoscope is inserted into the bladder, equipped with a video camera that allows visualizing the object and controlling the operation. The cystoscope is brought directly to the calculus, through which an energy impulse is transmitted. For crushing at the present time, ultrasound and laser energy is often used, which makes it possible to break the stones to the state of sand, which is washed from the bladder by a sterile liquid. Ultrasound is recommended for use in low-density concrements. Laser technology is considered the most effective and accurate. The use of a laser beam does not damage nearby tissues, but acts exactly on the object of crushing.

The method of electrohydraulic cystolithotripsy, in which a fixed stone is crushed from one side (the least strong), is more effective when placing stones in the ureter and kidneys. But it is also used to remove solid formations from the bladder.

A mechanical lithotriptor is also used, with which the calculi are fragmented step by step. The specialist grasps the stone, moving it to the center of the bladder, and there he crushes, periodically washing the bladder to ensure good visual control. The procedure continues until the formation is completely destroyed. Minuses of the pneumatic method are the probability of injuries of soft tissues or casting stones in the kidney.

After any endoscopic procedure, small fragments are removed by means of special devices or sucked off by vacuum from the urethra. Since the operation is performed under absolute visual control, urethral lesions are practically absent. Contact lithotripsy is performed in the hospital of the urological department under general or spinal anesthesia, where the patient usually spends two to three days. Sometimes after the procedure, there is a need for a catheter in the bladder.

Remote lithotripsy is  carried out by means of a narrowly directed short-time high-pressure pulse (shock acoustic wave). This method is shown in the case of secondary deposits, in the absence of obstructions to the outflow of urine and the location in the neck of the urethra. Stones that have arisen against the background of prostatic hyperplasia are not removed by this method.

This method of removal is the most sparing of all, does not require preliminary analgesia or, in the case of a low pain threshold of the patient, it is enough to inject an analgesic. When it is used, the integrity of the tissues is not impaired. The procedure for directing the shock wave is controlled by ultrasonic or roentgenological equipment. Extracorporeal shock wave therapy can be performed on an outpatient basis. However, its main drawback is not always the complete excretion of fragments from the bladder. The probability of success of this procedure is just over 50%. With incomplete excretion of fragments of concrements, the patient experiences complications in the form of periodic attacks of pain. In this way, the removal of stones from the bladder is well carried out in women, since a short and wide urethra allows easy removal of shattered stone fragments outwards. In men, the fragments can be removed in 1-1.5 hours after the procedure of crushing with a laparoscope (through micro cuts) or percutaneous puncture (puncture).

Percutaneous suprapubic cystolitholapaxia  is the operation of choice in childhood, since it allows not to injure the urethra. In adults, this operation is carried out for the removal without crushing large enough stones (with contraindications to crushing) or in combination with remote lithotripsy to remove large fragments that do not exit through the urethra. The stones are removed through a microcut in the lower abdomen and the bladder membrane. The operation is performed under general anesthesia in the hospital, and some time is required for recovery after the intervention.

An open surgical procedure to remove stones is  performed if it is impossible to get to them through the urethra (inflammation, constriction, adenoma of the prostate gland). From the previous operation, the procedure is characterized by a large volume and, correspondingly, traumatism. The surgeon makes a cut in the lower abdomen and in the bladder membrane, his internal examination and removal of solid formations becomes available, after which he is sutured, and seams are placed on the wound.

In order to prevent bladder dysplasia and development of neoplasms in the presence of visually perceptible transformations of the internal membrane of the organ after removal of the stone, a tissue biopsy is taken for subsequent histological examination.

Performed under general anesthesia, after the operation for a few days, a catheter is installed. During the operation, remove stones larger than 4 cm or ingrown into the shell of the bladder. This type of surgical treatment is chosen when it is necessary to simultaneously remove other pathologies - adenoma of the prostate gland, diverticulum of the bladder.

The main disadvantages of cavitary surgery are traumatic and long-term rehabilitation.

Contraindications to the procedure

Methods of removal using endoscopic equipment are not used to treat patients with anatomical features in the structure of the skeleton and urinary organs that block access through natural openings of the body to stones, large (more than 4 cm in size) and not visualized stones.

Patients with pacemakers, tumor processes of the genito-urinary organs, terminal stage of renal dysfunction, and decreased haemostatic are contraindicated in contact and remote lithotripsy.

