Out-of-the-Box Thinking Coupled with Basic Principles of Endourology: The Perfect Recipe to Mitigate a Crisis

Surgical interventions for bladder stones include endoscopic procedures (transurethral or percutaneous), open surgery, and laparoscopic or robotic-assisted removal. Minimally invasive techniques are preferred owing to favorable risk profile and shorter hospital stays.1 While transurethral endoscopic interventions are common, several factors may preclude their use. Patient factors include urethral pathology (strictures, prior urethral surgery, and diverticula), limiting instrument passage and increasing the risk of urethral trauma; acute urinary infection or inflammation; severe bladder outflow obstruction from prostatic enlargement or other causes requiring concomitant treatment; anatomical alterations such as reconstructed bladders; and inability to position in lithotomy. Technical factors include large and hard stones (>3–4 cm) and instrument limitations (e.g., lack of continuous irrigation).2–4 The next best alternatives are percutaneous cystolithotripsy (PCCL) and laparoscopic or robotic-assisted retrieval. PCCL offers multiple advantages over laparoscopic retrieval. It achieves effective stone clearance with minimal mucosal trauma, low blood loss, and rapid hospital discharge. By avoiding peritoneal entry, PCCL reduces surgical morbidity and the risks of visceral injury and postoperative adhesions. The percutaneous tract accommodates larger nephroscopic instruments with continuous outflow, facilitating rapid fragmentation without the technical demands of laparoscopic suturing. The shorter operative times favor its application in high-risk patients.5 Conversely, laparoscopic removal allows concomitant treatment of underlying prostatic obstruction. Laparoscopic simple prostatectomy can be extraperitoneal or transperitoneal, while prostate access can be transvesical or transcapsular. Transperitoneal prostatectomy offers a larger working space and better visualization. Transvesical access is suitable for trilobar hyperplasia, whereas transcapsular access for bilobar hyperplasia.6–8 This case report demonstrates the practical application of these principles, highlighting how adaptive surgical decision making can optimize outcomes in complex presentations.