A robust 80-year-old male on active surveillance for low-risk adenocarcinoma of the prostate developed painless gross hematuria. He reported minimal to moderate lower urinary tract symptoms with an American Urologic Association symptom score of 10 and a quality of life score of 2.
He does not use any medications for benign prostatic hyperplasia (BPH). His physical exam is unremarkable. His prostate is smooth, without nodules, and is estimated to weigh 40-60 grams. Laboratory evaluation reveals a serum creatinine level of 0.9 mg/dL and PSA of 6.3 ng/mL. A computed tomography urogram is obtained and is shown in the images below. What is the most appropriate step to take next?
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Bladder stones account for approximately 5% of all urolithiasis encountered in the Western world.1 Until the 20th century, treatment of bladder stones was so risky that Hippocrates in his oath specifically advised to leave the procedure to a professional. (“I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners.”) This recommendation may be the first designation of a surgical subspecialty. Today, the vast majority of bladder stones can be removed through transurethral approaches. Mechanical crushing of stones with forceps, holmium-YAG laser pulverization, ultrasonic lithotripsy, pneumatic lithotripsy, electrohydraulic lithotripsy can all accomplish this task via cystoscopic access.
Urologic dogma dictates that nearly all bladder stones stem from bladder outlet obstruction and resulting urinary stasis. Objective evidence reveals that the physiology of bladder stone formation is likely more complex. In one study, only about 50% of patients with bladder stones exhibited evidence of bladder outlet obstruction when undergoing urodynamic testing.1 These data challenge the historical recommendation that every patient with a bladder stone must undergo a concomitant bladder outlet-reducing procedure such as transurethral resection of the prostate, especially given ever-improving efficacy of medical management for BPH. Nevertheless, the most recent AUA guidelines2 continue to recommend bladder outlet reducing surgery for patients with bladder stones, and the debate continues in the literature.3
1. Millan-Rodriguez F, Errando-Smet C, Rousaud-Baron F, Izquierdo-Latorre F, Rousaud-Baron A, Villavicencio-Mavrich H. Urodynamic findings before and after noninvasive management of bladder calculi. BJU Int. 2004 Jun;93(9):1267-70.
2. AUA Clinical Guidelines for Management of BPH. 2010 [cited 02/25/2011].
3. Philippou P, Volanis D, Kariotis I, Serafetinidis E, Delakas D. Prospective Comparative Study of Endoscopic Management of Bladder Lithiasis: Is Prostate Surgery a Necessary Adjunct? Urology. 2011 Feb 4.