List of Abbreviations
UUT – upper urinary tract
BPH – benign prostatic hyperplasia
CI – confidence interval
ESWL – extracorporeal shock wave lithotripsy
UTI – urinary tract infection
CT – computed tomography
mg – milligram
mm – millimeter
mmol – millimole
INR – international normalized ratio
IC – urolithiasis (urolithiasis disease)
ICD-10 – International Classification of Diseases 10th Revision
BL – bladder
НПВС – non-steroidal anti-inflammatory and antirheumatic drugs
РКИ – randomized controlled trial
US – ultrasound examination
TUR – transurethral resection
AUA – American Urological Association
EAU – European Association of Urology
HU – Hounsfield unit
Terms and Definitions
Remote cystolithotripsy (SWL) is a method of extracorporeal shock wave disintegration of bladder stones (code A22.28.010).
Open cystolithotomy is an open surgical method for the removal of bladder stones (code A16.28.024 – cystotomy + code A16.28.017 – removal of bladder stones)
Transurethral contact cystolithotripsy is a method of disintegration and removal of bladder stones via the natural urinary tract (code A16.28.017.001);
Percutaneous cystolithotripsy is a method of percutaneous disintegration and removal of bladder stones (code A16.28.072 (cystostomy) + code A16.28.017 (removal of bladder stones)).
Open urethrolithotomy is an open surgical method for the removal of urethral stones (code A16.28.035 – external urethrotomy + code A16.28.036 – removal of urethral stones).
Contact urethrolithotripsy is a method of disintegration and removal of urethral stones via the natural urinary tract (code A03.28.002 – urethroscopy + code A16.28.036 – removal of urethral stones).
Transurethral cystolithotripsy is a method of disintegration and removal of bladder stones via the natural urinary tract (code A16.28.017.001 – transurethral contact cystolithotripsy).
Bladder drainage is a method of restoring urine outflow from the urinary bladder via the natural urinary tract or percutaneously (codes: A16.28.025 – epicystostomy; A16.28.072 – cystostomy; A11.28.007 – urinary bladder catheterization).
Computed tomography of the kidneys and urinary tract is an imaging method for the urinary tract, including the kidneys, entire ureters, urinary bladder, and urethra, using a computed tomograph:
Non-contrast (native): Computed tomography of the abdominal cavity and retroperitoneum (A06.30.005.001) + Spiral computed tomography of the pelvic organs in women / in men (A06.20.002.001 / A06.21.003.001).
Contrast-enhanced: Computed tomography of the kidneys and upper urinary tract with intravenous bolus contrast administration (A06.28.009.001) + Spiral computed tomography of the pelvic organs in women / in men with intravenous bolus contrast administration (A06.20.002.002 / A06.21.003.002).
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Lower urinary tract stones are a form of urolithiasis characterized by the presence of calculi in the bladder cavity and/or urethra.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The etiology and pathogenesis of lower urinary tract stones are multifactorial, accounting for approximately 5% of urinary system calculi [1]. By etiology, they can be divided into primary, secondary, and migrated stones.
Primary (endemic) stones develop in the absence of concomitant urinary tract pathology, most commonly in children living in regions with dietary animal protein deficiency, low fluid intake, and chronic diarrhea. Bladder stones in children peak in incidence at 3 years of age [2].
Secondary bladder stones form due to urinary tract pathology, such as bladder outlet obstruction, neurogenic dysfunction, bacteriuria, foreign bodies (including catheters), diverticula, or following urinary augmentation or diversion. In adults, the main predisposing factor is bladder outlet obstruction, which accounts for 45 to 79% of bladder stones [1].
Migrated stones are typically calculi under 1 cm that have "descended" from the upper urinary tract and, if unable to pass spontaneously, serve as a "nidus" for further growth in the bladder. Patients with a history of bladder stones more frequently have urolithiasis and associated stone-formation risk factors [3].
Intravesical prostatic protrusion is an independent risk factor for bladder stone formation in patients with BPH undergoing transurethral resection (TURP) [4]. Other risk factors include older age and low Qmax [5].
To date, the metabolic abnormalities underlying secondary bladder stones remain poorly studied. In an analysis of 86 patients with BPH, the frequency of calcium-containing stones (oxalate, phosphate) was 42%, magnesium ammonium phosphate stones 33%, uric acid stones 14%, and mixed-composition stones 10% [1].
Most patients with bladder stones have a reduced diuresis volume due to insufficient fluid intake [6].
Since bladder outlet obstruction is diagnosed less frequently in children than in adults, bladder stones have a different etiology. The main role may be played by abnormalities in the biochemical composition of urine, including hypocitraturia, hyperoxaluria, and hypocalciuria, as well as low urine volume [6].
Urethral stones can be primary, which form in the urethra de novo, or secondary and migrated, entering the urethra from the upper urinary tract or bladder. Urethral stones are most frequently localized in the prostatic urethra, and less commonly in the penile and bulbar urethra. Spontaneous passage of urethral stones may be hindered by any urethral pathology: stricture, meatal stenosis, or benign prostatic hyperplasia [7].
Migrated urethral stones can form both in the bladder [8] and the upper urinary tract [9]. The majority of urethral stones consist of calcium oxalate (85%–90%) [10]. The frequency of bladder and upper urinary tract stones in patients with urethral stones is 2% and 18%, respectively [10].
The etiology of primary urethral stones is most commonly associated with urethral obstruction due to urinary stasis within a urethral diverticulum. The presence of foreign bodies and urinary tract infections provides an optimal environment for stone formation [11]. Infectious stones most frequently involve Escherichia coli, Proteus spp., and Enterococci [12]. In most cases, they are small, round, lack a nucleus, and consist mainly of struvite (magnesium ammonium phosphate), although calcium phosphate and uric acid stones have also been described [13]. The primary cause of primary urethral stone formation is urethral stricture. Another cause is the use of hair-bearing skin flaps and grafts in the treatment of urethral strictures or hypospadias. In these cases, hairs act as nidi for the precipitation of lithogenic salts, resulting in the formation of primary urethral stones [14].
