Surgical management of complex cystolithiasis is challenging in patients with a closed bladder neck and history of multiple abdominal surgeries.  We present a 51 year old female patient with a history of traumatic spinal cord injury with pelvic fractures and resultant neurogenic bladder.  Her surgical history includes transabdominal bladder neck closure with bladder augmentation and creation of a continent catheterizable stoma two years prior to presentation.  She was referred by a local urologist for management of a large bladder stone.  CT abdomen/pelvis demonstrated a 3cm stone and significant amount of bowel anterior to the bladder.

The patient was positioned in dorsal lithotomy.  Pouchoscopy was performed via flexible ureteroscope through the catheterizable stoma to visualize the stone's relative location and mobility.  A 14F Foley was inserted per stoma for intraoperative decompression.  An inverted U incision line was made on the anterior vaginal wall overlying the bladder base, and lidocaine was instilled for hemostasis and hydrodissection.  After incision, sharp and blunt dissection was carried out in an avascular plane to dissect the vagina off of the bladder.  Electrocautery was utilized to open perivesical tissue and the bladder detrusor layer transversely.  Further sharp dissection of perivesical tissue was carried out using Metzenbaum scissors.  The bladder was then filled via stoma foley to improve visualization of the bladder mucosa.  Cystotomy was made and the bladder was entered through our transvaginal approach.  The 3cm bladder stone was removed, intact, using a Babcock.  The bladder was closed in two layers with absorbable suture in a running watertight fashion.  The bladder was re-filled to test the cystotomy closure and was noted to be watertight.  The outer detrusor layer was closed with running locking 2-0 Polysorb, and a separate layer of perivesical tissue was closed over our two-layer bladder closure using simple interrupted stitches.  The vaginal flap was closed with running locking 2-0 Polysorb.

Operative time was 92 minutes. Estimated blood loss (EBL) was 25cc. The patient was discharged on postoperative day 0 with a 14F Foley in the catheterizable channel. The Foley was removed at the 3-week postoperative visit, and patient was symptom-free and resumed clean intermittent catheterization with no issues.  No complications were reported within 1 year following surgery.

We demonstrate the feasibility of a novel transvaginal cystolithotomy approach for the management of complex bladder stones in female patients with bowel overlying bladder and no urethral access.