Suprapubic Drainage During Transurethral Cystolithotripsy for Large Bladder Stones

This is a prospective, randomized, controlled, parallel-group clinical trial conducted at the Department of Urology, Beni-Suef University Hospital, Faculty of Medicine, Beni-Suef University, Egypt. Adult patients with radiologically confirmed bladder stones greater than 2 cm who are scheduled for elective transurethral cystolithotripsy will be enrolled after written informed consent.

Participants will be randomized in a 1:1 ratio into two groups. The control group will undergo standardized transurethral Holmium:YAG laser cystolithotripsy using a 17 Fr cystoscope sheath with conventional irrigation and transurethral evacuation only. The experimental group will undergo the same procedure with adjunctive 8 Fr suprapubic catheter drainage inserted under ultrasound guidance and cystoscopic visualization. The suprapubic catheter will be connected to free drainage during lithotripsy to assist bladder decompression and irrigation outflow. It will not be used for stone fragmentation, stone extraction, tract dilation, sheath placement, or percutaneous cystolithotripsy.

All procedures will use the same standardized cystoscopic access, Holmium:YAG laser platform, irrigation system, and transurethral evacuation method. The primary outcome is total operative time, measured from cystoscope insertion into the urethra until endoscopic confirmation of complete stone clearance and completion of final urethral catheter placement. Postoperative follow-up will continue for 30 days, including assessment of stone-free status by imaging and recording of perioperative complications.

Inclusion criteria

• Age 18 years or older.
• Radiologically confirmed bladder stone with maximum diameter greater than 2 cm.
• Scheduled for elective transurethral cystolithotripsy.
• Sterile urine culture before surgery, or adequately treated urinary tract infection according to culture sensitivity.
• Fit for spinal or general anesthesia.
• Ability to provide written informed consent.

Exclusion criteria

• Urethral stricture preventing safe cystoscopic access.
• Active uncontrolled urinary tract infection or sepsis.
• Neurogenic bladder with severely impaired bladder emptying requiring chronic catheterization.
• History of bladder cancer or suspected bladder tumor requiring simultaneous transurethral resection of bladder tumor.
• Coagulopathy or uncorrected bleeding tendency.
• Patients requiring concomitant transurethral resection of the prostate, Holmium laser enucleation of the prostate, or other prostate surgery in the same session.
• Previous pelvic radiotherapy or major lower urinary tract reconstruction.
• Pregnancy.
• Refusal to participate.