The presence of a vascular aneurysm in the zone of wave action and mental illness also refers to factors unfavorable for conducting operations.

Relative contraindications are pregnancy, active tuberculosis, acute infectious and inflammatory diseases of the genitourinary system, dermatosis and dermatitis in the wave action zone, uncontrolled high blood pressure and other decompensated diseases of the cardiovascular system.

Percutaneous suprapubic litholapaxy is contraindicated in patients who had previously undergone operative interventions on the pelvic organs and the lower part of the peritoneum, inadequate occupancy and capacity of the bladder.

Diabetics are not recommended to have open cystolithotomy. The expediency of carrying out this type of operative intervention is considered individually, contraindications to it are common for abdominal operations.

Complications after the procedure are most often found in patients older than 55 years of age and due to non-compliance with the recommended diet. The group of high probability of risk of postoperative complications includes persons suffering from alcoholism, cirrhosis of the liver, cancerous tumors of various localization, congestive heart failure and violations of liver function in severe form.

Surgical intervention by means of endoscopic technique is much more sparing. The ability to work and the opportunity to live in the usual rhythm of the operated patients is restored one week after the operation. The consequences after the procedure of open cystolithotomy prolong the recovery period to about a month, or even more. However, after this operation, there is a smaller percentage of the restoration of the formation of stones in the bladder.

The advantage of transurethral cystolitholapaxy before an open surgery is a reduction in traumatic tissue damage and a practical absence of complications. Follow-up monitoring of patients suggests that more than 90% of endoscopic surgeries performed were successful.

Among complications, urinary tract infections are most often detected, much less often - damage to the wall of the bladder, development of sodium deficiency, bleeding.

[19], [20], [21], [22], [23], [24]

Care after the procedure

After the operation under general anesthesia, the patient usually sleeps in the ward for a while. The body temperature from anesthesia usually decreases, so the patient should be well covered and not disturbed. However, it must be under the control of medical personnel, which monitors the body temperature and the appearance of the patient. After the operation, there may be an increase in body temperature. This is normal after anesthesia, both general and spinal, but the cause of it should be clarified. The activity of the cardiovascular, respiratory and nervous systems is also monitored.

If necessary, after an open surgery, and sometimes after transurethral removal, a short-term course of catheterization of the bladder is performed periodically, until the manifestations of multicomponent anesthesia disappear. A five-day course of antibiotic therapy may be prescribed for the prevention of urinary tract infection or if present before surgery.

After the stone crushing procedures, the patient is observed for three weeks with an ultrasound examination of the bladder to ensure that stone fragments are removed. To deduce them the medicines prescribed by the doctor and a diet after removal of stones from a bladder will help.

With urolithiasis, nutrition should be varied, and the consumed volume of products should correspond to the standard daily norms for the content of proteins, fats and carbohydrates. Drinking fluids should be in such a volume that the adult allocated per day from one and a half to two liters of urine.

Food restrictions depend on exchange disorders. With a tendency to the formation of urate stones, it is necessary to limit meat smoked products and dishes from by-products, not to get carried away by strong broths, jellied meat and chill. The use of roast meat is also better restricted. Do not lean on canned meat and fish, generously flavor the dishes with spices. Fish is better to eat low-fat varieties. The formation of urates is promoted by vegetable proteins - mushrooms and legumes, and also - nuts. Alcohol is harmful in general, but in this case it is better to prefer white wine and light beer.

The formation of calcium-oxalate stones provokes meat products and canned fish, pickles and smoked products. It is necessary to reduce consumption of cottage cheese and cheese. Do not get involved in salad and spinach, celery and sorrel. Limit the use of dishes from potatoes and cauliflower. Such vegetables as pepper, radish, carrots, too, should be consumed in limited quantities. From the list of your favorite berries and fruits you will have to cross out raspberries, strawberries, black currants and figs. Minimize confectionery with cocoa, it is undesirable to get carried away with strong tea and coffee.

The formation of calcium-phosphate stones is promoted by dairy products, in particular - cottage cheese and any cheeses. It is necessary to limit the consumption of most vegetables and fruits. Preference in the formation of the diet to give meat, fish, fat and sauerkraut, fats - plant origin. Without restrictions, you can eat any flour dishes.

The patient should periodically examine the metabolism and urinary system to prevent relapse of urolithiasis.

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