Farid Setyono, dr

Incision of the bladder for removal of a calculus.

(Dorland's Medical Dictionary for Health Consumers, 2007)

(Clinical anatomy by regions 8 th editions, 2010)
(Clinical anatomy by regions 8 th editions, 2010)
 Stone size > 2cm
 Hard bladder stones that can not be solved with a
lithotriptor
 Multiple bladder stone
 Not obtained access through the urethra
 Concomitant open prostatectomy or diverticulectomy

 (SOP Urologi, 2007)

• Suspicious of bladder malignancy
• Unclear cause of gross hematuria
• Bleeding disorder

(Campbell,10th ed)
 Pinset anatomis and
Pinset chirrurgis scapel handle
 Kocher
Mosquito Clamp
Ellis Sharp Spreader
Double langenback Needle Holder
Spreader millin
Suction Tip
Doek Clamp
Catheter and
Suction Drain Speed mash
Stone Tang (Stein tang)
 Marking operation site 1 day before
 Informed Consent
 Patient in general anesthesia or spinal block.
 Operator in the left patient for right handed.
 Patient in supine position, lift the lower back if needed.

(Hinman’s Atlas of Urologic Surgery,3rd ed)

• Taken X-ray on viewer
• Desinfects the abdomen, penis, and both inner thigh
with Povidone Iodine 10%
• Cover it with sterile drappings.
• Reading patient’s checklist

• (Hinman’s Atlas of Urologic Surgery,3rd ed)

• Draw the incision design
• Make the incision 2 finger
upper symphisis pubis
• Open layer by layer

(Hinman’s Atlas of Urologic Surgery,3rd ed)

 Incise the fascia transversely
 widened with the scissors

(Hinman’s Atlas of Urologic Surgery,3rd ed)

 Enter between the recti and
separate them bluntly.
 Hold the muscles back with
two retractors to expose
the prevesical fat.

(Hinman’s Atlas of Urologic Surgery,3rd ed)

Extraperitoneal fat and
peritoneum overlying the
bladder seen

Reflect the peritoneum

upward with gauze piece

Identify the bladder (Hinman’s Atlas of Urologic Surgery,3rd ed)

 Place two 3- 0 chromic
catgut (CCG) stay sutures
into the bladder wall well
above the symphysis.

 (Hinman’s Atlas of Urologic

Surgery,3rd ed)
• With suction at
hand,incise the bladder
vertically between the
sutures with the
metzenbaum, and enter
the bladder.
• quickly replace it with the
tip of the suction.

(Hinman’s Atlas of Urologic

Surgery,3rd ed)
 Enlarge the opening
 Grasp the stone with stone tang and remove it
(evaluate the size, color, and number of stone).

(Hinman’s Atlas of
Urologic Surgery,3rd ed)
• Washout the bladder cavity with normal saline
• Evaluate the bladder wall
• (for tumor or diverticle), the ureter ends (for stones and
ureteric jet), and size of bladder neck. Inspect the base of
the bladder for other stones.
• Take specimen for bladder biopsy if the size of the
stone is more than 3 cm.
• Evaluate the prostate through the bladder neck
 Washout the bladder cavity through the catheter.
 Close the bladder with a running 3-0 plain catgut suture
applied to the muscularis mucosal layer.
 Reinforce it with interrupted sutures of 3-0 polyglactin
placed through the seromuscularis.
 Fill the bladder with 250 cc of normal saline through
urethral catheter, evaluate if there is any leaks within
the sutures.
 Leave the catheter in place secure it with 10 cc of sterile
water.
 Put the draine on cavum retzii and fixation the draine
• Place a small suction drain
(paravesical) to exit
through the wound for a
few days.
• Stitch layer by layer
• fascia of rectus
abdominis muscle with
polyglactin 1-0
• subcutaneous tissue with
plain catgut 3-0
• the skin with stepler
• Close the wound with tulle
and sterile gauze.

(Hinman’s Atlas of Urologic

Surgery,3rd ed)
 Intraoperative Early Postop Late Postop

• Bleeding • Bleeding • Peritonitis

• False route to • Infection • Other
peritoneal infections
cavity • Fistules
• Damage to
other
intraabdominal
organs

(Campbell,10th ed.2004)
 Remove the catheter after day 7.
 Remove the drain after 2 day remove the catether
when the production is minimal (<20 cc/24 hour).
 Analyze the composing material of the stone.

 (Campbell,10th ed. 2004)