單階段手術：耻骨上前列腺切除術及膀胱切開取石術合併輔助輸尿管鏡碎石術
- 病例報告與文獻回顧

黃品叡¹、吳紘岳¹、周芷伃²、鄭如惠³、蔡蔓綺⁴、李建儀⁵

¹李綜合醫療社團法人大甲李綜合醫院 外科部 泌尿外科

²李綜合醫療社團法人大甲李綜合醫院 護理部

³李綜合醫療社團法人苑裡李綜合醫院 護理部

⁴疾病管制署中區管制中心 檢疫科

⁵臺中榮民總醫院 泌尿醫學部

A One-Stage Procedure of Suprapubic Prostatectomy and Open Vesicolithotomy with Hand-Assisted Ureteroscopic Lithotripsy: A Case Report and Literature Review

Pin-Jui Huang¹, Hung-Yueh Wu¹, Chih-Yu Chou², Ru-Hui Cheng³, Man-Chi Tsai⁴, Jian-Ri Li⁵

¹Division of Urology, Department of Surgery, Dajia Lee Hospital

²Nursing Department, Dajia Lee Hospital

³Nursing Department, Yuanli Lee Hospital

⁴Quarantine Department, Central Regional Center, Centers for Disease Control, Ministry of Health and Welfare

⁵Department of Urology, Taichung Veterans General Hospital

Introduction:

Large prostate size is a major factor that makes urological endoscopic surgery challenging. In some cases, a conversion to a laparotomy or extraperitoneal approach may be necessary. This article presents a case involving large bladder stones and a left ureteral stone in a patient with significant prostate enlargement. Initially, endoscopic management was unsuccessful. However, a one-stage procedure involving suprapubic prostatectomy, open vesicolithotomy, and hand-assisted ureteroscopic lithotripsy was successfully performed in a subsequent operation. Relevant literature on this condition is also reviewed in this article.

Case Presentation:

An 86-year-old male with prostate enlargement and lower urinary tract symptoms had been on alpha-blocker therapy for several years. He developed intermittent dysuria and lower abdominal pain over several weeks, prompting a visit to the urology outpatient department. A plain X-ray of the kidneys, ureters, and bladder (KUB) revealed three large bladder stones (4 cm, 4 cm, and 3 cm). Cystoscopic lithotripsy was scheduled, but intraoperatively, a large trilobular prostate and high bladder neck were observed, preventing the cystoscope from passing through the prostatic urethra despite multiple attempts. Postoperative abdominal CT showed a prostate size exceeding 80 ml and three bladder stones, as previously identified on the KUB film, as well as a small left ureteral stone (0.6 cm).

Initially, a two-stage operation was considered: first open vesicolithotomy and suprapubic prostatectomy, followed by ureteroscopic management due to the high anesthesia risk and prolonged operative time. However, after discussion, a single-stage operation involving hand-assisted ureteroscopy prior to bladder closure was considered feasible. Following careful planning and preparation, open vesicolithotomy and suprapubic prostatectomy were performed using an extraperitoneal approach. Insertion of the ureteroscope was initially challenging, but with guidewire assistance and direct visualization by hand, ureteroscopy and lithotripsy were successfully performed. The ureteral stone fragments were retrieved from the bladder using a basket and direct hand removal. A 6Fr, 26 cm double-J stent was placed in the left ureter via guidewire, and a Fr.22 three-way Foley catheter was placed in the bladder. The bladder wall was closed in layers at the end of the procedure. Total operative time was 143minutes, with a blood loss of approximately 200 ml.

Discussion:

Traditionally, a staged approach has been recommended for cases requiring both open and endoscopic management. However, staged operations may have limitations, including longer operative times, greater blood loss, anatomical changes, persistent symptoms, and a higher infection rate. Additionally, if the patient’s condition worsens after the first procedure, residual disease may remain untreated. In this patient’s case, total operative time was less than two and a half hours, with acceptable blood loss. During surgery, anatomical changes in the angle between the bladder neck and ureteral orifice were observed, which could have complicated ureteroscopy in a staged operation. Fortunately, performing ureteroscopic management before bladder wall closure allowed for direct hand assistance, enabling accurate identification of the ureteral orifice and successful guidewire and ureteroscope insertion.

Conclusion:

For cases involving prostate enlargement, bladder stones, and ureteral stones, an extraperitoneal approach with direct hand-assisted ureteroscopic management may offer a safe and effective treatment option.