A foreign body can also serve as a nidus for stone formation, such as radioactive seeds after brachytherapy, which can migrate or protrude into the prostatic urethra. Following cryoablation, ischemic necrosis of the prostate develops, which, combined with persistent inflammation, creates conditions for stone formation [15,16].
1.3 Epidemiology of the Disease or Condition
Bladder stones account for about 5% of all urinary tract stones [17]. In developed countries, they account for 8% of urolithiasis-related deaths [18]. Bladder stones are detected more frequently in men than in women, with a ratio ranging from 10:1 to 4:1 [1,19]. The age distribution is bimodal: the first peak occurs in children aged 3 years (in developing countries) [19,20], and the second peak at 60 years of age [1]. Primary bladder stones rarely recur after removal [21].
Bladder stones are detected in 3–4.7% of patients undergoing surgical treatment for BPH [22,23], 19–39% and 36–67% of patients with incomplete and complete spinal cord injury, respectively [24], and 2.2% of patients with an indwelling catheter [25]. The incidence of bladder stone formation following heterotopic intestinal reservoir construction is 0–3% [26,27], orthotopic ileal neobladder construction is 0–34% [27–34], and sigmoid conduit construction is 4–6% [31,35].
The prevalence of urolithiasis in renal transplant recipients reaches 1–1.8% [17,18]. Although kidney stones are diagnosed in the majority of cases, bladder stones are also detected. The risk of their formation is reduced when absorbable sutures are used to create anastomoses [36,37].
Urethral stones account for 0.3–1% of all urolithiasis cases. Obstruction due to a urethral stone is a very rare initial presentation of urolithiasis [38,39]. Over the past few decades, a decrease in the incidence of urethral stones has been observed in developed countries [38,40–42].
Urethral stones are much more common in men than in women, which is attributed to the shorter length of the female urethra and higher voiding velocity in adolescence and young adulthood. The first peak occurs in early childhood, and the second at 30–40 years of age [10,13].
Posterior urethral stones are more common (up to 88% of cases) than anterior urethral stones [8].
1.4 Features of Coding the Disease or Condition
N21.0 – Calculus of bladder
N21.1 – Calculus of urethra
N21.8 – Other lower urinary tract calculi
N21.9 – Calculus of lower urinary tract, unspecified
1.5 Classification of the disease or condition
Stratification of bladder stones can be based on etiology and composition. By etiology, stones are classified as primary, secondary, and migrated (see Appendix A3) [43]. By composition, bladder stones are divided into infectious (magnesium ammonium phosphate in 33% of cases) and non-infectious (calcium oxalate and calcium phosphate – 42%, uric acid – 14%, mixed composition stones – 10%) [1].
By etiology, urethral stones can be divided into primary, which form in the urethra de novo, and secondary or migrated, which enter the urethra from the upper urinary tract or bladder. By localization, they are divided into anterior and posterior urethral stones [10].
1.6 Clinical presentation of the disease or condition
The main symptoms of urinary bladder (UB) stones are pollakiuria, hematuria (typically terminal), dysuria, or suprapubic pain that worsens at the end of urination [44-46]. Sudden movements and exertion can aggravate the symptoms. Acute urinary retention is another possible manifestation [47]. Detrusor overactivity is detected in 2/3 of men with UB stones and is more common with stones >4 cm in size. In some cases, a urinary tract infection (UTI) may be the sole symptom of a stone [44,48]. Additionally, a UB stone can lead to urinary incontinence if it becomes wedged in a narrowed UB neck, preventing the closure of the external sphincter [49].
In children, symptoms may also include penile retraction, dysuria, urinary retention, enuresis, and rectal prolapse (associated with straining due to UB spasms). In 10% of cases, UB stones are asymptomatic and detected incidentally [2,50].
Symptoms of urethral stones depend on the type and location of the stone. In cases of migrated stones, renal colic may develop initially, followed by lower urinary tract symptoms within 1-2 weeks [13]. Acute painful urinary retention due to sudden stone impaction is the most observed presentation. Other symptoms include a weak urinary stream, interrupted urination, gross hematuria, and dysuria. Stones in the posterior urethra typically cause pain in the perineal or rectal region, whereas anterior urethral stones cause pain in the glans penis. In primary urethral stones or urethral diverticulum stones, patients report constant pain during urination, voiding symptoms, chronic pelvic pain, or recurrent UTIs.
Women usually present with pollakiuria and, in rare cases, urinary incontinence [12]. A "string of stones" (stone street) in the urethra has been described in the literature [51].
Physical examination for posterior urethral stones is usually unremarkable, except for mild prostate tenderness, whereas stones located in the bulbous or penile urethra may be palpable as a dense mass along the urethra. In women, palpation reveals a dense mass along the anterior vaginal wall [9,12]. Primary urethral stones have a more protracted clinical course and milder symptoms.
Migrated stones present acutely with a sudden onset of symptoms. When urination is preserved or in the presence of a urethral diverticulum stone, patients present after a significant time interval [12,52,53].
With delayed presentation, stones may reach a large size or lead to the development of a urethrocutaneous or urethrorectal fistula [9]. Fistulous complications are more common in patients with sensory impairments, particularly infants or individuals with spinal cord injuries [9,54].
2. Diagnostics, medical indications and contraindications for diagnostic methods
2.1 Complaints and Anamnesis
Diagnostic criteria: the diagnosis is established based on medical history, patient complaints, laboratory findings, and instrumental examinations. The most reliable criterion for diagnosis is the visualization of calculi via bladder ultrasound and CT.
Complaints in lower urinary tract stones depend on the localization of the calculus. The main complaints in UB stones are pollakiuria, blood in the urine, dysuria, or suprapubic pain that intensifies at the end of urination [44-46]. Sudden movements and exertion may aggravate the symptoms. Acute urinary retention can be another manifestation [47]. Children complain of dysuria, urinary retention, and enuresis. In 10% of cases, UB stones are asymptomatic and found incidentally [2,50]. For urethral stones, acute painful urinary retention upon sudden impaction is the most common presentation. Other symptoms include a weak urinary stream, intermittent urination, gross hematuria, and dysuria. Posterior urethral stones typically cause pain in the perineum or rectum, while anterior urethral stones cause pain in the glans penis. In primary urethral stones or urethral diverticulum stones, patients note constant pain during urination, voiding symptoms, chronic pelvic pain, or recurrent UTIs. Primary urethral stones have a more protracted course and milder symptoms.
It is recommended to take a detailed medical history for the initial diagnosis in adults and children with suspected UB or urethral stones [2,17,44-46].
Urolithiasis (ICD), including episodes of stone passage;
comorbidities, including benign prostatic hyperplasia (BPH);
medication intake that promotes urolithiasis;
history of urinary system surgeries;
inflammatory diseases of the urinary system [1,2,4,9,47].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
2.2 Physical Examination
It is recommended to perform a physical examination of the anterior abdominal wall, perineum, external genitalia, and peripheral nervous system in adults and children with lower urinary tract stones [9,47].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: Physical examination of the external genitalia with assessment of the peripheral nervous system (including digital rectal examination, evaluation of perineal tone and sensation in adults) does not diagnose UB stones, but is essential for identifying conditions that may predispose to their development. Examples include meatal stenosis, an enlarged prostate gland upon digital rectal examination in adults, and scars from prior penile/perineal surgeries. For posterior urethral stones, physical examination is typically unremarkable except for mild prostate tenderness, whereas in bulbous or penile localization, stones may be palpated as a firm mass along the urethra. In women, palpation reveals a firm mass along the anterior vaginal wall [9,12,52,53,55,56].
2.3 Laboratory Diagnostics
It is recommended that adults and children with lower urinary tract stones undergo a complete blood count (CBC) (including white blood cell count, differential leukocyte count, and erythrocyte sedimentation rate (ESR)) and urinalysis to determine the presence and severity of an inflammatory response [57,58].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the results of the aforementioned tests indicate signs of inflammation (leukocyturia, bacteriuria, hematuria, leukocytosis, left shift in the leukocyte formula, elevated ESR) [59].
It is recommended to perform a general routine biochemical blood test (levels of creatinine, uric acid, sodium, and potassium in the blood) in adults and children with urolithiasis to assess renal function and metabolic causes of stone formation [59].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: determination of blood creatinine and potassium levels indicates the presence of renal failure [60].
It is recommended to perform microbiological (culture) urine testing for bacterial pathogens using automated seeding and determining antimicrobial susceptibility in adults and children with lower urinary tract stones to detect bacteriuria prior to elective surgery, for the prevention and selection of effective treatment methods for intra- and postoperative infectious complications [57,61].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform a coagulogram (screening hemostasis test) (activated partial thromboplastin time (APTT), international normalized ratio (INR), and blood fibrinogen level) in adults and children with lower urinary tract stones when planning surgical treatment to assess risks and prevent hemorrhagic complications [57,61].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform a urinary stone mineral composition analysis using a reliable method (X-ray diffraction or infrared spectroscopy) in all urolithiasis patients at initial diagnosis in cases of spontaneous stone passage or after active removal, to determine further diagnostic and therapeutic tactics and select the optimal outpatient metaphylaxis method [57].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.4 Instrumental Diagnostics
2.4.1 Lower urinary tract stones
It is recommended to perform bladder ultrasound or urethral ultrasound in adults and children with suspected lower urinary tract stones to determine the localization and size of the stone [62-64, 110, 111]
LoE 2Level of recommendation confidence for adults – A (Level of evidence – 2).
LoE 5Level of recommendation confidence for children – C (Level of evidence – 5).
Comment: the sensitivity and specificity of bladder ultrasound in detecting stones are 20-83% and 98-100%, respectively [62,63,110,111]. Transrectal ultrasound can detect posterior urethral stones, while penile ultrasound using a linear transducer can diagnose anterior urethral stones [64].
It is recommended to perform a kidney ultrasound in adults and children with lower urinary tract stones in order to rule out upper urinary tract stones [62,67].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
It is recommended to perform a non-contrast CT of the urinary system (computed tomography of the abdominal cavity and retroperitoneal space (A06.30.005.001) + spiral computed tomography of the pelvic organs in women / in men (A06.20.002.001 / A06.21.003.001)) in adults and children with lower urinary tract stones in order to rule out upper urinary tract stones [67]
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comment: Ultrasound and CT allow for the diagnosis of upper urinary tract stones, given their high incidence (up to 18%) [12].
It is recommended to perform urethrocystography (code A06.28.011 – ascending urethrography + code A06.28.007 – cystography) in case of suspected lower urinary tract stones to identify potential urethral stricture, bladder neck sclerosis, or urethral fistula [68].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comment: during urethrocystography (code A06.28.011 – ascending urethrography + code A06.28.007 – cystography), a urethral stone appears as a filling defect. In addition, the method makes it possible to diagnose urethral stricture and fistulas, the presence of which may affect treatment tactics. The method is the basis for diagnosing urethral stones.
It is recommended to perform urine flow rate measurement (uroflowmetry) with determination of residual urine volume (except for children under 3 years of age) in patients with lower urinary tract stones to rule out concomitant diseases of the bladder, prostate gland, and urethra [60,69,109].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
2.5 Other Procedures
It is recommended to rule out their secondary nature (due to BPH, urethral stricture, NDO, and UTI (diagnostics of these conditions are described in the relevant clinical guidelines)) prior to bladder stone removal in adults and children [45,60].
