Small stones may be managed conservatively in the hope that they will pass spontaneously.
Where active management is required, endoscopy is the surgical intervention of choice. Small stones may simply be washed out of the bladder via a cystoscope. Larger stones must first be fragmented. Traditionally, this is by litholapaxy. A lithotrite - a modified cystoscope that incorporates stone-crushing jaws - is introduced through the urethra into the bladder. The stone is crushed and the fragments then washed out by irrigation.
ESWL may also be used as, in a full bladder, the stone is easily localised. However, one cannot always be certain that the fragments will pass especially if there is underlying outflow obstruction.
Stones that cannot be fragmented are removed by open surgery. Through a suprapubic incision, the bladder vault is opened and the stone removed directly - cystolithotomy.
Any treatable cause of stone formation e.g. outflow obstruction, or any consequence of it e.g. squamous carcinoma, should be treated as required.
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