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Bladder Neck Contracture

  1. May be congenital, seen in children (Marion’s disease: due to congenital bladder neck hypertrophy), or   acquired (fibrotic prostate or following TURP)
  2. Treatment:
    1. Medical: Alpha 1 blocker.
    2. Surgical: A; Dilatation, B; Transurethral incision of bladder neck; C; Sphincteroplasty (Bonin’s operation): kind of V-Y plasty of bladder neck.
      1. Prostatic Calculi
        1. Endogenous calculi are composed mainly of calcium phosphate.
        2. Often, they are asymptomatic but may present as prostatitis or retention.
        3. Treatment of symptomatic stones: TURP (not very effective because most of the stones are peripherally located), or retropubic prostatolithotomy.
      2. Corpora Amylaceae is amorphous debris, always pigmented desqumated epithelium in Prostatic duct and forerunner or Prostatic calculi.
Urinary Bladder
  1. Ectopia Vesicae
    1. This is due to incomplete development of lower anterior abdominal wall associated with incomplete development of ant. wall of bladder. This is more common in males (4:1). Incidence is 1 in 50,000. The bladder mucosa is exposed and muco - cutaneous junction is well defined. It is often associated with inguinal and/or umbilical hernia. In males there is complete Epispadias. Prostate or seminal vesicles are rudimentary or absent.
    2. In females clitoris is cleft and labia majora is separated anteriorly. In both sexes there is separation of pubic symphysis. The exposed mucous memb. may undergo metaplastic changes, with development of Adenocarcinoma.
    3. Associated anomalies
      1. Epispadias                                                         
      2. Bifid clitoris                      
      3. Undescended testis
      4. Widening of pubic symphysis                       
      5. Cloacal extrophy             
      6. Inguinal hernia
      7. Ureteral reflux
    4. Treatment Options:
      1. Diversion of urine in colon or rectum.
      2. Excision of bladder and ileal conduit.
      3. Repair consisting of reconstruction of bladder, creating a new symphysis after iliac bone osteotomy and recounstructed urethra is placed behind the pubis. 
Pseudoextrophy: The presence of musculoskeletal defect of extrophy with no major defect in urinary tract.
  1. Urinary Retention
    1. Acute: In males it is commonly caused by BPH, Urethral stricture, Phimosis or meatal stenosis/ scabbing and rarely by stones. In females, causes are retroverted gravid uterus, Stone or psychological.
      1. On examination bladder lump is present. It is important to examine lower limb reflexes and anal tone to rule out neurogenic bladder. Prostatic/ meatal size must be evaluated.
      2. After excluding the history of trauma (if present get a RGU done before catheterization), retention should be relieved by catheterization. If catheterization fails (usually due to stricture and rarely due to BPH),
      3. retention is relieved either by suprapubic puncture cystostomy or suprapubic cystostomy (SPC-Riche’s technique).
    2. Chronic: Usually it is painless. Overflow incontinence may be present. Neurogenic bladder must be ruled out. In these cases short course of decompression by catheterization must be tried before doing definitive surgery (except in Neuro. bladder).
    3. Other Causes: Retention may be caused by certain drugs (e.g. Antihistaminic, INH, Anticholenergic, Tricyclic Antidepressants and antihypertensive), post operatively either due to Spinal anaesth., or local muscular spasm. 
  2. Neurogenic Bladder:
    1. Lesion Above D-10: (Upper motor neuron bladder). Detrusor contractions are present but ineffective as they are associated with sphincter spasm also.
      Because of high pressure upper tract show deterioration in function. Later on bladder capacity decreases.
    2. Lesion at D10-L2: Essentially an upper motor neuron bladder but loss of sympathetic afferents and sensory efferent from the bladder.
    3. Lesion at S2-S4: (Lower motor neuron bladder). Sensation is usually intact (T11-12), but bladder contraction is poor.
      Patient may empty his bladder with abdominal straining. If motor nerves are intact, sphinteric in-coordination is present. LMN bladder is of large capacity and reflux is common. CIC is used to keep the bladder empty.
Urodynamic Study
  1. Flow Rate: Normal flow rate from a full bladder is 20-25 ml/sec in males and 25-30 ml/sec in females. A flow rate of <10 is considered evidence of obstruction. (>15ml/sec in males and >25ml/sec in females)
  2. Cystometry: Performed by artificially simulating bladder filling and emptying while obtaining pressure and other measurements. It is helpful in assessing bladder capacity, accommodation, sensation, contractility, voluntary control, and response to drug.
  3. Sphincteric Function: Is evaluated by recording electromyographic activity of the voluntary component of the sphincter, or by recording the intraurethtral pressure of the sphincteric unit.
  1. Incontinence
    1. Causes of Incontinence: In males most common cause is outlet obstruction (BPH) and overflow incontinence. In female most common cause is stress incontinence.  
    2. Other causes are discussed in symptomatology.
    3. Treatment: Aim is to keep the patient dry, odourless, decrease skin excoriation, protect from UTI and Back-pressure. Indwelling catheter is not a good option, if need be then SPC should be done. External sphincteric weekness can be treated by gracilis sling or electrical stimulation.
    4. In lower motor type of bladder intermittent catheterization is helpful. In upper motor (spastic type of bladder) it is important to keep the intra-vesical pressure low by drugs (anti-cholenergics to decrease bladder tone/ anti-adrenergics to lessen sphicteric tone), Sphicterotomy or by urinary diversion.
    5. For stress incontinence, Marshall Marchetti (suprapubic approach), where paraurethral tissue is hitched to retropubic ligaments or Edward Williams operation (retropubic approach) is helpful.
Treatment Options
DRUGS To increase bladder neck strength.: Adrenergic agonist
To decrease strength of bladder neck: Adrenergic blockers
Mixed action on bladder neck and CNS: Tricyclic drugs
Intermittent self Catheterization  
Device for collection or control Condom catheter
Indwelling catheter
Penile clamps
Outlet surgery Prostatectomy
Bladder neck incision (widening)
Artificial sphincter
Bladder Augmentation Ileocystoplasty
Urinary diversion  
Bladder neck elevation
Marshall Marchetti op.
Edwards Williams’ op.
  1. Nocturnal enuresis:
    It can be primary or secondary. Usually no organic lesion is found though bladder may be unstable.
    Treatment consists of Pharmacotherapy (imipramine) & Behaviour modification (bladder training, responsibility reinforcement, conditioning therapy).
  2. Diverticulum Of The Bladder:
    The normal intra-vesical pressure at micturation is 35 cm of water but in outlet obstruction pressure as high as 100 cm is seen leading to trabeculation and protusion of bladder mucosa between muscle layers.
    1. Congenital: Consists of all layers of bladder wall. Usual seat is at the dome, which represent persistent lower part of urachus. This may become a seat of infection or stone.  
    2. Pulsion diverticulum: Seen in outlet obstruction. Commonest site is near the ureteric orifice, thus may cause ureteric obstruction.
      Complications: Recurrent infections, Squamous metaplasia (15%) and even Carcinoma, Stone formation in diverticulum and back-pressure changes due to ureteric obstruction.
      Presentation: Presenting symptoms are of lower urinary tract obstruction, recurrent infection, stone, hematuria or hydronephrosis.
      Diagnosis: Cystoscopy, IVP (to see the condition of the upper tract), MCU and USG.
      Treatment: If the pouch has a narrow neck, is a seat of infection, stone, malignancy etc. then it requires      treatment. Small diverticulum heals only by bladder drainage or relieving the outlet obstruction. Large diverticulum requires excision.
    3. Traction diverticulum: A portion of the bladder protruding through the inguinal or femoral hernial orifices forming a wall of hernia (Sliding hernia).
  3. Urinary Fistulas
    1. Congenital: Ectopia Vesicae, Patent Urachus or in association with imperforate anus
    2. Traumatic: Penetrating wound, injury or avascular necrosis caused by surgery or RT.
    3. Vesicovaginal Fistula: Obstetrical cause (neglected labour), Gynecological cause (total hysterectomy), Radiotherapeutic cause, malignant infiltration (Ca. Cx)
    4. Presentation: Continuous day and night urinary leak from vagina and skin excoriation. Fistulous opening is more clearly seen from the vaginal side. To differentiate between VVF and Uretero vaginal fistula, methylene blue is injected in the bladder a swab is placed in the vagina. Blue coloring of the swab suggests VVF.
    5. Investigations: Cystoscopy, IVP, MCU
    6. Treatment: Surgical closure of fistula by abdominal or vaginal route (Martius flap: Fat of labia major is used for interposition after repair.
  4. Bladder Trauma
    1. Bladder trauma is usually seen in blunt injury (15% of pelvic fracture). Iatrogenic injury is seen in Gynecological operations, hernia repair, TURP or rectal surgery.
    2. When the bladder is full, direct blow results to intraperitoneal bladder injury (20%) – More common in males. Injury associated with pelvic fracture fragments result in extraperitoneal rupture (80%).
    3. First investigation is Cystogram/RGU and it should always be done before attempting to catheterize. Plain X-ray demonstrates pelvic fracture and lower abdominal haziness due to urine or clots.
    4. IVP should be done to rule out injuries to kidney or ureter. Cystoscopy is usually not helpful since bleeding and clots obscure visualization.
    5. Most common type of bladder injury is extra peritoneal rupture.
    6. Site of localization of urine in extra peritoneal rupture of urinary bladder is perivesicle space.
    7. Site of localization of urine in intra peritoneal rupture of urinary bladder is peritoneal cavity.
    8. Complications:
      Pelvic abscess, Peritonitis, Partial incontinence.
    9. Treatment:
      Extra peritoneal rupture can managed with conservative treatment only –
      1. Foleys catheterization for 2-3 weeks;
      2. Repair of the rupture (repair is done intravesically)
      3. SPC.
In intraperitoneal rupture repair is done by exploratory laparotomy and repair of urinary bladder. 
  1. Injuries To The Urethra
    1. Urethral injury
      1. Trauma is the most common cause
      2. Most male posterior urethral injuries are result of blunt pelvic trauma.
      3. Most common cause of anterior urethral trauma result from straddle injury.
      4. It may be bulbous/ membranous urethra rupture or complete/ incomplete; total/ partial.
      5. Most common Rupture of bulbous urethra: Seen in perineal injuries. Presents with urethral hemorrhage, perineal haematoma and retention of urine.
      6. Site of localization of urine:
        1. Posterior uretheral (membranous urethra) injury – deep perineal pouch.
        2. Bulbous uretheral injury    
  • Extravasation of urine in arterial abdominal wall.
    • Genitalia
    • Never in thigh  (because of holden’s line i.e fusion of collies fascia with deep fascia of thigh)
    • Penile uretheral injury – extravasastion of urine only in shaft of penis.
    • Patient is advised not to pass urine. If voiding has occurred a local swelling may be noted. Perineum is tender with a mass. P/R reveals a normal prostate. RGU is investigation of choice.
    • Treatment: If no extravasation is noted then, gentle catheterization may be tried. Otherwise a SPC is performed (immediate repair may be tried but the procedure is difficult and incidence of later on stricture is high). 
    • In cases of minor leak, repeat dye study is performed after 7 days, in extensive injury one should wait for 3 weeks. If extensive extravasation is present then drainage of extravasated urine from perineum should be performed at the first surgery otherwise infection / abscess may follow.
    • Later on open urethroplasty with end to end anastomosis or Internal urethrotomy may be performed.
  1. Injuries to membranous urethra: Commonly seen in association with fracture pelvis. The prostate is displaced superiorly (Due to rupture of puboprostatic ligament) and a hematoma forms at periprostatic and perivesical space.
  • Most important sign of urethral injury is blood at meatus. Patient presents with urinary retention, suprapubic fullness, perineal hematoma and floating prostate on P/R.
  • Complications: Stricture, incontinence, impotency.
  • Treatment: Immediate temporary measure is SPC. Primary repair by rail-roading may be done but chances of stricture formation is very high.
  1. A second stage (after 3 months of primary surgery) retrupubic urethroplasty may be performed. In cases of incomplete rupture endoscopic urethrotomy is curative.
  2. Investigation of choice – Cystourethrogram (Retrograde) 
Extra Edge:
  • Goblet sign and Stipple sign describe the appearance of ureteral dilation below the site of an intraluminal ureteral filling defect, best seen at retrograde pyelography (RGP)
  • The Stipple sign refers to the pointillistic end-on appearance on IVP or RGP of contrast material tracking into the interstices of a papillary lesion.
  • Because maturity of TCC have a papillary configuration, presence of this sign should raise the suspicion of TCC, while the Stipple sign is best seen in large papillary bladder tumors, it can occur anywhere in urothelial tumor, which expresses papillary architecture.
  1. Injury To The Penis:
    1. Penile fracture may be caused by excessive bending / trauma to the erect penis. There is rupture of Tunica albugenia. Presentation is penile pain and hematoma.
    2. This may be treated by immediate surgery and repair of tunical laceration with drainage of hematoma.
  1. Cystitis
    Common causes are
    1. Incomplete emptying (e.g. BPH, urethral stricture, phimosis, bladder diverticulum and neurogenic   bladder).
    2. Stone or foreign body in the bladder.
    3. Lowered general resistance e.g. malnutrition.
    4. Infection may reach the bladder by ascending route (commonest organism is E. coli), Descending from kidney, Hematogenous or Lymphogenous (from Tubes, vagina or intestine).
    5. Presenting features are Frequency, dysuria, pain, pyuria and hematuria.
    6. Treatment consists of Culture sensitivity and antibiotics accordingly.
Interstitial Cystitis (Hunner’s ulcer or elusive ulcer): This condition is mainly seen in women. It is characterized by Paracystitis and fibrosis of bladder musculature leading to decreased bladder capacity. Inflammation is seen in all layers of bladder wall. Presentation is mainly because of bladder inflammation (Dysuria, hematuria) or due to decreased bladder capacity (Frequency). Pain relieves by act of micturation.
Cystoscopy is diagnostic.
  1. Urinary Bladder carcinoma
    1. Most are transitional cell carcinomas
    2. Superficial tumors are usually low grade and associated with a good prognosis
    3. Muscle invasive tumors are of higher grade and have a poorer prognosis
    4. Most common site is triagone of urinary bladder.
      1. Etiological factors
        1. Smoking is most common risk factor
        2. Occupational exposure (20% cases)
        3. Chemical implicated - aniline dyes, chlorinated hydrocarbons, Naphthylamine   Aniline dyes Cyclophosphamide exposure
        4. Tyre, Rubber, cable and Dye industries
        5. Cigarette smoking
        6. Analgesic abuse e.g. phenacitin
        7. Pelvic irradiation - for carcinoma of the cervix
        8. Schistosoma hematobium associated with increased risk of squamous carcinoma (Bilharzia)
      2. Pathological staging
        Requires bladder muscle to be included in specimen
        Staged according to depth of tumor invasion
        1. Tis In-situ disease
        2. Ta Epithelium only
        3. T1 Lamina propria invasion
        4. T2 Superficial muscle invasion
        5. T3a Deep muscle invasion
        6. T3b Perivesical fat invasion
        7. T4 Prostate or contiguous muscle
          Grade of tumor also important
          1. G1 Well differentiated
          2. G2 Moderately well differentiated
          3. G3 Poorly differentiated
Clinical Presentation
  1. 80% present with painless hematuria
  2. Also present with treatment-resistant infection or bladder irritability.