GCR CLE 5Level of recommendation C (level of evidence – 5)
Comment: eliminating the cause of bladder stone formation helps reduce the recurrence rate (see Appendix A3) [45,60].
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
3.1.1 Bladder stones
It is recommended to consider litholytic therapy (described in the clinical guidelines "Urolithiasis") in adult patients with bladder stones consisting of uric acid (except for sodium or ammonium urates), as well as those with contraindications to surgical treatment [104,105].
GCR CLE 5Level of recommendation C (level of evidence – 5)
Comments: Stones consisting of uric acid (except for sodium or ammonium urates) can be dissolved by oral administration of medications. Indirect data on the chemical composition of a stone can be obtained by determining its density during SCT (no more than 600 HU), by radiolucency on a plain abdominal urogram, or by determining the concentration of hydrogen ions (pH measurement) of urine. Stone dissolution is carried out by alkalinizing urine to 6.8–7.2 and is monitored via urine pH measurements at regular intervals three times a day [108]. To correct urine pH, citrate mixtures can be used (potassium bicarbonate + citric acid + sodium citrate; potassium citrate + magnesium citrate + theobromine, and other combinations) until a urine pH of 6.8–7.2 is reached, without exceeding the recommended daily dosage of the drug. Citrate therapy should be prescribed for one month, followed by a follow-up bladder ultrasound to assess the degree of response to therapy. If a reduction in stone volume is confirmed, prolongation of therapy for another two months should be considered, followed by a follow-up bladder ultrasound to assess response, and, if necessary, an extension of therapy for another three months [104,105]. Careful monitoring is required during therapy (see urolithiasis guidelines).
Given the impossibility of determining the chemical composition of a bladder stone and the risks of complications, it is not recommended to perform irrigation chemolysis through a urethral catheter/cystostomy [70,71,106].
GCR CLOE 4Grade of Recommendation C (Level of Evidence – 4
Comments: irrigation chemolysis is time-consuming and can lead to chemical cystitis [70,71,106].
3.1.2 Urethral stones
There are no published studies on the conservative treatment of urethral stones in literature.
3.2 Surgical Treatment
3.2.1 Indications for surgical treatment of bladder stones
An indication for surgical treatment of bladder stones is the absence of spontaneous passage and lack of effect from conservative treatment. Bladder stones <1 cm in size can be observed given the high probability of spontaneous passage. In the absence of spontaneous passage, surgical treatment is indicated. Data on the optimal time interval for switching to active bladder stone removal are not presented in literature.[72]
3.2.2 Surgical treatment of patients with bladder stones
Minimally invasive methods for treating patients with bladder stones have been widely introduced into clinical practice, which help reduce the risk of complications and shorten the duration of hospitalization and recovery. Open, laparoscopic, robot-assisted, endoscopic (transurethral or percutaneous) interventions and extracorporeal shock wave cystolithotripsy can be performed for bladder stones [67].
It is recommended to perform transurethral contact cystolithotripsy (code A16.28.017.001) as the first line of treatment in adults and children with bladder stone(s) [67].
GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)
Comment: Transurethral contact cystolithotripsy has an advantage over open cystolithotomy in terms of operative time, catheterization, and hospitalization with comparable efficacy [67]. In addition, transurethral contact cystolithotripsy has an advantage in terms of hospitalization duration, recovery period, and pain severity compared to percutaneous cystolithotripsy [67].
In children, the duration of hospitalization and catheterization after transurethral contact cystolithotripsy is lower compared to open cystolithotomy. Efficacy and complication rates for both methods are comparable [67]. The efficacy of laser and pneumatic transurethral contact cystolithotripsy is comparable, but pneumatic lithotripsy is accompanied by a higher rate of complications (mild degree) [73-75].
Open cystolithotomy, transurethral contact cystolithotripsy, and percutaneous cystolithotripsy have comparable efficacy rates in children. Extracorporeal shock wave lithotripsy is less effective for treating stones in children [69].
Transurethral contact cystolithotripsy in children has become the modern standard of treatment for stones in the bladder [76] and urethra, with good results achieved in 80% [10]. Holmium laser lithotripsy is preferred over electrohydraulic and pneumatic lithotripsy due to the minimization of concomitant urethral injuries [77,78]. Transurethral contact cystolithotripsy in adults takes less time when using a nephroscope or resectoscope than a cystoscope, with comparable efficacy [79-81]. Mechanical, pneumatic, and laser lithotripsy are equally effective for the endoscopic removal of bladder stones in adults and children [67].
It is recommended to perform percutaneous cystolithotripsy (code A16.28.025 + code A16.28.017) if transurethral access is difficult or impossible, as well as when associated with a high risk of urethral stricture in young children or in a history of spinal cord injury [67,82-84].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: in patients with urethral stricture, the duration of catheterization and surgery, as well as blood loss, were lower for percutaneous cystolithotripsy than for open cystolithotomy [67,82-84].
During percutaneous cystolithotripsy, the duration of hospitalization and catheterization is lower than for open cystolithotomy, but it takes longer and is associated with a higher rate of perioperative complications. Efficacy rates are comparable [67,82,84]. At the same time, percutaneous cystolithotripsy requires longer catheterization and hospitalization compared to transurethral access, despite comparable efficacy [85,86]. The advantage of transurethral access is operative time and a low risk of stricture development [69].
Percutaneous cystolithotripsy in children is effective for bladder stone sizes from 0.7 to 4 cm [84].
It is recommended to perform open, laparoscopic (in adults), robot-assisted (in adults) cystolithotomy (code A16.28.017) or ESWL (extracorporeal shock wave cystolithotripsy) if endoscopic treatment is not feasible [67].
