Cystoscopy and crushing of a bladder stone (litholapaxy)

This publication includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence-based sources. It is, therefore, a reflection of best urological practice in the UK. It is intended to supplement any advice you may already have been given by your GP or other healthcare professionals. Alternative treatments are outlined below and can be discussed in more detail with your Urologist or Specialist Nurse.

This procedure involves crushing or disintegration of bladder stone(s) using telescopic instruments or laser and removal of the stone fragments using suction apparatus.

Open surgery, observation.

You will usually be admitted on the same day as your surgery. You will normally receive an appointment for pre-assessment to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the Consultant, Specialist Registrar, House Officer and your named nurse.

You will be asked not to eat or drink for 6 hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Please be sure to inform your surgeon in advance of your surgery if you have any of the following:

• an artificial heart valve or a coronary artery stent
• a heart pacemaker or defibrillator.
• an artificial joint.
• an artificial blood vessel graft.
• a neurosurgical shunt.
• any other implanted foreign body.
• a regular prescription for Warfarin, Aspirin or Clopidogrel (Plavix®).
• a previous or current MRSA infection.
• a high risk of variant-CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human-derived growth hormone).

At some stage during the admission process, you will be asked to sign the second part of the consent form giving permission for your operation to take place, showing you understand what is to be done and confirming that you wish to proceed. Make sure that you are given the opportunity to discuss any concerns and to ask any questions you may still have before signing the form.

Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you.

You will usually be given injectable antibiotics before the procedure, after checking for any allergies.

A special telescope is inserted into the bladder to see the stones. These are then broken up using a crushing instrument, a mechanical disintegration probe or a laser. The stone fragments are removed from the bladder and a catheter inserted.

In general terms, you should expect to be told how the procedure went and you should:

• Ask if what was planned to be done was achieved.
• let the medical staff know if you are in any discomfort.
• ask what you can and cannot do.
• feel free to ask any questions or discuss any concerns with the ward staff and members of the surgical team.
• ensure that you are clear about what has been done and what is the next move.

The catheter will be removed within 24-48 hours following which you will be able to pass urine normally. Some burning, frequency of urination and bleeding are common within the first 24-48 hours after catheter removal.

It is not unusual for a plain X-ray of your abdomen to be performed on the day after surgery to confirm that all the stone fragments have been removed.

Most procedures have a potential for side-effects. You should be reassured that, although all these complications are well-recognised, the majority of patients do not suffer any problems after a urological procedure.

Common (greater than 1 in 10)

• Mild burning or bleeding on passing urine for short period after operation.
• Temporary insertion of a catheter.
• Need for an additional procedure (e.g. resection of the prostate gland) if this is thought to be the cause of the stone formation.

Occasional (between 1 in 10 and 1 in 50)

• Infection of bladder requiring antibiotics.
• Permission for telescopic removal/ biopsy of bladder abnormality/ stone if found.
• Recurrence of stones or residual stone fragments.

Rare (less than 1 in 50)

• Delayed bleeding requiring removal of clots or further surgery.
• Injury to the urethra causing delayed scar formation.
• Very rarely, perforation of the bladder requiring a temporary urinary catheter or return to theatre for open surgical repair.

Hospital-acquired infection

• Colonisation with MRSA (0.9% - 1 in 110).
• Clostridium difficile bowel infection (0.2% - 1 in 500).
• MRSA bloodstream infection (0.08% - 1 in 1250).

The rates for hospital-acquired infection may be greater in high-risk patients e.g. with long-term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions.