Manejo exitoso de síndrome de vejiga hiperactiva refractaria con toxina botulínica A / Successful management of refractory overactive bladder syndrome with botulinum toxin A

Introducción: El síndrome de vejiga hiperactiva (VHA) afecta hasta al 43% de las mujeres. La terapia escalonada incluye cambios de hábitos, fármacos y neuromodulación. Hasta el 40% de las pacientes llegan a requerir terapia avanzada alternativa, como toxina botulínica (TB). Objetivo: Reportar los resultados del tratamiento con toxina botulínica en mujeres con VHA refractaria a tratamiento de primera y segunda línea, en un hospital público en Chile. Método: Estudio de cohorte retrospectivo desde una base de datos recolectada prospectivamente del Hospital Sótero del Río entre 2018 y 2022. Se incluyeron 33 pacientes con tratamiento farmacológico y neuromodulación previa, con una edad promedio de 57 años, sometidas a inyección cistoscópica de TB a detrusor, analizando datos demográficos, antecedentes y complicaciones. Se realizó seguimiento con frecuencia miccional, paños/día, escala de gravedad de Sandvik (ISI) y encuesta Patient Global Impression Improvement (PGI-I). Resultados: Los datos comparativos pre/post TB, respectivamente, fueron: frecuencia miccional diurna 11/6 y nocturna 5/1; paños/día 5/3; ISI 8/3. Veinte de 33 mujeres refirieron estar excelente o mucho mejor (PGI-I). Conclusiones: Es posible realizar manejo con TB en mujeres con VHA refractaria a primera y segunda línea, con buenos resultados e impacto significativo en la calidad de vida.

Introduction: Overactive bladder syndrome (OABS) affects up to 43% of women. Staggered therapy includes habit changes, drugs, and peripheral neuromodulation. Up to 40% of patients may require advanced alternative therapy such as botulinum toxin A (BT). Objective: To report the results of treatment with TB in women with OABS refractory to first- and second-line treatment in a public hospital in Chile. Method: Retrospective cohort study from prospectively collected database from Hospital Sótero del Río between 2018 and 2022. Thirty-three patients with previous pharmacological treatment and neuromodulation were included, with an average age of 57 years, undergoing cystoscopic injection of TB to detrusor. Demographic data, history, and complications were analyzed. Follow-up was performed with voiding frequency, cloths/day, Sandvik Severity Scale (ISI) and Patient Global Impression Improvement (PGI-I) survey. Results: Comparative data pre/post TB, respectively showed: daytime voiding frequency 11/6 and nighttime 5/1; cloths/day 5/3; ISI 8/3. 20 of 33 women reported being excellent or much better (PGI-I). Conclusions: TB management in women with OABS refractory to first- and second-line treatment has good results and significant impact on quality of life.

Absceso recurrente de la glándula de Skene en paciente joven: reporte de caso / Recurrent abscess of Skene's gland in a young patient: case report

Las glándulas de Skene se encuentran localizadas en la región lateral de la uretra distal, por lo general son asintomáticas sin embargo en ciertas ocasiones pueden obstruirse creando acumulación de líquido en su interior, el cual provoca síntomas, abscesos o quistes que pueden ser tratados con tratamiento médico o quirúrgico. En este caso se presenta una mujer que consulta en múltiples ocasiones por salida de secreción purulenta de la glándula de skene, ya tratada con esquemas antibióticos en 3 ocasiones, sin embargo al persistir con recurrencia de absceso a pesar de antibioterapia se realiza abordaje quirúrgico para resección de la misma (AU)

Skene's glands are located in the lateral region of the distal urethra, are usually asymptomatic however on certain occasions they can become clogged creating accumulation of fluid inside, which causes symptoms, abscesses or cysts They can be treated with medical or surgical treatment. In this case, a woman is presented who consults in multiple sometimes due to discharge of purulent secretion from the skene's gland, she already treated with antibiotic regimens on 3 occasions, however When abscess recurrence persists despite antibiotic therapy, performs surgical approach for its resection

Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report / Sepse aguda pós-operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso

Abstract Background: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. Objective: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. Case report: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. Conclusions: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Resumo Justificativa: A sepse é uma disfunção orgânica fatal com características clínicas inespecíficas que podem imitar outras condições clínicas com quadro hipermetabólico, como a hipertermia maligna. Os cenários são extremamente desafiadores para a anestesia perioperatória e requerem intervenção urgente. Objetivo: Ilustrar a necessidade de intervenção e consulta precoces para uma assistência adicional na abordagem e exclusão de hipertermia maligna e outras possíveis causas durante tal cenário. Relato de caso: Paciente do sexo masculino, 63 anos, submetido à cistoscopia eletiva com cistoscópio flexível e biópsia transretal da próstata guiada por ultrassom sem intercorrências. No pós-operatório, o paciente desenvolveu sintomas que levantaram a suspeita de hipertermia maligna. O protocolo de hipertermia maligna foi imediatamente iniciado, inclusive a administração de dantrolene e uma consulta pela linha direta da associação de hipertermia maligna, juntamente com outros diagnósticos e manejos intervencionistas com vistas ao aprimoramento do paciente. Enquanto a administração precoce de dantrolene ajudou na estabilização hemodinâmica do paciente, a consulta com outros anestesistas e com a Associação de Hipertermia Maligna, juntamente com repetidos exames físicos e laboratoriais, ajudou a excluir a hipertermia maligna como o possível diagnóstico. O paciente recuperou-se mais tarde na unidade de terapia intensiva, onde recebeu tratamento para a bacteremia detectada em suas hemoculturas. Conclusões: A sepse compartilha sintomas clínicos que mimetizam a hipertermia maligna. Enquanto a sepse progride rapidamente para lesões secundárias, a hipertermia maligna é uma ameaça à vida. Proporcionar o tratamento ideal requer um bom julgamento clínico e um alto nível de suspeita quanto aos cuidados oportunos e apropriados, como a administração precoce de dantrolene e a consulta pela linha direta da Associação de Hipertermia Maligna para assistência adicional, que podem resultar em desfechos positivos.

Non-functional paraganglioma of urinary bladder managed by transurethral resection

ABSTRACT Purpose As a rare bladder tumor, paraganglioma of the urinary bladder (PUB) is frequently misdiagnosed as bladder cancer, particularly for the non-functional type. To date, transurethral resection remains a controversial treatment for non-functional PUB. This study aimed to identify the clinical features, pathological characteristics, prognosis, and safe/effective treatment of non-functional PUB using transurethral resection of the bladder tumor (TURBT). Materials and Methods The clinical records, radiological data, pathological characteristics and follow-up times were retrospectively reviewed in 10 patients with clinically and pathologically proven non-functional PUB in our hospital from January 2008 to November 2016. All patients underwent TURBT treatment. Results The incidence of non-functional PUB in patients with bladder cancer was 0.17%. The mean age at diagnosis was 44.5 ± 13.6 years (range, 29-70 years), and the patient population had a female: male ratio of 3: 2. No patients had excess catecholamine (CA) whilst four patients had painless hematuria. All neoplasms were completely resected via TURBT. The majority of samples were positive for immunohistochemical markers including chromogranin A (CgA) and Synaptophysin (Syn), but were negative for cytokeratins (CKs). Only a single recurrence was observed from the mean follow-up period of 36.4 ± 24.8 months. Conclusion Complete TURBT is a safe and efficient treatment that serves both diagnostic and therapeutic purposes. Histopathological and immunohistochemistry examinations are mandatory for diagnostic confirmation. Long-term follow-up is recommended for patients with non-functional PUB.

