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Vesicolithotomy

Randa Halfian
Definition
Incision of the bladder for removal of a
calculus.

(Dorland's Medical Dictionary for


Health Consumers.2007)
Anatomy
Bladder
Composed of 3 layers detrussor muscle
Bladder mucosa: transitional cells
Collect urine 300-450cc
Fully bladder stimulate the micturition
centre (S2-4 ) contraction of detrussor
muscle, opening bladder neck,
relaxation urethral sphincter

(Dasar-dasar Urologi. Edisi 3 2012)


Indication
Stone size > 2,5 cm
Bladder stones that can not be
solved with a lithotriptor
Multiple bladder stone
Not obtained access through the
urethra
(SOP Urologi)
Contraindication
Suspicious of bladder malignancy
Unclear cause of gross hematuria
Bleeding disorder

(Campbell Walsh, 10th ed, 2012)


Preparation

Surgical cap, mask, sterile


gawn, sterile hand gloves

Disinfection clamp, doek clamp Sterile gauze, povidone iodin


10%
Preparation

Electronic cauter
Surgical blade no 23, 11, scalpel
handle

Langenbac
k Kocher
Sharp spreader Suction
Allis clamp
Preparation

Pean/mosquito
Pinset Scissors Metzenbaum Needle holder
clamp

Stone forceps
Spreader
Preparation
Vicryl 1-0

Foley cath + Stappler Redon Drain


urobag

Plain cut gut 3- Vicryl 3-0 Chromic gut 3-


0 0
Procedures
Marking one day before operation
Placement the imaging
Patient in general anesthesia or spinal
block.
Operator in the left patient (right handed).
Patient in supine position.

(Hinmans Atlas of Urologic Surgery,3rd ed)


Reading patients checklist
Desinfects the abdomen, penis, and both
inner thigh with Povidone Iodine 10%
Cover it with sterile drappings.

(Hinmans Atlas of Urologic Surgery,3rd ed)


Procedures
Draw the incision design
Make the incision 2
finger upper symphisis
pubis
Open layer by layer

(Hinmans Atlas of Urologic Surgery,3rd ed)


Procedures

Incise the fascia


transversely .
widened with the
scissors

(Hinmans Atlas of Urologic Surgery,3rd ed)


Procedures
Enter between the
recti and separate
them bluntly.
Hold the muscles
back with two
retractors to expose
the prevesical fat.

(Hinmans Atlas of Urologic


Surgery,3rd ed)
Extraperitoneal fat and
peritoneum overlying
the bladder seen

Reflect the peritoneum


upward with gauze
piece

(Hinmans Atlas of Urologic Surgery,3rd ed


Identify the bladder
Place two 3- 0
chromic catgut
stay sutures into
the bladder wall
well above the
symphysis.

(Hinmans Atlas of Urologic


Surgery,3rd ed)
Procedures

Incise the bladder


vertically between
the sutures with
mesh no 11 .

(Hinmans Atlas of Urologic


Surgery,3rd ed)
Procedures
Enlarge the incision with crown
clamp
Grasp the stone with stone tang
and remove it (evaluate the size,
color, and number of stone).

(Hinmans Atlas of
Urologic Surgery,3rd
ed)
Washout the bladder cavity with normal
saline
Evaluate the bladder wall
(for tumor or diverticle), the ureter ends (for
stones and ureteric jet), and size of bladder
neck. Inspect the base of the bladder for other
stones.
Take specimen for bladder biopsy if the
size of the stone is more than 3 cm.
Evaluate the prostate through the bladder
Procedures
Insert a 16 F urethral catheter then
washout the bladder cavity through
the catheter.
Close the bladder with a running 3-0
plain catgut suture applied to the
muscularis mucosal layer.
Reinforce it with interrupted sutures of
3-0 polyglactin placed through the
seromuscularis.
Fill the bladder with 250 cc of
normal saline through urethral
catheter, evaluate if there is any
leaks within the sutures.
Procedures
Place a small suction drain
(paravesical) to exit
through the wound for a
few days.
Stitch layer by layer
fascia of rectus
abdominis muscle with
polyglactin 1-0
subcutaneous tissue with
plain catgut 3-0
the skin with stepler
Close the wound with tulle
and sterile gauze.

(Hinmans Atlas of Urologic


Surgery,3rd ed)
Complications of Cytostomy

Intraoperativ
Early Postop Late Postop
e
Bleeding Bleeding Peritonitis
Damage to Other
other infections
intraabdomin Fistules
al organs

(Campbell,10th
ed)
Post Surgical Care
Remove the catheter after day 7.
Remove the drain if the production is
minimal (<20 cc/24 hour) after catheter
removal.
Analyze the composing material of the
stone.

(Campbell-walsh, 10th ed)


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