Investigation of painless hematuria

  1. Urinalysis
  2. Mid stream urine
  3. Serum urea and creatinine
  4. Ultrasound - bladder and kidneys
  5. KUB - to exclude urinary tract calcification
  6. Flexible cystoscopy
  7. Consider IVU if no pathology identified


Management of Bladder Cancer
Nature of Lesion Management Approach
Superficial Endoscopic removal, usually with intravesical therapy
Invasive disease Cystectomy ± systemic chemotherapy (before or after surgery)
Metastatic disease Curative or palliative chemotherapy (based on prognostic factors) ± surgery

Superficial TCC

  1. Requires transurethral resection and regular cystoscopic follow-up
  2. Consider prophylactic chemotherapy if risk factor for recurrence or invasion (e.g. high grade.
  3. Consider immunotherapy
  4. BCG = attenuated strain of Mycobacterium bovis
  5. Reduces risk of recurrence and progression
  6. 50-70% response rate recorded
  7. Occasionally associated with development of systemic mycobacterial infection

Carcinoma in-situ

  1. Carcinoma-in-situ is an aggressive disease
  2. Often associated with positive cytology
  3. 50% patients progress to muscle invasion
  4. Consider immunotherapy
  5. If fails patient may need radical cystectomy

Invasive TCC

  1. Choices are between radical cystectomy and radiotherapy
  2. Radical cystectomy has an operative mortality of about 5%
  3. Urinary diversion achieved by:
    1. Valve rectal pouch - modified ureterosigmoidostomy
    2. Ileal conduit
    3. Neo-bladder
  4. Local recurrence rates after surgery are approximately 15% and after radiotherapy alone 50%
  5. Pre-operative radiotherapy is no better than surgery alone
  6. Adjuvant chemotherapy may have a role
  1. Pathology: Normal urothelium is composed of 3-7 layers of tr. cell epi.
    1. Papilloma (2%): A fine papillary tumour with a fine fibro-vascular stalk supporting an epithelial layer of normal tr. cell with normal polarity. Papilloma is has a good prognosis.
    2. Transitional Cell Carcinoma: (90%). Commonly appear as exophytic papillary lesion.  CIS is recognized as flat nonpapillary anaplastic epithelium. Urothelium lacks normal polarity and cells have larger nucleoli. It may occur as focal or diffuse independent lesion or may be seen with other exophytic lesion. 
Nontransitional cell tumours:
  1. Adenocarcinoma: <2% of bladder Tm. Primary adenocarcinoma is preceded by Cystitis glandularis or metaplasia. Primary Adeno Ca. is seen at the floor but those associated with persistent urachus occur at the dome. It is also seen with Extrophy bladder. Overall prognosis is poorer in Adeno Ca. than TCC.
  2. Squamous cell carcinoma: 5-10% of all bladder cancer. It is associated with chronic infection, vesical calculi, chronic catheter use or Schistosomiasis. Prognosis is poorer than TCC.
  3. Undifferentiated carcinoma: (<2%)
  4. Mixed Carcinoma: Combination of transitional, glandular, squamous or undifferentiated pattern. Most are large and infiltrating at the time of diagnosis.
  5. The common metastatic tumour to the bladder include, in order of frequency melanoma, lymphoma, stomach, breast, kidney and lung.
  6. Presentation: Hematuria is the most common symptom (85-95%).  Irritative voiding symptoms (frequency, urgency and dysuria) may be present. Metastasis may present with bone pain, flank pain from retroperitoneal spread or ureteral obstruction.
Lab Findings:
  1. Cystoscopy: Diagnosis is confirmed by Cystoscopy. Primary resection of the tumour / biopsy can be performed simultaneously.
  2. Gold standard for diagnosis is biopsy obtained during cystoscopy & biopsy.
  3. Urinary cytology and flow cytometry: Exfoliated cells from normal and neoplastic epithelium can readily be identified. High grade and infiltrating carcinoma and CIS are easily detected but low grade malignancy may be missed.
  4. Cell surface antigen: Blood group and related antigen (ABH, T and Lewis) are detected on cell surface of RBC,some epithelial cells and secretion. Invasive and in situ carcinoma and superficial cancer showing progression to higher grade show loss of cell surface antigen.
  5. Imaging modality of choice is CECT abdomen and pelvis.
  6. Although the presence of bladder tumour is confirmed by Cystoscopy but spread, extravesical extension and condition of the upper tract is determined by CT scan. USG can be used as a screening modality. Advantages of MRI over CT are that, contrast is not needed and neurovascular bundle is more clearly delineated.
Guidelines for the Treatment of Transitional Cell Carcinoma of the Bladder
Cancer Stage Initial Treatment Option
Tis TUR + intravesical immunotherapy (BCG)
Ta (single, small focus) TUR
Ta (large, multifocal) TUR + BCG or intravesical chemotherapy
T1 (low grade) TUR + BCG or intravesical chemotherapy
T1 (high grade) TUR + (BCG or intravesical chemotherapy) or radical cystectomy
T2-T4 Radical cystectomy
  Neoadjuvant chemotherapy + radical cystectomy
  Radical cystectomy + adjuvant chemotherapy
  Neoadjuvant chemotherapy + chemotherapy + irradiation
Any T, N+, M+ Systemic chemotherapy followed by selective surgery or irradiation

BCG, bacille Calmette-Guérin; TUR, transurethral resection.
Ref: Sabiston Textbook of Surgery, 18th Edition Ch 77
  • Treatment
  1. Intravesical Chemotherapy:
    Comparisons between Intravesical Agents
Agent MW Peri-op Use Risk Group Cystitis (%) Other Toxicity Dropout (%) Concentration/Dosage Cost*
Doxorubicin (Adriamycin) 580 Yes Low-Intermediate 20-40 Fever, allergy, contracted bladder, 5% 2-16 50 mg/50 mL $36
Epirubicin 580 Yes Low-Intermediate 10-30 Contracted bladder rare 3-6 50 mg/50 mL $595
Thiotepa 189 Yes Low-Intermediate 10-30 Myelosuppression 8%-19% 2-11 30 mg/30 mL $80
Mitomycin 334 Yes Low-Intermediate 30-40 Rash 8%-19%, contracted bladder 5% 2-14 40 mg/20-40 mL $130
BCG N/A No Intermediate-High 60-80% Serious infection, 5% 5-10 1 vial/50 mL $150
Interferon 23,000 No Salvage <5% Flu-like symptoms 20% Rare 50-100 MU/50 mL $670-$1340
Gemcitabine 300 Yes Salvage Mild Occasional nausea <10 1-2 g/50-100 mL $540-$1080
Drugs used in intravesical chemotherapy
  • Mitomycin C                     
  • Thiotepa
  • Epirubicin                          
  • BCG (most effective)
  • BCG is attenuated strain of Mycobacterium bovis
  • Mechanism of action: Immunologically mediated
    - Exact mechanism is not known
    - Binds to fibronectin on bladder cells and elicits TH1 responses  
  • Most effective intravesical chemotherapy
Contraindications of BCG
Absolute Relative
• Immunosuppressed patients           
• Gross hematuria                                
• Immediately after TURBT                  
• Traumatic catheterization                
• Total urinary incontinence            
• History of BCG sepsis                      
•  Deranged LFT
•  Previous history of Koch's
•  UTI
•  Poor performance status


  • MC is frequency, urgency and dysuria
  • Patients with severe BCG sepsis (high fever, chills confusion, hypotension, jaundice) should be treated with ATT. 
  1. Surgery:
    1. Transurethral resection or laser vaporization:
    2. Partial cystectomy: Patients with T1-T3 tumours, localized along the posterior lateral wall or dome are candidates for partial cystectomy. 2cm. tumour free margin should be left. Tumour implantation at wound may be minimized with short course of Radiotherapy (1000 to 1600 rads) or by intravesical chemotherapy, pre-opratively.
    3. Radical Cystectomy: This implies removal of Bladder with its peritoneal attachments, prostate and seminal vesicles in males and in females removal of uterus, cervix, anterior veginal vault, urethra and ovaries.
    4. Radiotherapy: External beam radiotherapy (5000 to 7000 cGy) for infiltrating Ca.
    5. Chemotherapy: It is used for systemic control. Single most active agent is cysplatin. Other effective agents are methotrexate, vinblastin, cyclophosphamide and 5FU. Combination regimens are MVAC, CMV, CISCA. 
Vesical Stones
  1. Etiology: Bladder outlet obstruction remains the most common cause of bladder calculi in adults. Crystals are formed in this static urine; therefore, larger calculi develop.
  2. Other etiologic factors are spinal cord injuries, bladder inflammation secondary to external beam radiation or foreign bodies that act as a nidus for stone formation
  3. Clinical: Suprapubic pain, dysuria, intermittency, terminal gross hematuria, frequency, hesitancy, and nocturia. Another common symptom is sudden termination of voiding with some degree of associated pain, initiated by the stone impacting the bladder neck.
    1. Most common type of stone in adult is uric acid stone, in pediatric population most are composed of impure mixture of ammonium acid urate & calcium oxalate with phosphate.
    2. Bladder stone in spinal injury patient are of struvite or calcium phosphate stone.
    3. Physical feature from soft to hard from being smooth to spiculated (termed JACKA stones)
  4. Workup:
    1. Urinalysis: Bladder calculi can be associated with positive testing for nitrite, leukocyte esterase, and blood. Microscopic crystals usually are consistent with the composition of the stone.
    2. Urine culture/sensitivity document and direct treatment of infections.
    3. Urography of the kidneys, ureters, bladder: The initial test of choice remains the plain radiograph (KUB). It demonstrates the presence of radiopaque stones.
    4. Intravenous pyelogram: These tests demonstrate the stone as a filling defect in the bladder. If the filling defect moves when the patient is repositioned, presence of a stone is highly likely (differential diagnosis includes clot, fungal ball, and papillary urothelial carcinoma on a stalk). Q
    5. Nonmobile filling defects could be calculi attached to the bladder wall via a stitch or in a diverticulum (differential diagnosis includes urothelial carcinoma, clot, and calculus).
    6. Ultrasonography: Shows a classic hyperechoic object with posterior shadowing, & identifies both radiolucent and radiopaque stones.
    7. Computed tomography & MRI - Spiral CT (UN enhanced) is the most sensitive & specific test in diagnosing calculi along urinary tract.
    8. Cystoscopy remains the most commonly used test to confirm the presence of bladder stones and plan treatment.
  5. Treatment
    1. Surgical therapy: Currently, 3 different surgical approaches to this problem exist.
    2. Unlike renal and most ureteral calculi, ESWL has shown little efficacy in most centers. Second approach in adults is transurethral cystolitholapaxy. If indicated at the completion of lithotripsy, transurethral resection of the prostate (TURP) or transurethral incision of the prostate (TUIP) can be accomplished.
    3. The third approach, open suprapubic cystostomy to remove the stone(s) intact can be employed with larger and harder stones.
    4. Transcellular litholapaxy is the most common general modality used to treat bladder caluli.

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