Removal of intramural trapped intrauterine device by cystoscopic incision of bladder wall

ABSTRACT A healthy 37 - year - old woman referred to our clinic with one - year history of recurrent urinary tract infection, dysuria and frequency. Her past medical history informed us that an IUD (Copper TCu380A) had been inserted 11 years ago. Eleven months after the IUD insertion she had become pregnant, unexpectedly. At that time, she had undergone gynecological examination and abdominal ultrasound study. However, the IUD had not been found, and the gynecologist had made the diagnosis of spontaneous fall out of the IUD. She had experienced normal pregnancy and caesarian section with no complications. On physical examination, pelvic examination was normal and no other abnormalities were noted. Urinalysis revealed microhematuria and pyuria. Urine culture was positive for Escherichia coli. Ultrasound study revealed a calculus of about 10 mm in the bladder with a hyperdense lesion. A plain abdominal radiograph was requested which showed a metallic foreign body in the pelvis. We failed to remove the IUD by cystoscopic forceps because it had strongly invaded into the uterine and bladder wall. Despite previous papers suggesting open or laparoscopic surgeries in this situation (1, 2), we performed a modified cystoscopic extraction technique. We made a superficial cut in the bladder mucosa and muscle with J - hook monopolar electrocautery and extracted it completely with gentle traction. This technique can decrease the indication of open or laparoscopic surgery for extraction of intravesical IUDs. In the other side of the coin, this technique may increase the risk of uterovesical fistula. Therefore, the depth of incision is important and the surgeon should cut the bladder wall superficially with caution. Although present study is a case report which is normally classified as with low level of evidence, it seems that our modified cystoscopic extraction technique is a safe and useful method for extraction of partially intravesical IUDs.

Cystoscopy-assisted laparoscopy for bladder endometriosis: modified light-to-light technique for bladder preservation

ABSTRACT Introduction Endometriosis is a disease with causes still unclear, affecting approximately 15% of women of reproductive age, and in 1%-2% of whom it may involve the urinary tract. The bladder is the organ most frequently affected by endometriosis, observed around 85% of the cases. In such cases, the most effective treatment is partial cystectomy, especially via videolaparoscopy. Study Objective, Design, Size and Duration In order to identify and delimit the extent of the intravesical endometriosis lesion, to determine the resection limits, as well as to perform an optimal reconstruction of the organ aiming for its maximum preservation, we performed a cystoscopy simultaneously with the surgery, employing a modified light-to-light technique in 25 consecutive patients, from September 2006 to May 2012. Setting Study performed at Campinas Medical Center – Campinas – Sao Paulo – Brazil.Participants/materials, setting and methods: Patients aged 27 to 47 (average age: 33.4 years) with deep endometriosis with total bladder involvement were selected for the study. The technique used was conventional laparoscopy with a transvaginal uterine manipulator and simultaneous cystoscopy (the light-to-light technique). A partial videolaparoscopic cystectomy was performed with cystoscopy-assisted vesical reconstruction throughout the entire surgical time. The lesions had an average size of 2.75cm (ranging from 1.5 to 5.5cm). The average surgical time was 137.7 minutes, ranging from 110 to 180 minutes. Main Results Postoperative follow-up time was 32.4 months (12-78 months), with clinical evaluation and a control cystoscopy performed every six months. No relapse was observed during the follow-up period. Conclusions A cystoscopy-assisted partial laparoscopic cystectomy with a modified light-to-light technique is a method that provides adequate identification of the lesion limits, intra or extravesically. It also allows a safe reconstruction of the organ aiming for its maximum preservation.

Female sexual function following a novel transobturator sling procedure without paraurethral dissection (modified-TOT)

ABSTRACT Purpose To determine whether there is a difference in sexual function after modified and classical TOT procedures. Materials and Methods Of the 80 sexually active women with SUI, 36 underwent an original outside-in TOT as described by Delorme, and 44 underwent modified TOT procedure, between 2011 and 2015. The severity of incontinence and sexual function were evaluated using International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and Female Sexual Function Index (FSFI) questionnaires preoperatively and 3 months after surgery. Results The postoperative ICIQ-SF score was significantly lower than the preoperative ICIQ-SF score in both groups (p=0.004 for modified TOT and p=0.002 for classical TOT). There was no significant difference in the ICIQ-SF score reduction between the two groups (14.1±2.1 vs. 14.4±1.9; p=0.892). Complication rates according to the Clavien-Dindo classification were also similar in both groups. In both groups, difference between preoperative and postoperative FSFI scores revealed a statistically significant improvement in all domains. Comparison of postoperative 3-month FSFI scores of modified and classical TOT groups showed statistically significant differences in arousal, lubrication and orgasm domains. Desire, satisfaction, pain and total FSFI scores did not differ significantly between two groups. Conclusion The modified TOT technique is a simple, reliable and minimal invasive procedure. The cure rate of incontinence and complication rates are the same as those of the classical TOT technique. However, due to the positive effects of minimal tissue damage on sexual arousal and orgasmic function, modified TOT has an advantage over the classical TOT.

