Simple Solution to a Difficult Problem: Removal of Large Bladder Calculi Using a Laparoscopic Entrapment Sac

Introduction and Objectives: Percutaneous management of large bladder calculi with the use of a laparoscopic entrapment sac is a minimally invasive procedure that may have advantages over open cystolithotomy and transurethral cystolithotripsy, as well as standard percutaneous cystolithotomy. We first performed this procedure in 2008, and refined it after our initial publication in 2013 by changing the position from lithotomy to supine by using a urethral catheter postoperatively instead of a suprapubic (SP) catheter, by using ultrasound guidance for access, and by changing the procedure from being inpatient to outpatient. Our objective is to assess the continued feasibility of percutaneous entrapment sac cystolithotomy (PESC) and describe modifications that simplify the technique (mPESC), comparing outcomes and complications. Methods: Forty seven male patients underwent PESC from 2008 to 2019, 16 who had PESC and 31 who had mPESC. After extraction of calculi, either an SP catheter was placed, or the wound was closed and a urethral catheter was placed. Operative and follow-up parameters were compared between the two cohorts. Results: All patients were rendered stone free. Procedure time and length of stay were both significantly shorter in the mPESC cohort. Stone burden and estimated blood loss were equivalent between cohorts. There were no complications of urethral trauma in either cohort. The PESC cohort had higher rates of leakage from the SP site (25% vs 0%), increased need for catheter over 5 days (18.8% vs 0%), and greater likelihood of recurrent retention (12.5% vs 6%). Conclusions: Modifications of PESC, mPESC, leads to fewer complications and reduced length of stay compared with the original PESC procedure. This safe and efficacious technique can reduce morbidity during the management of large bladder calculi and is well suited for an outpatient procedure.