Level of Evidence AGrade of Evidence 2Level of Recommendations A (Grade of Evidence – 2)
Comment: SWL is inferior in efficacy to open or endoscopic interventions in both adults and children [67,87–90]. The efficacy of SWL is affected by residual urine volume, stone composition, and stone size [91]. In children, open cystolithotomy is considered the gold standard for the surgical treatment of bladder stones; however, the method is limited by the invasiveness of the surgery itself, the need for prolonged postoperative catheterization, a long hospital stay, the risk of wound infection, and the need for analgesia [83]. The literature provides no data on the threshold bladder stone size at which endoscopic treatment should not be offered.
It is recommended to perform open cystolithotomy (code A16.28.024 + code A16.28.017) without catheter and drainage placement in children with primary bladder stones in uncomplicated cases (no history of UTI, surgery for bowel anomalies, or bladder dysfunction) [83,92].
Level of Recommendations CLevel of Evidence 3Level of Recommendation C (Level of Evidence – 3)
Comment: tubeless open cystolithotomy (without drain tubes and a catheter, with two-layer closure of the bladder wall) has an advantage over standard cystolithotomy in terms of hospital stay duration, with comparable rates of long-term or intraoperative complications [92].
It is recommended to perform single-stage combined treatment in adult patients with bladder stones and bladder outlet obstruction due to BPH [93–96].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
Comment: Simultaneous removal of bladder stones does not increase the risk of severe complications after surgical treatment of BPH; however, the combined approach carries a higher risk of urinary incontinence and UTI in the early postoperative period [93-96]. No differences are reported in long-term follow-up [95].
3.2.3 Surgical treatment of patients with urethral stones
For urethral stones, observation and watchful waiting are not applicable [10]
It is recommended for stones localized in the posterior urethra to push them back into the bladder for subsequent transurethral contact cystolitholapaxy [72,97].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: SWL and endoscopic fragmentation are more effective when the stone is localized in the urinary bladder. The efficacy of SWL reaches 60% [97], and that of laser lithotripsy reaches 85–90% [10,13]. Some authors suggest using a set of instruments for mini-percutaneous lithotripsy [98] if ureterolitholapaxy is required.
It is recommended to remove navicular fossa stones under anesthesia using forceps. If this manipulation cannot be performed, ventral urethral meatotomy is indicated [10].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: Anterior urethral stones are practically impossible to displace into the urinary bladder. In some cases, the stone can be "milked" out through the meatus, but this can lead to urethral injury [10], so it is permissible only for stones with a smooth surface [77]. The administration of lidocaine gel into the urethra to perform this manipulation has been described [10,99].
It is recommended if it is impossible to displace a urethral stone into the urinary bladder, to perform contact ureterolitholapaxy (code A03.28.002 + code A16.28.036) [77].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: the efficacy of ureterolitholapaxy reaches 85–90% [10,13,53,77].
It is recommended to perform open ureterolithotomy (code A16.28.035 - external urethrotomy + code A16.28.036 – removal of urethral stones) when endoscopic treatment is ineffective [56,77,100].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: endoscopic lithotripsy can be time-consuming and accompanied by mucosal trauma with subsequent stricture development [10]. In addition, for urethral diverticulum stones, excision of the diverticulum with stone removal is indicated. Bladder diverticulectomy can be performed simultaneously with urethroplasty [56,77,100].
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Specific rehabilitation for patients with bladder and urethral stones after surgery is not used due to the lack of efficacy data.
It should be taken into account that after surgical relief of bladder outlet obstruction, the risk of delayed hemorrhage is up to 5% during the first month; therefore, strenuous physical activity should be avoided during this period.
5. Prevention and Dispensary Observation
There are no published studies in the literature comparing various methods of conservative, medical, or surgical treatment in adults or children with bladder stones, nor comparing follow-up regimens. Determining the etiology of bladder stones and their prevention are of paramount importance.
To date, no convincing data on dietary recommendations or medical metaphylaxis of bladder stones in adults have been published. Recommendations for upper urinary tract stones are the optimal option, especially in the case of migrated stones.
If possible, the cause of secondary bladder stones (e.g., bladder outlet obstruction) must be eliminated. The necessity of correcting metabolic factors has not been confirmed. In cases where the cause cannot be eliminated (indwelling catheter, neurogenic bladder dysfunction, post-augmentation or urinary diversion status), the correction of metabolic disorders may help reduce the risk of recurrence.
It is recommended for children with primary (endemic*) bladder stones to prevent recurrence by maintaining adequate fluid intake, a mixed diet with dairy porridges, and additional intake of vitamins A and B. In addition, diarrhea must be corrected. Children over one year of age should additionally consume eggs, meat, and boiled cow's milk [6].
*endemic regions include countries in Africa and Asia
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Contradictory data have been published regarding a potential association between bladder stones and transitional cell carcinoma [101-103], but it remains unknown whether regular cystoscopy is necessary.
5.1 Follow-up care
Corresponds to the general recommendations for urolithiasis (see clinical guidelines "Urolithiasis")
6. Organization of Medical Care
Indications for elective hospitalization:
1) Bladder stones requiring surgical treatment;
2) Urethral stones requiring surgical treatment;
Indications for emergency hospitalization:
1) Acute urinary retention;
2) Uncontrolled pain syndrome;
Indications for patient discharge from the hospital:
1) Restoration of urine outflow from the urinary bladder;
2) Absence of signs of systemic inflammation;
3) Absence of risk of complications.
It is necessary to inform the patient with an indication for surgical removal of bladder and urethral stones in detail about all existing treatment methods and their complications in order to raise awareness and assist in making a decision on the choice of surgical method.