Intraoperative breakage of Sachse's knife blade: A rare complication of optical internal urethrotomy (one case managing experience)

ABSTRACT Optical internal urethrotomy (OIU) is the most common procedure performed for short segment bulbar urethral stricture worldwide. This procedure most commonly performed using Sachse’s cold knife. Various perioperative complications of internal urethrotomy have been described in literature including bleeding, urinary tract infection, extravasation of fluid, incontinence, impotence, and recurrence of stricture. Here we report a unique complication of breakage of Sachse knife blade intraoperatively and its endoscopic management.

Urothelial neoplasm of the bladder in childhood and adolescence: a rare disease

ABSTRACT Purpose: Bladder tumors are rare in children and adolescents. For this reason, the diagnosis is sometimes delayed in pediatric patients. We aimed to describe the diagnosis, treatment, and follow-up methods of bladder urothelial neoplasms in children and adolescents. Materials and Methods: We carried out a retrospective multicenter study involving patients who were treated between 2008 and 2014. Eleven patients aged younger than 18 years were enrolled in the study. In all the patients, a bladder tumor was diagnosed using ultrasonography and was treated through transurethral resection of the bladder (TURBT). Results: Nine of the 11 patients (82%) were admitted with gross hematuria. The average delay in diagnosis was 3 months (range, 0–16 months) until the ultrasonographic diagnosis was performed from the first episodes of macroscopic hematuria. A single exophytic tumor (1–4cm) was present in each patient. The pathology of all patients was reported as superficial urothelial neoplasm: two with papilloma, one with papillary urothelial neoplasm of low malignant potential (PUNLMP), four with low grade pTa, and four with low grade pT1. No recurrence was observed during regular cystoscopic and ultrasonographic follow-up. Conclusions: Regardless of the presence of hematuria, bladder tumors in children are usually not considered because urothelial carcinoma in this population is extremely rare, which causes a delay in diagnosis. Fortunately, the disease has a good prognosis and recurrences are infrequent. Cystoscopy may be unnecessary in the follow-up of children with bladder tumors. We believe that ultrasonography is sufficient in follow-up.

Bipolar plasma vaporization using plasma-cutting and plasma-loop electrodes versus cold-knife transurethral incision for the treatment of posterior urethral stricture: a prospective, randomized study

OBJECTIVE: Evaluate the efficiency and safety of bipolar plasma vaporization using plasma-cutting and plasma-loop electrodes for the treatment of posterior urethral stricture. Compare the outcomes following bipolar plasma vaporization with conventional cold-knife urethrotomy. METHODS: A randomized trial was performed to compare patient outcomes from the bipolar and cold-knife groups. All patients were assessed at 6 and 12 months postoperatively via urethrography and uroflowmetry. At the end of the first postoperative year, ureteroscopy was performed to evaluate the efficacy of the procedure. The mean follow-up time was 13.9 months (range: 12 to 21 months). If re-stenosis was not identified by both urethrography and ureteroscopy, the procedure was considered “successful”. RESULTS: Fifty-three male patients with posterior urethral strictures were selected and randomly divided into two groups: bipolar group (n=27) or cold-knife group (n=26). Patients in the bipolar group experienced a shorter operative time compared to the cold-knife group (23.45±7.64 hours vs 33.45±5.45 hours, respectively). The 12-month postoperative Qmax was faster in the bipolar group than in the cold-knife group (15.54±2.78 ml/sec vs 18.25±2.12 ml/sec, respectively). In the bipolar group, the recurrence-free rate was 81.5% at a mean follow-up time of 13.9 months. In the cold-knife group, the recurrence-free rate was 53.8%. CONCLUSIONS: The application of bipolar plasma-cutting and plasma-loop electrodes for the management of urethral stricture disease is a safe and reliable method that minimizes the morbidity of urethral stricture resection. The advantages include a lower recurrence rate and shorter operative time compared to the cold-knife technique.

Forgotten and fragmented ureteral j stent with stone formation: combined endoscopic management

Objective : Ureteral stents are widely used in endo-urological procedures. However, ureteral stents can be forgotten and cause serious complications, including fragmentation, migration and urosepsis.

There are few reports about forgotten and fragmented ureteral stents with stone formation. We aimed to present this rare case with successful combined endo-urological management.

Efficacy of Antibiotic Prophylaxis in Cystoscopy to Prevent Urinary Tract Infection: a Systematic Review and Meta-Analysis

To estimate the efficacy of antibiotic prophylaxis to prevent urinary tract infection in patients (both gender) who undergo a cystoscopy with sterile urine.

Ventral inlay buccal mucosal graft urethroplasty: A novel surgical technique for the management of urethral stricture disease

To describe the novel technique of ventral inlay substitution urethroplasty for the management of male anterior urethral stricture disease. A 58-year-old gentleman with multifocal bulbar stricture disease measuring 7 cm in length was treated using a ventral inlay substitution urethroplasty. A dorsal urethrotomy was created, and the ventral urethral plated was incised. The edges of the urethral plate were mobilized without violation of the ventral corpus spongiosum. A buccal mucosa graft was harvested and affixed as a ventral inlay to augment the caliber of the urethra. The dorsal urethrotomy was closed over a foley catheter. No intraoperative or postoperative complications occurred. Postoperative imaging demonstrated a widely patent urethra. After three years of follow-up, the patient continues to do well with no voiding complaints and low postvoid residuals. Ventral inlay substitution urethroplasty appears to be a safe and feasible technique for the management of bulbar urethral strictures.

Transurethral resection of fibrotic scar tissue combined with temporary urethral stent placement for patients with in anterior urethral stricture

Introduction Fibrotic scar formation is a main cause of recurrent urethral stricture after initial management with direct vision internal urethrotomy (DVIU). In the present study, we devised a new technique of combined the transurethral resection of fibrotic scar tissue and temporary urethral stenting, using a thermo-expandable urethral stent (MemokathTM 044TW) in patients with anterior urethral stricture. Materials and Methods As a first step, multiple incisions were made around stricture site with cold-cutting knife and Collins knife electrode to release a stricture band. Fibrotic tissue was then resected with a 13Fr pediatric resectoscope before deployment of a MemokathTM 044TW stent (40 – 60mm) on a pre-mounted sheath using 0° cystoscopy. Stents were removed within 12 months after initial placement. Results We performed this technique on 11 consecutive patients with initial (n = 4) and recurrent (n = 7) anterior urethral stricture (April 2009 – February 2013). At 18.9 months of mean follow-up (12-34 months), mean Qmax (7.8±3.9ml/sec vs 16.8 ± 4.8ml/sec, p < 0.001), IPSS (20.7 vs 12.5, p = 0.001 ), and QoL score (4.7 vs 2.2, p < 0.001) were significantly improved. There were no significant procedure-related complications except two cases of tissue ingrowth at the edge of stent, which were amenable by transurethral resection. In 7 patients, an average 1.4 times (1-5 times) of palliative urethral dilatation was carried out and no patients underwent open surgical urethroplasty during the follow-up period. Conclusion Combined transurethral resection and temporary urethral stenting is a effective therapeutic option for anterior urethral stricture. Further investigations to determine the long-term effects, and safety profile of this new technique are warranted. .

Lipiodol as a Fiducial Marker for Image-Guided Radiation Therapy for Bladder Cancer

Purpose To evaluate Lipiodol as a liquid, radio-opaque fiducial marker for image-guided radiation therapy (IGRT) for bladder cancer.Materials and Methods Between 2011 and 2012, 5 clinical T2a-T3b N0 M0 stage II-III bladder cancer patients were treated with maximal transurethral resection of a bladder tumor (TURBT) and image-guided radiation therapy (IGRT) to 64.8 Gy in 36 fractions ± concurrent weekly cisplatin-based or gemcitabine chemotherapy. Ten to 15mL Lipiodol, using 0.5mL per injection, was injected into bladder submucosa circumferentially around the entire periphery of the tumor bed immediately following maximal TURBT. The authors looked at inter-observer variability regarding the size and location of the tumor bed (CTVboost) on computed tomography scans with versus without Lipiodol.Results Median follow-up was 18 months. Lipiodol was visible on every orthogonal two-dimensional kV portal image throughout the entire, 7-week course of IGRT. There was a trend towards improved inter-observer agreement on the CTVboost with Lipiodol (p = 0.06). In 2 of 5 patients, the tumor bed based upon Lipiodol extended outside a planning target volume that would have been treated with a radiation boost based upon a cystoscopy report and an enhanced computed tomography (CT) scan for staging. There was no toxicity attributable to Lipiodol.Conclusions Lipiodol constitutes a safe and effective fiducial marker that an urologist can use to demarcate a tumor bed immediately following maximal TURBT. Lipiodol decreases inter-observer variability in the definition of the extent and location of a tumor bed on a treatment planning CT scan for a radiation boost.

Role of multisclice and virtual cystoscopy versus ultrasound and color doppler study in evaluation of urinary bladder neoplasms

The virtual cystoscopy and the color Doppler examinations are good modalities in assessment of the urinary bladder neoplasms. This study is done to assess the accuracy of CTVC and color Doppler ultrasound in detection of the urinary bladder neoplasms. The examination was done between June 2010 and December 2012 on 60 patients known or suspected to have urinary bladder neoplasm. They were examined using CTVC and color Doppler ultrasound. Bladder scanned using multislice CT at a slice thickness of 1 mm. The data were transferred to a workstation for interactive navigation. Findings obtained from CTVC and ultrasound were compared with results from conventional cystoscopy and with pathological findings. By the conventional cystoscopy; the 43 patients in the group A showed 53 lesions. There were [35/43 patients] with single lesion while there were [8/43 patients] more than one lesion. While the other 17 patients in group B showed 11 patient with no focal lesions and 6 patients with 6 focal lesions. By virtual cystoscopy; 56 lesions were detected in both groups; 51 plus 5 lesions in group A and B respectively. There were 3 false negative lesions with a failure rate of 3/56. By ultrasound; 56 lesions were detected in both groups; 53 plus 3 lesions respectively. So in virtual cystoscopy and ultrasound the results were as follows: positive predictive values: 100%; negative predictive value: 78.6%; sensitivity: 94.9%; specificity: 100%. Although the definitive diagnosis of some suspected urinary bladder tumors is only possible with conventional cystoscopy and biopsy, CTVC and color Doppler ultrasound are a minimally or non-invasive techniques which provide beneficial information about urinary bladder lesions

Percutaneous intervention of large bladder calculi in neuropathic voiding dysfunction

PURPOSE: To report our results and rationale for treating large bladder calculi in patients with neuropathic voiding dysfunction (NVD) using percutaneous cystolithalopaxy. MATERIALS AND METHODS: Ten patients with a previously diagnosed NVD presenting with a large stone burden were identified from our department database and a retrospective review of case notes and imaging was performed. RESULTS: Percutaneous access to remove bladder stones (range 8x7 to 3x2 cm) had a mean surgery length of 150 min and blood loss of 23 mL. Six of the seven patients treated percutaneously were discharged on the day of surgery and suffered no complications, while one patient experienced poor suprapubic tube drainage and required overnight admission with discharge the following day. Transurethral removal of stone burden (range 4x4 to 4x3 cm) had a mean surgery length of 111 min and blood loss of 8 mL. Each of these three patients were under our care for less than 23 hours, and one patient required a second attempt to remove 1x0.5 cm of stone fragments. There was no statistical difference between mean operative times and estimated blood loss, p = 0.5064 and p = 0.0944 respectively, for the two treatment methods. CONCLUSION: In this small series, percutaneous cystolithalopaxy was a safe, effective, and often preferred minimally invasive option for removal of large calculi in patients with NVD. We suggest possible guidelines for best endoscopic approach in this population, although a larger and prospectively randomized series will be ideal for definitive conclusions.