Open Cystolithotomy - Urinary Bladder Stone Removal Surgery

It is a urological procedure used for bladder stone removal. It is typically performed in the case of large or multiple bladder stones whose removal is impossible through an endoscopic procedure. Various other techniques can be used for bladder stone removal, such as:

1. Percutaneous Endoscopic Cystolithotomy 
2. Transurethral Endoscopic Cystolithotomy
3. Chemodissolution 
4. Extracorporeal Shockwave Lithotripsy 

The methods mentioned above may or may not be successful in treating larger stones. Open cystolithotomy is considered the most effective treatment, but it has risks and benefits.

Anatomy and Physiology of the Urinary System

The urinary system filters toxins and waste products from the blood, producing urine as an end product. The working of the urinary system can be explained as follows:

1. The body absorbs nutrients from food to convert them into energy. 
2. After absorbing these nutrients, only waste and toxins remain in the blood and bowel (a tube-shaped organ in the lower part of the digestive system that goes from the stomach to the anus). 
3. The kidney and urinary system help eliminate the liquid waste products (urea) from the blood to maintain the equilibrium of sodium, potassium, and water in the blood.  
4. Urea is removed along with water and other waste products by the urinary system to form urine. 

Kidneys, renal pelvis, ureters, bladder, and urethra form the urinary system. 

1. Once the urine is formed, the ureters carry the urine from the kidney to the bladder. 
2. The walls of the bladder expand to store the urine and contract to empty the urine through the urethra. 
3. When the bladder doesn’t empty, the urine can become concentrated. This concentrated urine crystallises over time and forms a urinary bladder stone. 
4. Conditions, such as prostate gland enlargement that prevent urine flow from the bladder, can cause bladder stones. 

Open cystolithotomy is performed to treat large bladder stones that cannot be removed with conservative management. A conservative approach can include medicines and hydration.

Patients for whom conservative management and minimally invasive techniques, such as percutaneous cystolithotomy (PCCL), are not effective methods of treatment need to undergo open cystolithotomy. The suitable candidates for this procedure are those who have the following:

1. One or multiple large bladder stones that are more than 2 centimetres in size.
2. Hard calculi (stone) that are invulnerable to the endoscopic approach.
3. Abnormal anatomy of the urinary system may not allow safe access to the stone during the endoscopic approach.
4. A medical condition (besides bladder stones) that requires other open procedures, such as prostatectomy or diverticulectomy.

Open cystolithotomy is performed under general anaesthesia. After the operation, the patient spends a few days in the hospital until the advice of the doctor.

1. It steps involve making an incision in the bladder and removing the bladder stone(s). 
2. Before starting the surgery, the surgeon performs a cystoscopy to identify the size and location of the stone. 
3. Cystoscopy is the first procedure performed during the operation. It involves the following steps:
   1. At first, the patient is placed in a supine position.
   2. An anaesthesiologist induces general anaesthetic or spinal anaesthetic so the patient doesn’t feel any pain or discomfort during the procedure. General anaesthesia renders the patient sleepy during the operation, whereas spinal anaesthesia numbs the patient from the waist down.
   3. After the patient is anaesthetised, a telescope is inserted into the bladder through the urethra to get a clear view of the inside. 
   4. For full inspection, the bladder is stretched by filling fluid inside it, improving the visibility of its full lining. 

The operation performed after cystoscopy involves the following steps:

1. Once the bladder is examined, the surgeon makes an incision in the lower abdomen to reach the bladder. 
2. When the bladder is visible, it is opened so the stone can be removed. 
3. After the removal of the stone, the bladder is closed using sutures that dissolve in the body over time and need not be removed. 
4. Finally, a catheter is placed inside the bladder through the urethra to drain the urine from the bladder.

Prior to the open cystolithotomy, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Open Cystolithotomy

If the patient has a bladder stone, the doctor performs a physical exam and orders imaging procedures to check the size and location of the stone. The imaging tests may also help determine how much urine flow is obstructed due to the stone. These tests may include:

1. CT scan 
2. An X-Ray of the abdomen 
3. Renal ultrasound 

The imaging tests help in making a better decision regarding the treatment approach. Based on the test results, the doctor discusses the treatment options that are most suitable for the patient. 

Before the surgery, the patient can expect the following things:

1. The doctor explains the surgical procedure in detail.
2. Fasting may be required six hours before the operation. 
3. The doctor may also prescribe antibiotics to avoid the risk of infection.

On the day of Open Cystolithotomy

Usually, the patient is admitted on the same day of the surgery. He or she can expect the following on the day of his or her surgery:

1. The doctor takes written consent from the patient after discussing all the risks and benefits of the procedure. 
2. The patient is made to change into a hospital gown and taken to the operation room or the Pre Anaesthesia Unit (PAU) to start an IV line in the arm to supply medications and IV fluids. The medications help the patient relax and put him or her in a sleep-like condition.
3. The surgical area is shaved and cleaned using an antiseptic solution. 
4. The healthcare providers monitor the patient’s vitals throughout the surgery. 
5. Once the surgery starts, the family of the patient is informed. 
6. After the surgery, the healthcare providers take the patient to a recovery room. Here the patient is monitored until his or her health condition becomes stable.

It may take up to two weeks to recover from open cystolithotomy. However, the recovery time may also vary depending on the size of the incision and the patient’s health condition. The doctor can provide more accurate information regarding recovery depending on the severity of the patient’s surgery.

The recovery process at the hospital

1. Open cystolithotomy is an inpatient surgery, so the patient has to stay in the hospital for around ten days, depending on his or her recovery.
2. The catheter (inserted during the operation to drain urine from the bladder) remains in place for 7-14 days. How long the catheter stays depends on the size of the incision. 
3. Feeling pain is not uncommon after surgery. The doctor gives medications for effective pain management. 
4. Wound drainage may also occur after 1-2 days. 
5. Once the patient’s condition is stable, he or she is allowed to leave the hospital. The doctor may give specific instructions for recovery at home.

Recovery process/expectation after hospital discharge

The patient should avoid lifting heavy weights until the doctor approves. 

Don’t soak the surgical area in water. Pat dry the stitches after taking a bath.

First follow-up appointment

The patient usually visits the doctor 7-10 days after the surgery. During the visit, the doctor examines the bladder to check if the catheter can be removed. Cystography (an imaging test used to examine the bladder) may also be performed to check if there is any leakage.

Open cystolithotomy is an effective surgical approach for bladder stone removal and has a high success rate. In most cases, it is found to be 100 per cent successful.

Every surgery has some risks and complications along with benefits. Similarly, open cystolithotomy also has certain possible complications. These may include:

1. Pain and burning sensation while passing urine that can also be followed by a small amount of blood (this can last for a few days after the surgery)
2. Post-operative infection 
3. Fever
4. Slow healing of the bladder, requiring the need for a catheter for a longer period 
5. Injury to the urethra during the surgery 
6. Leakage in the bladder 
7. Insertion of a new catheter if the patient is unable to pass urine after the first catheter is removed. 

If the patient develops a fever or experiences intense pain or bleeding while passing urine, he or she must call the doctor immediately.

If a urinary bladder stone is not removed, it can cause severe pain and difficulty passing urine. Untreated bladder stones can get in the way of urine flow, where it exits the bladder into the urethra, which can lead to the risk of repeated urinary tract infections. This can further damage the bladder or the kidneys as well. 

The cost of Open Cystolithotomy ranges from ₹1,30,000 to ₹2,50,000. The cost varies based on the following factors:

1. Type of open cystolithotomy
2. Age of the patient
3. The medical condition of the patient
4. The type of hospital facility availed - individual room or shared