Current clinical practice includes many surgical options for treating patients with lower urinary tract stones, which may have equivalent final efficacy. However, each method differs in complication rates, stone-free time, and degree of invasiveness. In some cases, the choice of treatment method depends on the physician's preferences, leaving the patient unaware of the pros and cons of a particular method, which negatively affects treatment adherence. The working group considers it necessary to inform the patient in detail about all existing methods for removing lower urinary tract stones and their complications.
7. Additional Information
No.
Criteria for Evaluating the Quality of Medical Care
No. | Quality criteria | Performance evaluation |
A physical examination of the anterior abdominal wall, perineum, external genitalia, and peripheral nervous system was performed | Yes/no | |
A microbiological (culture) urine test for bacterial pathogens with antimicrobial susceptibility testing was performed | Yes/no | |
An ultrasound examination of the bladder or urethra was performed in case of suspected lower urinary tract stones in adults and children | Yes/no | |
A renal ultrasound was performed in adults and children with lower urinary tract stones | Yes/no | |
A non-contrast CT of the urinary system was performed (Computed tomography of the abdominal and retroperitoneal organs (A06.30.005.001) + Spiral computed tomography of the pelvic organs in women / in men (A06.20.002.001 / A06.21.003.001)) | Yes/no | |
Uroflowmetry (urine flow rate measurement) with determination of residual urine volume was performed (except for children under 3 years of age) | Yes/no | |
Ascending urethrography was performed in case of suspected lower urinary tract stone (A06.28.011) | Yes/no |
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Appendix A1. Working Group Composition
Head of the Working Group: Alexey G. Martov – MD, Corresponding Member of the Russian Academy of Sciences, Professor, Head of the Department of Urology and Andrology, MBUIANO FSBI SSC FMBC named after A.I. Burnazyan, Senior Researcher, MROC Lomonosov Moscow State University, Head of the Urology Center, Central Clinical Hospital of Civil Aviation, Moscow.
Secretary of the Working Group: Revaz R. Kharchilava – PhD, Director of the Praxi Medica Medical Practice Training Center, Sechenov First Moscow State Medical University (Sechenov University), Moscow.
Members of the Working Group:
Gagik N. Акоpyan – MD, Professor, Institute of Urology and Human Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow;
Nariman K. Gadzhiev – MD, Professor, Department of Hospital Surgery, St. Petersburg State University, Deputy Director for Medical Work (Urology), Pirogov Clinic of High Medical Technologies, St. Petersburg State University, St. Petersburg;
Kozyrev German Vladimirovich – D.Sc. in Medicine, Professor at the Department of Pediatric Surgery and Urology-Andrology named after L.P. Alexandrov, Sechenov First Moscow State Medical University (Sechenov University), Director of the Association of Pediatric Urologists-Andrologists (APUA).;
Malkhasyan Vigen Andreevich – D.Sc. in Medicine, Head of Urology Department No. 67, S.P. Botkin Moscow Multidisciplinary Clinical Research Center; Professor at the Department of Urology, Russian University of Medicine of the Russian Ministry of Health, Moscow.
Prosyannikov Mikhail Yurievich – D.Sc. in Medicine, Head of the Urolithiasis Department, Lopatkin Scientific Research Institute of Urology and Interventional Radiology – branch of the National Medical Research Radiological Center of the Russian Ministry of Health; Professor at the Department of Biomedical Safety, Bauman Moscow State Technical University, Moscow;
Shiranov Kirill Alexandrovich – Ph.D. in Medicine, Urologist, Rostov-on-Don Consultative and Diagnostic Center, Rostov-on-Don, Russia
Conflict of interest: all members of the Working Group have confirmed that there is no financial support or conflict of interest to declare.
Appendix A2. Methodology for Developing Clinical Guidelines
The target audience for these clinical guidelines includes specialists with higher medical education in the following specialties:
Urology
Pediatric Urology-Andrology
Internal Medicine
General Practice (Family Medicine)
Surgery
Anesthesiology and Intensive Care
Table 1 – Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2 – Scale for assessing levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural healing factors (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report or case series, case-control study |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3 – Scale for assessing grades of recommendation (GR) for prevention, diagnosis, treatment, and medical rehabilitation methods, including those based on natural healing factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision – at least once every 3 years, or whenever new information on the management of patients with the given condition becomes available. The decision to update is made by the Russian Ministry of Health based on proposals submitted by professional medical non-profit organizations. The submitted proposals must take into account the results of a comprehensive assessment of drugs and medical devices, as well as the results of clinical approbation.
Appendix A3. Reference Materials
Appendix A3. Etiological classification of bladder stones [EAU Guidelines. Edn. presented at the EAU Annual Congress Paris 2024. ISBN 978-94-92671-23-3.]
Type of bladder stones | Primary | Secondary | Migrated |
Cause/Association | Develop in the absence of concomitant urinary tract pathology, typically in children from regions with dietary animal protein deficiency, low fluid intake, and chronic diarrhea | Infravesical obstruction (BPH, urethral strictures) | Pass spontaneously from the upper urinary tract where they formed, and can act as a "nidus" for further growth in the urinary bladder |
Neurogenic bladder dysfunction | |||
Chronic bacteriuria | |||
Foreign bodies (including catheters) | |||
Bladder diverticula | |||
Bladder augmentation | |||
Urinary diversion |
Appendix B. Physician Action Algorithms
Algorithm for the diagnosis and treatment of patients with bladder stones
1The type of lithotripsy is determined by the surgeon (mechanical, laser, pneumatic, ultrasonic).
2In children with primary bladder stones and no history of infectious complications, surgeries, or bladder dysfunction, it is preferable not to place drains and catheters following open cystolithotomy.
3Urinary stone mineral analysis is performed in all cases of a primary urolithiasis episode, recurrence during medical prophylaxis, early recurrence after invasive treatment and complete stone removal, and late recurrence after a prolonged stone-free period (see clinical guidelines for "urolithiasis").
