STONE DISEASE

Percutaneous versus transurethral cystolithotripsy
Tugcu V, Polat H, Ozbay B, Gurbuz N, Eren GA, Tasci AI
Department of Urology, Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
J Endourol. 2009; 23: 237-41

• Purpose: To compare transurethral cystolithotripsy (TUCL) and percutaneous cystolithotripsy (PCCL) modalities performed during simultaneous transurethral resection of the prostate (TURP) in patients with prostate hyperplasia and large bladder stones.
• Patients and Methods: Sixty-three patients with prostate volume > 40 cc and aggregate stone size > 2.5 cm were enrolled in the study between August 2003 and February 2007. TUCL (n = 38) or PCCL (n = 25) procedures were performed during simultaneous TURP. In the TUCL group, the stones were removed after fragmentation through a 23F cystolithotripter with pneumatic lithotripsy. This was followed by TURP, performed with a 26F continuous-flow resectoscope. In the PCCL group, the stones were removed through a suprapubic 30F Amplatz sheath after fragmentation. TURP was then performed with the suprapubic sheath providing continuous drainage.
• Results: Mean age and prostate volumes of the groups were similar. Mean aggregate stone sizes were significantly larger in the PCCL group. The operative time for stone removal was significantly less in the PCCL group while time needed for TURP was statistically similar in the two groups. In the TUCL group, three patients had residual stones necessitating repeated TUCL and urethral stricture developed in three patients.
• Conclusion: The smaller caliber of the working channel during TUCL, compared with PCCL, necessitates disintegration of the stones into smaller fragments. This elongates the duration of the intervention and results in increased urethral and bladder trauma. Combined TURP and PCCL is a safer, more effective, and much faster alternative to combined TURP and TUCL in patients with large bladder stones and prostate hyperplasia.
  
  
• Editorial Comment
  The study is limited in its retrospective nature, but provides important support for the empiric approach utilized by the authors. It is clear that transurethral approach carries a higher risk of urethral stricture - this may be related to the duration of instrumentation during stone extraction or it may be related to the size and duration of post-operative catheterization. The authors emphasize the importance of stone extraction prior to TURP as bleeding from the prostatic fossa may obscure the identification of residual stone. The authors also emphasize the importance of leaving the Amplatz sheath in place during the TURP as premature removal of this may lead to extraperitoneal extravasation of irrigation fluid. Another advantage of a percutaneous approach not mentioned by the investigators would be the use of an ultrasonic lithotripter through a rigid nephroscope as a more efficient means of stone clearance. Lastly, it is important to note that these recommendations are specific for men - though less common, larger stones in women can be effectively addressed cystoscopically with a rigid nephroscope and ultrasonic lithotripter.

Dr. Manoj Monga
Professor, Department of Urology
University of Minnesota
Edina, Minnesota, USA
E-mail: endourol@yahoo.com