4To achieve a pH level >6.5, citrate mixtures (potassium bicarbonate + citric acid + sodium citrate; potassium citrate + magnesium citrate + theobromine, and other combinations) must be used with frequent pH monitoring and dose titration.
Appendix C. Patient Information
The urinary bladder has two functions: urine storage and urine elimination. The average voided volume is 150–250 ml. Urine contains a large amount of various salts excreted by the kidneys. When the biochemical composition of urine is altered and there is an excessive concentration of uric acid, calcium, or phosphates, crystals may form. If they do not pass spontaneously during urination, bladder stones are formed. In addition to changes in urine composition, causes of bladder stones include voiding dysfunction (e.g., in men with benign prostatic hyperplasia), infection, foreign bodies in the bladder (mesh for urinary incontinence, sutures from bladder closure during pelvic surgery), and others. Bladder stones account for up to 5% of all urinary tract stones. An even rarer location for stones is the urethra. Causes may include urethral narrowing (stricture), saccular outpouchings of the wall (diverticula), or hair growth if hypospadias surgical repair was performed using a skin flap.
Symptoms
Bladder stones may cause no symptoms until they reach a large size. The main symptoms of stones are frequent urination, blood in the urine (typically at the end of urination), difficulty urinating, or suprapubic pain that worsens at the end of urination. Sudden movements and physical exertion can exacerbate the symptoms. Another manifestation may be acute urinary retention when a stone becomes wedged in the bladder neck.
In children, symptoms may also include penile retraction, dysuria, urinary retention, enuresis, and rectal prolapse (associated with straining due to bladder spasms).
Symptoms of urethral stones depend on the type and location of the stone. With migrated stones, renal colic may develop initially, followed by lower urinary tract symptoms in 1–2 weeks. Acute painful urinary retention due to sudden stone impaction is most common. Other symptoms include a weak urinary stream, interrupted urination, gross hematuria, and difficulty urinating.
Pain from a bladder or urethral stone may radiate to the back or thighs, the glans penis or scrotum (in men), or the perineum in women. The pain may be dull or sharp.
Causes of stone formation:
Changes in urine acidity associated with improper diet or inadequate fluid intake.
Urine "stasis" in the bladder. In the presence of a diverticulum (saccular wall outpouching) and prostate enlargement, a variable amount of urine remains after voiding (residual urine).
Urinary tract infections increase the risk of bladder stone formation.
Gout, in which a large amount of uric acid is excreted in the urine, is also a risk factor.
In some cases, the cause of stone formation is unknown.
Most bladder stones form within its lumen, but a small proportion may form in the kidneys and subsequently pass into the bladder.
Diagnostic methods:
The first-line method when bladder stones are suspected is an ultrasound examination (ultrasound) of the urinary bladder. This method makes it possible to confirm the presence and determine the size of the stone, as well as to evaluate prostate pathology in men and kidney pathology in individuals of both sexes. Another diagnostic method is radiography, which can visualize calcium-containing bladder stones. In some cases, you may be prescribed computed tomography (CT) to rule out kidney pathology. Blood and urine tests are necessary to determine the cause of stone formation and when planning treatment.
Treatment:
Practically all bladder and urethral stones require treatment. A rare exception is small stones that have spontaneously passed from the kidney, if they are visualized in the bladder after renal colic.
Conservative therapy.
Dissolution of bladder and urethral stones has low efficacy and is not recommended.
Surgical treatment.
There are 4 main methods for removing bladder and urethral stones: transurethral, extracorporeal shock wave lithotripsy, percutaneous (for bladder stones), and open surgery. The choice of surgical option depends on the size of the stone and the causes of its formation. Depending on whether the stone is located in the bladder or the urethra, the doctor may recommend various treatment options. In some cases, in addition to stone removal, surgery must be performed to eliminate the etiological factor (e.g., prostatic hyperplasia).
What will happen before the surgery?
You will be admitted to the ward 1–2 days prior to or on the day of surgery. Before this, you need to undergo an outpatient examination and tests. Check with your outpatient physician regarding the scope of examination required prior to hospitalization. If you are taking blood-thinning medications, consult your outpatient doctor on how to discontinue or replace them with other medications. Discuss any past drug allergies with your inpatient doctor. You need to bring all medications you take for concomitant conditions to the hospital.
On the day of surgery, eating food and drinking water is strictly prohibited. If you have diabetes mellitus, check with your attending physician regarding when to take your medications (especially if you use insulins and their analogs).
Extracorporeal shock wave lithotripsy (ESWL).
Extracorporeal shock wave lithotripsy is performed using a device that can break stones using focused shock waves (short high-energy wave pulses) transmitted through the skin. The stone absorbs the energy of the shock waves and breaks into smaller pieces. The stone fragments then pass out with urine. The procedure takes about 30-45 minutes. If you have a large stone, several sessions may be needed to completely break it up.
ESWL is contraindicated in:
− pregnancy;
− risk of severe bleeding;
− presence of uncontrolled infection;
− urinary tract obstruction below the stone;
− very hard stones (e.g., calcium oxalate stones).
Good to know! ESWL breaks the stone into small pieces. These fragments will pass in your urine for several days or weeks after the procedure. You may have blood in your urine, but this should not last more than 2 days. Your doctor may prescribe medications to help pass the fragments faster and reduce pain. ESWL may be accompanied by postoperative complications. During and after the procedure, you may have a urethral catheter inserted.
Postoperative complications may include:
− accumulation of stone fragments in the urinary bladder, causing acute urinary retention;
− blood in the urine.
You must return to the hospital immediately if:
− you develop a fever above 38°C;
− there is significant blood in the urine or passage of blood clots.
− You are unable to urinate independently
Transurethral contact cystolithotripsy / ureterolithotripsy.
Transurethral contact cystolithotripsy is the preferred treatment method for bladder and urethral stones. The procedure is usually performed under general anesthesia. During this procedure, a cystoscope (a long, thin instrument) is inserted through the urethra into the urinary bladder. Once the stone is found, it can be fragmented using a laser device or pneumatic lithotrite to break the stone into smaller pieces before they are washed out or removed with forceps. After stone removal, a catheter may be placed in the bladder to drain urine. It is usually removed in 1-2 days.
Urethral stones located near the external urethral meatus can sometimes be removed using forceps. Stones located close to the bladder can in some cases be pushed back into the bladder using an endoscope and cystolithotripsy can be performed using the technique described above.
Good to know! Transurethral contact cystolithotripsy may be accompanied by both intra- and postoperative complications, which in rare cases may require conversion to open surgery or reoperation.
The following may occur during surgery:
− injury to the bladder wall (up to 1%);
− bleeding that may require conversion to open surgery (0.1%);
Postoperative complications may include:
− fever (up to 0.5%);
− persistent blood in the urine (up to 10%)
− narrowing of the urethra (stricture) 0.5%;
You must return to the hospital immediately if:
− body temperature above 38 °C;
− inability to urinate;
− a large amount of blood in the urine.
Percutaneous cystolithotripsy.
Percutaneous cystolithotripsy is used for large bladder stones or when access via the urethra is not possible (e.g., in case of a stricture). The surgery is usually performed under general anesthesia. During this procedure, a small tube called a catheter is placed in the bladder to fill it. Next, a puncture of the bladder is performed in the suprapubic region, and a plastic tube (sheath) is inserted, through which an endoscope is introduced into the bladder. After visualizing the stone, some stones can be removed using forceps. Larger stones must be fragmented using a special pneumatic, ultrasonic, or laser device—cystolithotripsy. After removing the stone fragments from the bladder, a drainage tube is placed through the working channel used for the surgery to drain the bladder through the anterior abdominal wall (suprapubic cystostomy tube). These tubes are removed a few days after surgery.
Good to know! Percutaneous cystolithotripsy may be accompanied by both intra- and postoperative complications.
The following may occur during surgery:
− injury to the bladder wall (up to 3%);
− bleeding that may require conversion to open surgery (0.1%);
− fluid extravasation into the perivesical tissue (5%)
Postoperative complications may include:
− fever (up to 5%);
− persistent blood in the urine (up to 5%);
− urine leakage from the suprapubic fistula after removal of the cystostomy tube (5%).
You must return to the hospital immediately if:
− body temperature above 38 °C;
− inability to urinate;
− a large amount of blood in the urine.
Cystolithotomy and ureterolithotomy.
Cystolithotomy is used for large bladder stones or when endoscopic equipment is unavailable. The surgery is usually performed under spinal anesthesia. During this procedure, a small tube called a catheter is placed in the bladder to fill it. Next, an incision about 5-10 cm long is made in the suprapubic region, through which layer-by-layer access to the bladder is achieved. The bladder wall is opened, the stone is removed, after which a tube draining the bladder through the anterior abdominal wall is placed (cystostomy tube), and the anterior abdominal wall is closed in layers. In some cases, a cystostomy tube is not placed. These tubes are removed a few days after surgery, and skin sutures are removed in 7-10 days.
Good to know! Cystolithotomy may be accompanied by both intra- and postoperative complications.
The following may occur during surgery:
− bleeding that may require blood transfusion (0.1%);
− fluid extravasation into the perivesical tissue (5%)
Postoperative complications may include:
− fever (up to 5%);
− persistent blood in the urine (up to 5%);
− urine leakage from the suprapubic fistula after removal of the cystostomy tube (5%).
You must return to the hospital immediately if:
− body temperature above 38 °C;
− inability to urinate;
− a large amount of blood in the urine.
What are the benefits of the surgery?
Removal of a bladder or urethral stone will relieve you of pain and burning during urination, blood in the urine, and will improve your urinary function.
How long does the surgery take?
This depends on the size and hardness of the stone, and the surgical approach. On average, the surgery takes from 20 minutes to 1.5-2 hours.
Will you have drains after surgery?
Before the surgery, an intravenous catheter will be placed, which is removed the next day if you drink enough fluids. You will also have a urethral catheter placed to drain urine from the bladder into a collection bag. It is removed within 1 to 7 days depending on the type of surgery. If your stone was removed via an open or percutaneous approach, a suprapubic cystostomy tube coming out of the bladder through the abdomen may be placed to divert urine. There may be blood in the urine for up to 7 days.
How long will you stay in the hospital?
The length of hospital stay depends on the method of lower urinary tract stone removal. With endoscopic treatment, it usually does not exceed 2-3 days. If you underwent simultaneous removal of prostate adenoma or open surgery, you may spend about 5-7 days in the hospital.
Discharge information.
After surgery, you may experience burning during urination for 2-3 days.
Fever and the appearance of an unpleasant odor or cloudy urine with flakes indicate the development of inflammation. You need to consult a doctor for an evaluation. In such cases, systemic antibacterial medications are usually prescribed.
Blood may appear in the urine. If the intensity of the urine discoloration does not increase and no clots are passed, this may be related to the early postoperative period. Blood in the urine usually resolves within 4-7 days. You need to drink more fluids, observe bed rest, and avoid physical exertion.
A special diet is not required after surgery. You need to consume at least 2 liters of water evenly throughout the day.
It is not recommended to drive or return to work for at least 2-3 days after surgery, even if you feel well.
It is recommended to avoid sexual activity for 1 week after surgery.
General advice:
− drink 2 to 2.5 liters of water evenly throughout the day;
− choose pH-neutral beverages, such as water;
− monitor your urine output (should be about 2 liters per day);
− monitor the color of your urine: it should be light.
− drink even more if you live in a hot climate or exercise;
− eat a balanced and varied diet;
− avoid excessive intake of vitamin supplements.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable.