Is Cystolitholapaxy Sufficient in Patients with Bladder Stones Secondary to Benign Prostatic Obstruction?

Is Cystolitholapaxy Sufficient in Patients with Bladder Stones Secondary to Benign Prostatic Obstruction? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Is Cystolitholapaxy Sufficient in Patients with Bladder Stones Secondary to Benign Prostatic Obstruction? Mert Hamza Özbilen, Mahmut Can Karabacak, Taylan Tığlı, Mehmet Yoldas, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6783314/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To question the necessity of simultaneous BPO intervention with cystolitholapaxy in patients with BS due to BPO and to investigate the factors predicting secondary intervention. Methods A total of 235 male patients over 40 years of age who underwent cystolitholapaxy,had a follow-up period longer than 12 months,and were thought to have BS secondary to BPO were included in the study. Results 190 patients who did not require additional intervention were defined as group 1,and 45 patients who required secondary intervention were defined as group 2.Secondary surgical intervention was required at a rate of 19.5% with an average follow-up of 49 months.Mean peak urine flow rate(Qmax) was 11 m/s in group 1 and 8.6 m/s in group 2(p < 0.001),postvoid residual urine volume(PVR) was 85.5 mL in group 1 and 115.3 mL in group 2(p < 0.001),international prostate symptoms score(IPSS) was 16.7 in group 1 and 21.7 in group 2(p < 0.001).Total prostate volume (TPV)(p = 0.015) and serum prostate specific antigen(PSA)(p = 0.005) were also significantly higher in group 2.In the multivariate logistic regression analysis of factors predicting secondary intervention in patients undergoing cystolitholapaxy,low Qmax(odds ratio (OR) = 0.783,95% confidence interval(CI):0.670–0.915,p = 0.002),high PVR(OR = 1.019, 95%CI:1.008–1.031,p = 0.001),high IPSS(OR = 1.230,95%CI:1.124–1.345,p < 0.001) and high PSA(OR = 1.179,95%CI:1.026–1.356,p = 0.02) were found to be predictors for secondary intervention. Conclusion In patients with BS secondary to BPO,performing cystolitholapaxy offers a high likelihood of avoiding secondary intervention.Therefore, it would be more appropriate for urologists to decide on BPO surgery in addition to cystolitholapaxy by taking into account the parameters such as low Qmax,high PVR,high IPSS,and high PSA,which are predictors of secondary surgery in the preoperative period,with a patient-centered approach. bladder stones benign prostatic obstruction secondary intervention cystolitholapaxy INTRODUCTION Bladder stones(BS) are the most common stones of the lower urinary tract and constitute 5% of urinary system stone disease in developed countries [1]. BS often present with nonspecific symptoms. Pain, dysuria, hematuria, predominantly voiding lower urinary tract symptoms(LUTS) and predominantly storage LUTS are some of them [2]. These stones are traditionally classified as primary, secondary and migrant [3]. Although small stones can be expelled from the urethra on their own, surgical intervention may be performed for larger stones that cannot be expelled [4]. In adults,BS usually occur secondarily as a result of disorders that cause urinary stasis [5]. Benign prostatic obstruction(BPO) is one of the important causes of urinary stasis in adult patients.The incidence of BS in patients with BPO is 3–8% [6]. BPO is common in men aged ≥ 40 years,and BPO has been shown to be the most common cause of BS [7]. However,the presence of BPO and MT in this group of patients with abnormal urinary microenvironment,inflammation markers and metabolism is complex and multifactorial [8]. It has been suggested that BPO may be the etiological factor in 75% of BS cases,and this has led to the idea that the presence of BS is an absolute indication for surgical treatment of BPO [3]. However, urologists are in a dilemma regarding performing simultaneous BPO surgery on patients who will undergo surgical treatment due to BS [9]. Because there is currently not enough evidence to support the necessity of performing BPO surgery in addition to cystolitholapaxy in men aged ≥ 40 years diagnosed with BS, this situation is being questioned [10, 11]. The aim of this study is to question the necessity of simultaneous BPO intervention with cystolitholapaxy in patients with BS due to BPO and to investigate the factors predicting secondary intervention. MATERIAL AND METHODS This retrospective study was conducted in accordance with the Declaration of Helsinki after approval by the ethics committee of Health Sciences University Izmir Tepecik Health Practice and Research Hospital (IRB: 2022/04–14). Data on patients who underwent cystolitholapaxy between 2010 and 2022 were reviewed.Male patients over 40 years of age who underwent cystolitholapaxy,had a follow-up period longer than 12 months, and were thought to have BS secondary to BPO were included in the study.Patients with a history of urolithiasis, neuropathic bladder dysfunction, BS due to foreign bodies or trauma, bladder diverticula, previous or concurrent prostate surgery, history of urinary retention and indwelling catheter use, urinary diversion, urethral stricture,bladder tumor and prostate cancer, history of pelvic surgery, incomplete data,and those who could not be stone-free after cystolitholapaxy were excluded from the study.Accordingly,a total of 235 patients were evaluated after inclusion and exclusion criteria. These patients were defined as patients who did not require additional intervention(Group 1) and patients who underwent secondary intervention(Group 2). Informed consent was obtained from all patients included in the study. In the preoperative period,patients were evaluated with age, comorbid diseases, history of medical treatment for BPO, international prostate symptoms score(IPSS), physical examination, complete blood count,serum biochemistry tests,serum prostate specific antigen (PSA), urinalysis, urine culture, urinary system ultrasound(USG) (postvoid residual urine volume (PVR), total prostate volume (TPV), maximum diameter of the BS)and uroflowmetry.PVR was assessed in the supine position immediately after voiding. The greatest transverse (width), anteroposterior (depth) and superior-inferior(height) distances were recorded and PVR was calculated automatically by USG. TPV was evaluated based on the ellipsoid formula (0.52x width x height x length) where width (right-left) and height(anterior-posterior) were measured on the transverse plane, and length (cranial-caudal) was measured on the sagittal plane [ 12 ] .Appropriate antibiotic treatment was given to patients with positive urine cultures, and patients with no positive control cultures were operated on In patients who were predicted to be stone-free by direct vision after surgery,stone-free status was confirmed by postoperative bladder USG.Data on patients' age, mode of presentation, history of medical treatment for BPO, Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) score, IPSS, PSA, maximum diameter of the BS, TPV, peak urine flow rate (Qmax), PVR, presence of postoperative complications, follow-up period, and time until secondary intervention were collected. Under the title of complications, symptomatic urinary tract infection (UTI),fever and prolonged hematuria were evaluated. Statistical Analysis Continuous variables were presented as mean ± standard deviation (SD) or median (minimum-maximum) (interquartile range, IQR),while categorical variables were expressed as frequency and percentage [n (%)].The normality of data distribution was assessed using the Kolmogorov–Smirnov test. For group comparisons, the Student’s t-test was used when the normality assumption was met, whereas the Mann–Whitney U test was applied when the assumption was violated. Categorical variables were compared using the Chi-square test or the Fisher’s exact test where appropriate.To determine the independent predictors of secondary intervention,a multivariate logistic regression analysis was performed.A p-value of < 0.05 was considered statistically significant.All statistical analyses were conducted using IBM SPSS Statistics for Windows, version 27.0 (IBM Corp., Armonk, NY, USA). RESULTS Considering the inclusion and exclusion criteria,235 patients who underwent cystolitholapaxy between 2010 and 2022 were evaluated. Among these,190 patients who did not require additional intervention were defined as group 1,and 45 patients who required secondary intervention were defined as group 2. In our study, secondary surgical intervention was required at a rate of 19.5% with an average follow-up of 49 months. Comparative data of both groups are shown in Table 1.When these data were examined, the mean age was 59.3 ± 11.5 in group 1 and 63.1 ± 9.1 in group 2,and a statistically significant difference was found (p < 0.001).Mean Qmax was 11 m/s in group 1 and 8.6 m/s in group 2 (p < 0.001),PVR was 85.5 mL in group 1 and 115.3 mL in group 2(p < 0.001), IPSS was 16.7 in group 1 and 21.7 in group 2(p < 0.001).TPV(p = 0.015) and PSA(p = 0.005) were also significantly higher in group 2.The mean maximum diameter of BS was 24.9 ± 15.1 mm in group 1 and 28.6 ± 14.5 mm in group 2,and no difference was observed between the two groups(p = 0.135). No statistically significant difference was found between the patients' mode of presentation, history of medical treatment for BPO,CCI,and ASA scores.Complications occurred at a rate of 5.3% in group 1 and 4.4% in group 2(p = 0.659). The mean follow-up period was 47.3 months in group 1 and 56.1 months in group 2(p = 0.679),and the mean time until secondary intervention was 35.1 months. Multivariate logistic regression analysis of factors predicting secondary intervention in patients undergoing cystolitholapaxy is shown in Table 2.Accordingly,low Qmax(odds ratio (OR) = 0.783,95% confidence interval (CI):0.670–0.915,p = 0.002),high PVR(OR = 1.019,95%CI: 1.008–1.031, p = 0.001), high IPSS(OR = 1.230, 95%CI:1.124–1.345,p < 0.001) and high PSA(OR = 1.179,95%CI: 1.026–1.356,p = 0.02) were found to be predictors for secondary intervention.Age (OR = 1.016, 95%CI: 0.979–1.054, p = 0.405), maximum diameter of BS (OR = 1.004,95%CI: 0.978–1.031,p = 0.745) and TPV(OR = 1.001,95%CI: 0.985–1.018,p = 0.902) were not found to be predictors. Table 2 Multivariate logistic regression analysis of factors predicting secondary intervention in patients undergoing cystolitholapaxy (B: regression coefficient, OR: odds ratio, CI: confidence interval, IPSS: international prostate symptoms score, PSA: prostate specific antigen, BS: bladder stones, TPV: total prostate volume, Qmax: peak urine flow rate, PVR: postvoid residual urine volume) Multivariate logistic regression analysis B OR %95CI P value Age (years) 0.016 1.016 0.979 1.054 0.405 IPSS 0.207 1.230 1.124 - 1.345 < 0.001 PSA (ng/mL) 0.165 1.179 1.026 - 1.356 0.02 Maximum diameter of BS (mm) 0.004 1.004 0.978 - 1.031 0.745 TPV (g) 0.001 1.001 0.985 - 1.018 0.902 Qmax (m/s) -0.245 0.783 0.670 - 0.915 0.002 PVR (mL) 0.019 1.019 1.008 - 1.031 0.001 DISCUSSION In our study,which aimed to question the necessity of simultaneous BPO intervention in patients with BS secondary to BPO and to investigate the factors predicting secondary intervention, when the data of 235 patients were examined,45 patients(19.5%) required secondary intervention during an average follow-up period of 49 months.The mean time until secondary intervention was 35.1 months. In our study, age, PVR, IPSS, PSA were found to be high and Qmax was found to be low in patients requiring secondary intervention, while in multivariate logistic regression analysis, high PVR, IPSS, PSA and low Qmax were found to be predictors for secondary intervention.Studies in the literature have frequently compared BPO patients with BS and BPO patients without BS. Our study is the largest reported cohort that includes only patients with BS who had BPO and underwent cystolitholapaxy. The increase in life expectancy causes an increase in the aging male population and hence an increase in BPO. BS often occurs due to BPO [ 13 ]. It was found that BS was seen 8 times more frequently in patients with BPO than in those without BPO [ 14 ]. Both bladder stones and BPO presence cause a decrease in quality of life(QoL) in men [ 15 ]. Although some sources state that the presence of BS in men with BPO is an absolute indication for BPO surgery [ 16 ], the necessity of performing BPO surgery in addition to cystolitholapaxy in men is controversial [ 17 ]. Perhaps the most important factor in not requiring surgical intervention for BPO after cystolitholapaxy in patients may be that the patients' symptoms are related to BS itself. Studies in the literature have found that there is an improvement in IPSS and QoL scores,an increase in Qmax, and a reduction of PVR when only cystolitholapaxy is applied to patients with BS secondary to BPO [ 10 , 18 – 21 ]. When studies evaluating patients with BS secondary to BPO and those who underwent cystolitholapaxy were examined, it was stated that in a prospective study of 50 patients, BS occurred in only 2 patients (4%) and surgery for BPO was required in 4 patients (8%) in an average follow-up of 22.3 months [ 22 ]. In another study evaluating 23 patients, it was stated that recurrent BS occurred in only 4 patients (17.4%) during an average follow-up of 30 months [ 19 ] .In their study examining 34 patients, Yoshida et al. reported that recurrent BS were detected in only 6 patients (17.6%) during an average follow-up of 52.6 months and that this occurred after an average of 37.7 months, but they emphasized that only 4 patients (11.8%) required surgical intervention for prostate [ 20 ]. In the prospective randomized controlled study by Hasan et al., surgical intervention for BPO was required in 18% at 1-year follow-up and in 30% at 2-year follow-up [ 21 ]. Another study conducted on patients over 40 years of age reported that BS recurred at a rate of 17% in a median of 28 months and that BPO surgery was required at a rate of only 5% in a 3.8-year follow-up [ 23 ]. In the study by Savin et al., 22% of patients required surgery for BPO in a median of 34 months [ 24 ]. Another study, which reported a relatively high recurrent surgery rate, emphasized that BPO-related surgery was required at a rate of 34.3% with an average follow-up of 28.2 months [ 10 ]. Chapelle et al reported that 39% of patients had recurrence of BS and 44% underwent repeat surgery at a median follow-up of 19.5 months. However,only 56% of these patients underwent surgery related to BPO. In this study, when they established the balance of benefits and losses, it was emphasized that patients who underwent surgery for BPO in addition to BS did not provide significant benefit compared to patients who underwent cystolitholapaxy [ 9 ]. Although these studies in the literature show differences in terms of the patients they include, especially in terms of age, history of urolithiasis, and medical treatment history for BPO, it is noticeable that most of the patients in the studies do not require secondary intervention. Our study is the largest reported cohort among these studies, evaluating 235 patients with BS secondary to BPO and those who underwent cystolitholapaxy with a relatively long follow-up period (mean 49 months). In our study, 45 patients (19.5%) required secondary intervention and the mean time until secondary intervention was determined as 35.1 months. It has been shown that the presence of BS increases patients' symptoms and that concurrent BPO surgery is not necessary for most patients, as in our study. However, the lack of large prospective randomized controlled trials with long follow-up periods makes it difficult to identify the ideal patient who does not need concurrent BPO surgery. However, these patients should be informed that BPO surgery may be necessary in cases where a conservative approach is not possible or that a high rate of side effects may be seen when performed simultaneously [ 5 ]. Since secondary intervention is not required in most patients with BS secondary to BPO when only cystolitholapaxy is performed,the factors that predict secondary intervention in these patients need to be investigated.Studies in the literature have mostly evaluated the factors predicting the development of BS by comparing patients with BPO without BS and those with BS due to BPO.All patients in our study had a history of BS.Our study's evaluation of factors predicting secondary intervention in patients with a history of BS is considered to be methodologically stronger than other studies. It is known that the incidence of BPO increases rapidly with age and reaches almost 100% in the ninth decade [ 25 ]. It should not be forgotten that as men age, the incidence of BPO increases and this may lead to an increase in the incidence of BS [ 26 ]. In the study by Jung et al.,it was stated that increasing age in patients with BPO resulted in an increase in the risk of BS in multivariate analysis [ 27 ]. In another study,advanced age(OR = 1.078, 95%CI: 1.020–1.139, p = 0.008) was found to be an independent predictor for BS formation [ 28 ]. In our study,although age was found to be statistically higher in patients requiring secondary intervention (p < 0.001), it was found that it did not predict secondary intervention in multivariate analysis (OR = 1.016, 95%CI: 0.979–1.054, p = 0.405). Millan-Rodriguez et al emphasized that only high IPSS is an independent factor for secondary prostate surgery [ 22 ]. In the study by Kim et al., low Qmax (OR = 0.866, 95% CI: 0.768–0.977, p = 0.019) was found to be an independent predictor for BS formation [ 28 ]. In our study, both low Qmax (OR = 0.783, 95%CI: 0.670–0.915, p = 0.002) and high IPSS (OR = 1.230, 95% CI: 1.124–1.345, p < 0.001) were found to be predictors for secondary intervention. In a study comparing BPO patients with and without BS,PSA was found to be numerically higher in the BPO patients without BS group (p = 0.10),and this was attributed to the more frequent use of indwelling catheters in the BPO patients without BS group [ 11 ]. In general terms, the findings in this study may be limited by small study and control group sizes, as random variability of any outcome assessed in a small cohort is more likely to influence observed trends. In another study, PSA was not found to be a predictor of BS formation in multivariate analysis [ 16 ]. In our study, high PSA value(OR = 1.179, 95%CI: 1.026–1.356, p = 0.02) was found to be a predictor for secondary intervention. When the factors predicting prostate surgery were evaluated, it was emphasized in the literature that stone size was not a predictive factor [ 22 ]. Similarly, in our study, mean maximum diameter of BS (OR = 1.004, 95%CI: 0.978–1.031, p = 0.745) was not found to be a predictor for secondary intervention. In addition to BPO being more common in the older age group, it is known that TPV increases with age and the prostate grows at a rate of approximately 2-2.5% per year in older men [ 29 ]. Studies in the literature frequently emphasize that TPV is an independent predictor of BS formation due to BPO and the need for secondary intervention [ 21 , 24 , 27 ]. In the study by Kim et al., TPV was not found to be a predictor for MT development in multivariate analysis [ 28 ]. In the study by Huang et al.,PSA and TPV were found to be higher in patients without BS, while no factor was found to be predictive of MT formation in multivariate analysis [ 16 ]. In our study,although TPV was found to be statistically higher in patients requiring secondary intervention (p = 0.015),it was observed that it did not predict secondary intervention in multivariate analysis (OR = 1.001, 95%CI: 0.985–1.018, p = 0.902). Studies have highlighted that high PVR is one of the factors that predict intervention for BPO in patients with BS due to BPO [ 24 ]. In the study by Philippou et al.,multivariate logistic regression analysis indicated that only high PVR (OR = 1.033, 95%CI: 1.007–1.060, p = 0.014) was a predictor for BPO surgery [ 10 ]. Similarly,in the prospective randomized controlled study of Hasan et al.,high PVR (OR = 1.03, 95% CI: 1.01–1.04, p < 0.001) was found to be a factor predicting medical treatment failure and the need for surgery for BPO in the logistic regression analysis [ 21 ]. In our study,high PVR (OR = 1.019, 95%CI: 1.008–1.031, p = 0.001) was found to be a significant predictor for secondary intervention. In a recent study comparing patients who required and did not require recurrent intervention in patients who underwent cystolitholapaxy,it was reported that recurrent BS developed at a rate of 6.1% in a median follow-up of 20 months, but surgery for BPO was required at a rate of 41.9%. Age (p = 0.606), CCI (p = 0.141), PSA(p = 0.176), IPSS(p = 0.346), TPV(p = 0.780) parameters were found to be similar between the groups. In addition,Qmax was found to be significantly lower, and PVR and size of BS were significantly higher in patients requiring recurrent intervention.In regression analysis, high PVR (OR = 1.013, 95% CI: 1.007–1.019, p < 0.001) was found to be a predictive factor for recurrent intervention [ 30 ]. In our study, an average of 5.1% complications were observed. In a prospective randomized controlled study evaluating patients who underwent cystolitholapaxy,a complication rate of 5.7% was detected,similar to our study [ 31 ]. In the review of 411 patients who underwent cystolitholapaxy,it was stated that all complications were minor and that no Clavien > II complications were observed, therefore these surgeries had a low complication risk and it was emphasized that these surgeries were safe surgeries [ 32 ]. The most important limitation of our study is its retrospective design.Other limitations include the single-center nature of the study, lack of chemical composition of the intervened BS,failure to evaluate the number of BS and intravesical prostate protrusion, and failure to evaluate QoL as a separate parameter.The advantage of our study is that it is the largest reported cohort that includes only patients who underwent BS removal among patients with BS who have BPO. Multicentered,prospective,randomized studies with high number of patients will guide us in this context in the future. Abbreviations BPO= benign prostatic obstruction BS= bladder stones ASA= American Society of Anesthesiologists PSA= prostate specific antigen Qmax= peak urine flow rate PVR= postvoid residual urine volume IPSS= international prostate symptoms score TPV= total prostate volume CCI= Charlson Comorbidity Index LUTS= lower urinary tract symptoms QoL= quality of life UTI= urinary tract infection USG= ultrasound mo= months min= minimum max= maximum n= number IQR= interquartile range SD= standard deviation OR= odds ratio CI= confidence interval B= regression coefficient Declarations Authors’ Contributions: MH Özbilen: Protocol/project development, Manuscript writing/editing MC Karabacak: Data collection or management T Tığlı: Data collection or management M Yoldaş: Data analysis Ü Uysal: Data analysis MZ Keskin: Protocol/project development G Koç: Protocol/project development ZG Gürbüz: Protocol/project development Disclosure of potential conflicts of interest : The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article. Ethical approval: The study protocol was approved by the ethics committee of Health Sciences University Izmir Tepecik Health Practice and Research Hospital (IRB: 2022/04-14).The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Informed consent: Informed consent form was obtained from all patients. Acknowledgements: None References Schwartz BF, Stoller ML (2000) THE VESICAL CALCULUS. Urologic Clinics of North America 27(2):333-346. https://doi.org/10.1016/S0094-0143(05)70262-7 Papatsoris AG, Varkarakis I, Dellis A, Deliveliotis C (2006) Bladder lithiasis: from open surgery to lithotripsy. Urol Res 34(3):163-167. https://doi.org/10.1007/S00240-006-0045-5 Philippou P, Moraitis K, Masood J, Junaid I, Buchholz N (2012) The management of bladder lithiasis in the modern era of endourology. 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Arch Esp Urol 76(2):145-151. https://doi.org/10.56434/J.ARCH.ESP.UROL.20237602.16 Jung JH, Park J, Kim WT, Kim HW, Kim HJ et al (2017) The association of benign prostatic hyperplasia with lower urinary tract stones in adult men: A retrospective multicenter study. Asian J Urol 5(2):118. https://doi.org/10.1016/J.AJUR.2017.06.008 Kim JW, Oh MM, Park HS, Cheon J, Lee JG et al (2014) Intravesical prostatic protrusion is a risk factor for bladder stone in patients with benign prostatic hyperplasia. Urology 84(5):1026-1029. https://doi.org/10.1016/J.UROLOGY.2014.06.038 Lim K Bin (2017) Epidemiology of clinical benign prostatic hyperplasia. Asian J Urol 4(3):148-151. https://doi.org/10.1016/J.AJUR.2017.06.004 Anil H, Ünal U, Karamik K, Ortoglu F, Erçil H (2023) Bladder calculi concomitant with benign prostatic enlargement: is prostate surgery mandatory in patients who have never received medical therapy? Asian J Androl 25(5):604-607. https://doi.org/10.4103/AJA2022107 Bansal A, Kumar M, Sankhwar S, Goel S, Patodia M et al (2016) Prospective randomized comparison of three endoscopic modalities used in treatment of bladder stones. Urologia 83(2):87-92. https://doi.org/10.5301/URO.5000171 Akram M, Cerrato C, Enikeev D, Tokas T, Somani BK (2024) Safety and efficacy of laser lithotripsy for treatment of bladder calculi: evidence from a systematic literature review. Curr Opin Urol. https://doi.org/10.1097/MOU.0000000000001250 Table 1 Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1WJU.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6783314","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":468242401,"identity":"cad55968-934b-4fad-842b-e2b3a304e132","order_by":0,"name":"Mert Hamza Özbilen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYJACZiBOYGMHkh8bQHzGxgMEdDA2g7UANTLObGCQAFINxGkB2cXMC9bCwIBXi2577/PHBRV1eXzMzMce2+6wqdNtPwy0pcYmGpcWszPHDZtnnGErZmNmSzfOPZMmYXYmEajlWFpuAy4tN9IYm3nbeBLbmHnMpHPbDkuYHQBqYWw4jFvL/WcgLRJALfzfpC1BWs4/JKDlBhtIiwHIFjZpRpCWG4RsOZPGOJvnTALIL2aSvW1pkttuAG1JwOeX48cYPvMAQ0y+vfmZxM82G36z8+kPH3yoscGpBQdIIE35KBgFo2AUjAI0AADrOlqrWIGcbgAAAABJRU5ErkJggg==","orcid":"","institution":"Health Sciences University Adana City Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mert","middleName":"Hamza","lastName":"Özbilen","suffix":""},{"id":468242402,"identity":"f13e8086-507c-4649-9930-33eb80298713","order_by":1,"name":"Mahmut Can Karabacak","email":"","orcid":"","institution":"Health Sciences University Izmir Tepecik Health Practice and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mahmut","middleName":"Can","lastName":"Karabacak","suffix":""},{"id":468242403,"identity":"6b97150f-7b65-4d2b-96a5-80800583dcdc","order_by":2,"name":"Taylan Tığlı","email":"","orcid":"","institution":"Health Sciences University Izmir Tepecik Health Practice and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Taylan","middleName":"","lastName":"Tığlı","suffix":""},{"id":468242404,"identity":"cc07afd3-dc2d-45ff-9893-15d04086efc6","order_by":3,"name":"Mehmet Yoldas","email":"","orcid":"","institution":"Health Sciences University Izmir Tepecik Health Practice and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"Yoldas","suffix":""},{"id":468242405,"identity":"e1dc5e9c-66e3-438f-9374-218acb325831","order_by":4,"name":"Ümit Uysal","email":"","orcid":"","institution":"Health Sciences University Adana City Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ümit","middleName":"","lastName":"Uysal","suffix":""},{"id":468242406,"identity":"62a36c04-0b07-4fc0-bd8d-87e13a4412c5","order_by":5,"name":"Mehmet Zeynel Keskin","email":"","orcid":"","institution":"Health Sciences University Izmir Tepecik Health Practice and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Zeynel","lastName":"Keskin","suffix":""},{"id":468242407,"identity":"d1c336c6-1cd8-47fa-8bee-d0b8ec5ba089","order_by":6,"name":"Gökhan Koç","email":"","orcid":"","institution":"Izmir University of Economics Medicalpoint International Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gökhan","middleName":"","lastName":"Koç","suffix":""},{"id":468242411,"identity":"9ae69d3e-8973-4f5a-8f12-bc1463d51b6b","order_by":7,"name":"Zafer Gökhan Gürbüz","email":"","orcid":"","institution":"Health Sciences University Adana City Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zafer","middleName":"Gökhan","lastName":"Gürbüz","suffix":""}],"badges":[],"createdAt":"2025-05-30 09:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6783314/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6783314/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85625440,"identity":"8d68add4-d473-4687-a60f-e1205dc7f9b3","added_by":"auto","created_at":"2025-06-29 21:16:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":535089,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6783314/v1/e4ea351d-c2dc-4f85-a348-e24ae3927e75.pdf"},{"id":84308054,"identity":"993e7fcd-ed11-4751-96e0-fe3f5093a9a4","added_by":"auto","created_at":"2025-06-10 11:49:11","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":129301,"visible":true,"origin":"","legend":"","description":"","filename":"Table1WJU.docx","url":"https://assets-eu.researchsquare.com/files/rs-6783314/v1/003aa6cb0ac00d561b595c2c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is Cystolitholapaxy Sufficient in Patients with Bladder Stones Secondary to Benign Prostatic Obstruction? ","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBladder stones(BS) are the most common stones of the lower urinary tract and constitute 5% of urinary system stone disease in developed countries [1]. BS often present with nonspecific symptoms. Pain, dysuria, hematuria, predominantly voiding lower urinary tract symptoms(LUTS) and predominantly storage LUTS are some of them [2]. These stones are traditionally classified as primary, secondary and migrant [3]. Although small stones can be expelled from the urethra on their own, surgical intervention may be performed for larger stones that cannot be expelled [4].\u003c/p\u003e\n\u003cp\u003eIn adults,BS usually occur secondarily as a result of disorders that cause urinary stasis [5]. Benign prostatic obstruction(BPO) is one of the important causes of urinary stasis in adult patients.The incidence of BS in patients with BPO is 3\u0026ndash;8% [6]. BPO is common in men aged\u0026thinsp;\u0026ge;\u0026thinsp;40 years,and BPO has been shown to be the most common cause of BS [7]. However,the presence of BPO and MT in this group of patients with abnormal urinary microenvironment,inflammation markers and metabolism is complex and multifactorial [8].\u003c/p\u003e\n\u003cp\u003eIt has been suggested that BPO may be the etiological factor in 75% of BS cases,and this has led to the idea that the presence of BS is an absolute indication for surgical treatment of BPO [3]. However, urologists are in a dilemma regarding performing simultaneous BPO surgery on patients who will undergo surgical treatment due to BS [9]. Because there is currently not enough evidence to support the necessity of performing BPO surgery in addition to cystolitholapaxy in men aged\u0026thinsp;\u0026ge;\u0026thinsp;40 years diagnosed with BS, this situation is being questioned [10, 11].\u003c/p\u003e\n\u003cp\u003eThe aim of this study is to question the necessity of simultaneous BPO intervention with cystolitholapaxy in patients with BS due to BPO and to investigate the factors predicting secondary intervention.\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cp\u003eThis retrospective study was conducted in accordance with the Declaration of Helsinki after approval by the ethics committee of Health Sciences University Izmir Tepecik Health Practice and Research Hospital (IRB: 2022/04\u0026ndash;14). Data on patients who underwent cystolitholapaxy between 2010 and 2022 were reviewed.Male patients over 40 years of age who underwent cystolitholapaxy,had a follow-up period longer than 12 months, and were thought to have BS secondary to BPO were included in the study.Patients with a history of urolithiasis, neuropathic bladder dysfunction, BS due to foreign bodies or trauma, bladder diverticula, previous or concurrent prostate surgery, history of urinary retention and indwelling catheter use, urinary diversion, urethral stricture,bladder tumor and prostate cancer, history of pelvic surgery, incomplete data,and those who could not be stone-free after cystolitholapaxy were excluded from the study.Accordingly,a total of 235 patients were evaluated after inclusion and exclusion criteria. These patients were defined as patients who did not require additional intervention(Group 1) and patients who underwent secondary intervention(Group 2). Informed consent was obtained from all patients included in the study.\u003c/p\u003e\n\u003cp\u003eIn the preoperative period,patients were evaluated with age, comorbid diseases, history of medical treatment for BPO, international prostate symptoms score(IPSS), physical examination, complete blood count,serum biochemistry tests,serum prostate specific antigen (PSA), urinalysis, urine culture, urinary system ultrasound(USG) (postvoid residual urine volume (PVR), total prostate volume (TPV), maximum diameter of the BS)and uroflowmetry.PVR was assessed in the supine position immediately after voiding. The greatest transverse (width), anteroposterior (depth) and superior-inferior(height) distances were recorded and PVR was calculated automatically by USG. TPV was evaluated based on the ellipsoid formula (0.52x width x height x length) where width (right-left) and height(anterior-posterior) were measured on the transverse plane, and length (cranial-caudal) was measured on the sagittal plane [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e] .Appropriate antibiotic treatment was given to patients with positive urine cultures, and patients with no positive control cultures were operated on In patients who were predicted to be stone-free by direct vision after surgery,stone-free status was confirmed by postoperative bladder USG.Data on patients\u0026apos; age, mode of presentation, history of medical treatment for BPO, Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) score, IPSS, PSA, maximum diameter of the BS, TPV, peak urine flow rate (Qmax), PVR, presence of postoperative complications, follow-up period, and time until secondary intervention were collected. Under the title of complications, symptomatic urinary tract infection (UTI),fever and prolonged hematuria were evaluated.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n\u003cp\u003eContinuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median (minimum-maximum) (interquartile range, IQR),while categorical variables were expressed as frequency and percentage [n (%)].The normality of data distribution was assessed using the Kolmogorov\u0026ndash;Smirnov test. For group comparisons, the Student\u0026rsquo;s t-test was used when the normality assumption was met, whereas the Mann\u0026ndash;Whitney U test was applied when the assumption was violated.\u003c/p\u003e\n\u003cp\u003eCategorical variables were compared using the Chi-square test or the Fisher\u0026rsquo;s exact test where appropriate.To determine the independent predictors of secondary intervention,a multivariate logistic regression analysis was performed.A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.All statistical analyses were conducted using IBM SPSS Statistics for Windows, version 27.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e\n"},{"header":"RESULTS","content":"\u003cp\u003eConsidering the inclusion and exclusion criteria,235 patients who underwent cystolitholapaxy between 2010 and 2022 were evaluated. Among these,190 patients who did not require additional intervention were defined as group 1,and 45 patients who required secondary intervention were defined as group 2.\u003c/p\u003e\n\u003cp\u003eIn our study, secondary surgical intervention was required at a rate of 19.5% with an average follow-up of 49 months. Comparative data of both groups are shown in Table\u0026nbsp;1.When these data were examined, the mean age was 59.3 ± 11.5 in group 1 and 63.1 ± 9.1 in group 2,and a statistically significant difference was found (p \u0026lt; 0.001).Mean Qmax was 11 m/s in group 1 and 8.6 m/s in group 2 (p \u0026lt; 0.001),PVR was 85.5 mL in group 1 and 115.3 mL in group 2(p \u0026lt; 0.001), IPSS was 16.7 in group 1 and 21.7 in group 2(p \u0026lt; 0.001).TPV(p = 0.015) and PSA(p = 0.005) were also significantly higher in group 2.The mean maximum diameter of BS was 24.9 ± 15.1 mm in group 1 and 28.6 ± 14.5 mm in group 2,and no difference was observed between the two groups(p = 0.135). No statistically significant difference was found between the patients' mode of presentation, history of medical treatment for BPO,CCI,and ASA scores.Complications occurred at a rate of 5.3% in group 1 and 4.4% in group 2(p = 0.659). The mean follow-up period was 47.3 months in group 1 and 56.1 months in group 2(p = 0.679),and the mean time until secondary intervention was 35.1 months.\u003c/p\u003e\n\u003cdiv\u003eMultivariate logistic regression analysis of factors predicting secondary intervention in patients undergoing cystolitholapaxy is shown in Table 2.Accordingly,low Qmax(odds ratio (OR) = 0.783,95% confidence interval (CI):0.670–0.915,p = 0.002),high PVR(OR = 1.019,95%CI: 1.008–1.031, p = 0.001), high IPSS(OR = 1.230, 95%CI:1.124–1.345,p \u0026lt; 0.001) and high PSA(OR = 1.179,95%CI: 1.026–1.356,p = 0.02) were found to be predictors for secondary intervention.Age (OR = 1.016, 95%CI: 0.979–1.054, p = 0.405), maximum diameter of BS (OR = 1.004,95%CI: 0.978–1.031,p = 0.745) and TPV(OR = 1.001,95%CI: 0.985–1.018,p = 0.902) were not found to be predictors.\u003c/div\u003e\n\u003cdiv\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eMultivariate logistic regression analysis of factors predicting secondary intervention in patients undergoing cystolitholapaxy (B: regression coefficient, OR: odds ratio, CI: confidence interval, IPSS: international prostate symptoms score, PSA: prostate specific antigen, BS: bladder stones, TPV: total prostate volume, Qmax: peak urine flow rate, PVR: postvoid residual urine volume)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eMultivariate logistic regression analysis\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e%95CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.979\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.405\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIPSS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.230\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.345\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSA (ng/mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximum diameter of BS (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.978\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.745\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTPV (g)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.985\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.902\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eQmax (m/s)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.783\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.670\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePVR (mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn our study,which aimed to question the necessity of simultaneous BPO intervention in patients with BS secondary to BPO and to investigate the factors predicting secondary intervention, when the data of 235 patients were examined,45 patients(19.5%) required secondary intervention during an average follow-up period of 49 months.The mean time until secondary intervention was 35.1 months. In our study, age, PVR, IPSS, PSA were found to be high and Qmax was found to be low in patients requiring secondary intervention, while in multivariate logistic regression analysis, high PVR, IPSS, PSA and low Qmax were found to be predictors for secondary intervention.Studies in the literature have frequently compared BPO patients with BS and BPO patients without BS. Our study is the largest reported cohort that includes only patients with BS who had BPO and underwent cystolitholapaxy.\u003c/p\u003e\n\u003cp\u003eThe increase in life expectancy causes an increase in the aging male population and hence an increase in BPO. BS often occurs due to BPO [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. It was found that BS was seen 8 times more frequently in patients with BPO than in those without BPO [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. Both bladder stones and BPO presence cause a decrease in quality of life(QoL) in men [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although some sources state that the presence of BS in men with BPO is an absolute indication for BPO surgery [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e], the necessity of performing BPO surgery in addition to cystolitholapaxy in men is controversial [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003ePerhaps the most important factor in not requiring surgical intervention for BPO after cystolitholapaxy in patients may be that the patients\u0026apos; symptoms are related to BS itself. Studies in the literature have found that there is an improvement in IPSS and QoL scores,an increase in Qmax, and a reduction of PVR when only cystolitholapaxy is applied to patients with BS secondary to BPO [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eWhen studies evaluating patients with BS secondary to BPO and those who underwent cystolitholapaxy were examined, it was stated that in a prospective study of 50 patients, BS occurred in only 2 patients (4%) and surgery for BPO was required in 4 patients (8%) in an average follow-up of 22.3 months [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. In another study evaluating 23 patients, it was stated that recurrent BS occurred in only 4 patients (17.4%) during an average follow-up of 30 months [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] .In their study examining 34 patients, Yoshida et al. reported that recurrent BS were detected in only 6 patients (17.6%) during an average follow-up of 52.6 months and that this occurred after an average of 37.7 months, but they emphasized that only 4 patients (11.8%) required surgical intervention for prostate [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. In the prospective randomized controlled study by Hasan et al., surgical intervention for BPO was required in 18% at 1-year follow-up and in 30% at 2-year follow-up [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Another study conducted on patients over 40 years of age reported that BS recurred at a rate of 17% in a median of 28 months and that BPO surgery was required at a rate of only 5% in a 3.8-year follow-up [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. In the study by Savin et al., 22% of patients required surgery for BPO in a median of 34 months [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Another study, which reported a relatively high recurrent surgery rate, emphasized that BPO-related surgery was required at a rate of 34.3% with an average follow-up of 28.2 months [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. Chapelle et al reported that 39% of patients had recurrence of BS and 44% underwent repeat surgery at a median follow-up of 19.5 months. However,only 56% of these patients underwent surgery related to BPO. In this study, when they established the balance of benefits and losses, it was emphasized that patients who underwent surgery for BPO in addition to BS did not provide significant benefit compared to patients who underwent cystolitholapaxy [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eAlthough these studies in the literature show differences in terms of the patients they include, especially in terms of age, history of urolithiasis, and medical treatment history for BPO, it is noticeable that most of the patients in the studies do not require secondary intervention. Our study is the largest reported cohort among these studies, evaluating 235 patients with BS secondary to BPO and those who underwent cystolitholapaxy with a relatively long follow-up period (mean 49 months). In our study, 45 patients (19.5%) required secondary intervention and the mean time until secondary intervention was determined as 35.1 months.\u003c/p\u003e\n\u003cp\u003eIt has been shown that the presence of BS increases patients\u0026apos; symptoms and that concurrent BPO surgery is not necessary for most patients, as in our study. However, the lack of large prospective randomized controlled trials with long follow-up periods makes it difficult to identify the ideal patient who does not need concurrent BPO surgery. However, these patients should be informed that BPO surgery may be necessary in cases where a conservative approach is not possible or that a high rate of side effects may be seen when performed simultaneously [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eSince secondary intervention is not required in most patients with BS secondary to BPO when only cystolitholapaxy is performed,the factors that predict secondary intervention in these patients need to be investigated.Studies in the literature have mostly evaluated the factors predicting the development of BS by comparing patients with BPO without BS and those with BS due to BPO.All patients in our study had a history of BS.Our study\u0026apos;s evaluation of factors predicting secondary intervention in patients with a history of BS is considered to be methodologically stronger than other studies.\u003c/p\u003e\n\u003cp\u003eIt is known that the incidence of BPO increases rapidly with age and reaches almost 100% in the ninth decade [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. It should not be forgotten that as men age, the incidence of BPO increases and this may lead to an increase in the incidence of BS [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. In the study by Jung et al.,it was stated that increasing age in patients with BPO resulted in an increase in the risk of BS in multivariate analysis [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. In another study,advanced age(OR\u0026thinsp;=\u0026thinsp;1.078, 95%CI: 1.020\u0026ndash;1.139, p\u0026thinsp;=\u0026thinsp;0.008) was found to be an independent predictor for BS formation [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. In our study,although age was found to be statistically higher in patients requiring secondary intervention (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), it was found that it did not predict secondary intervention in multivariate analysis (OR\u0026thinsp;=\u0026thinsp;1.016, 95%CI: 0.979\u0026ndash;1.054, p\u0026thinsp;=\u0026thinsp;0.405).\u003c/p\u003e\n\u003cp\u003eMillan-Rodriguez et al emphasized that only high IPSS is an independent factor for secondary prostate surgery [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. In the study by Kim et al., low Qmax (OR\u0026thinsp;=\u0026thinsp;0.866, 95% CI: 0.768\u0026ndash;0.977, p\u0026thinsp;=\u0026thinsp;0.019) was found to be an independent predictor for BS formation [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. In our study, both low Qmax (OR\u0026thinsp;=\u0026thinsp;0.783, 95%CI: 0.670\u0026ndash;0.915, p\u0026thinsp;=\u0026thinsp;0.002) and high IPSS (OR\u0026thinsp;=\u0026thinsp;1.230, 95% CI: 1.124\u0026ndash;1.345, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were found to be predictors for secondary intervention.\u003c/p\u003e\n\u003cp\u003eIn a study comparing BPO patients with and without BS,PSA was found to be numerically higher in the BPO patients without BS group (p\u0026thinsp;=\u0026thinsp;0.10),and this was attributed to the more frequent use of indwelling catheters in the BPO patients without BS group [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. In general terms, the findings in this study may be limited by small study and control group sizes, as random variability of any outcome assessed in a small cohort is more likely to influence observed trends. In another study, PSA was not found to be a predictor of BS formation in multivariate analysis [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. In our study, high PSA value(OR\u0026thinsp;=\u0026thinsp;1.179, 95%CI: 1.026\u0026ndash;1.356, p\u0026thinsp;=\u0026thinsp;0.02) was found to be a predictor for secondary intervention. When the factors predicting prostate surgery were evaluated, it was emphasized in the literature that stone size was not a predictive factor [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similarly, in our study, mean maximum diameter of BS (OR\u0026thinsp;=\u0026thinsp;1.004, 95%CI: 0.978\u0026ndash;1.031, p\u0026thinsp;=\u0026thinsp;0.745) was not found to be a predictor for secondary intervention.\u003c/p\u003e\n\u003cp\u003eIn addition to BPO being more common in the older age group, it is known that TPV increases with age and the prostate grows at a rate of approximately 2-2.5% per year in older men [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Studies in the literature frequently emphasize that TPV is an independent predictor of BS formation due to BPO and the need for secondary intervention [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. In the study by Kim et al., TPV was not found to be a predictor for MT development in multivariate analysis [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. In the study by Huang et al.,PSA and TPV were found to be higher in patients without BS, while no factor was found to be predictive of MT formation in multivariate analysis [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. In our study,although TPV was found to be statistically higher in patients requiring secondary intervention (p\u0026thinsp;=\u0026thinsp;0.015),it was observed that it did not predict secondary intervention in multivariate analysis (OR\u0026thinsp;=\u0026thinsp;1.001, 95%CI: 0.985\u0026ndash;1.018, p\u0026thinsp;=\u0026thinsp;0.902).\u003c/p\u003e\n\u003cp\u003eStudies have highlighted that high PVR is one of the factors that predict intervention for BPO in patients with BS due to BPO [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. In the study by Philippou et al.,multivariate logistic regression analysis indicated that only high PVR (OR\u0026thinsp;=\u0026thinsp;1.033, 95%CI: 1.007\u0026ndash;1.060, p\u0026thinsp;=\u0026thinsp;0.014) was a predictor for BPO surgery [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. Similarly,in the prospective randomized controlled study of Hasan et al.,high PVR (OR\u0026thinsp;=\u0026thinsp;1.03, 95% CI: 1.01\u0026ndash;1.04, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was found to be a factor predicting medical treatment failure and the need for surgery for BPO in the logistic regression analysis [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our study,high PVR (OR\u0026thinsp;=\u0026thinsp;1.019, 95%CI: 1.008\u0026ndash;1.031, p\u0026thinsp;=\u0026thinsp;0.001) was found to be a significant predictor for secondary intervention.\u003c/p\u003e\n\u003cp\u003eIn a recent study comparing patients who required and did not require recurrent intervention in patients who underwent cystolitholapaxy,it was reported that recurrent BS developed at a rate of 6.1% in a median follow-up of 20 months, but surgery for BPO was required at a rate of 41.9%. Age (p\u0026thinsp;=\u0026thinsp;0.606), CCI (p\u0026thinsp;=\u0026thinsp;0.141), PSA(p\u0026thinsp;=\u0026thinsp;0.176), IPSS(p\u0026thinsp;=\u0026thinsp;0.346), TPV(p\u0026thinsp;=\u0026thinsp;0.780) parameters were found to be similar between the groups. In addition,Qmax was found to be significantly lower, and PVR and size of BS were significantly higher in patients requiring recurrent intervention.In regression analysis, high PVR (OR\u0026thinsp;=\u0026thinsp;1.013, 95% CI: 1.007\u0026ndash;1.019, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was found to be a predictive factor for recurrent intervention [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn our study, an average of 5.1% complications were observed. In a prospective randomized controlled study evaluating patients who underwent cystolitholapaxy,a complication rate of 5.7% was detected,similar to our study [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. In the review of 411 patients who underwent cystolitholapaxy,it was stated that all complications were minor and that no Clavien\u0026thinsp;\u0026gt;\u0026thinsp;II complications were observed, therefore these surgeries had a low complication risk and it was emphasized that these surgeries were safe surgeries [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe most important limitation of our study is its retrospective design.Other limitations include the single-center nature of the study, lack of chemical composition of the intervened BS,failure to evaluate the number of BS and intravesical prostate protrusion, and failure to evaluate QoL as a separate parameter.The advantage of our study is that it is the largest reported cohort that includes only patients who underwent BS removal among patients with BS who have BPO. Multicentered,prospective,randomized studies with high number of patients will guide us in this context in the future.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBPO= benign prostatic obstruction\u003c/p\u003e\n\u003cp\u003eBS= bladder stones\u003c/p\u003e\n\u003cp\u003eASA= American Society of Anesthesiologists\u003c/p\u003e\n\u003cp\u003ePSA= prostate specific antigen\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQmax= peak urine flow rate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePVR= postvoid residual urine volume\u003c/p\u003e\n\u003cp\u003eIPSS= international prostate symptoms score\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTPV= total prostate volume\u003c/p\u003e\n\u003cp\u003eCCI= Charlson Comorbidity Index\u003c/p\u003e\n\u003cp\u003eLUTS= lower urinary tract symptoms\u003c/p\u003e\n\u003cp\u003eQoL= quality of life\u003c/p\u003e\n\u003cp\u003eUTI= urinary tract infection\u003c/p\u003e\n\u003cp\u003eUSG= ultrasound\u003c/p\u003e\n\u003cp\u003emo= months\u003c/p\u003e\n\u003cp\u003emin= minimum\u0026nbsp;\u003c/p\u003e\n\u003cp\u003emax= maximum\u0026nbsp;\u003c/p\u003e\n\u003cp\u003en= number\u003c/p\u003e\n\u003cp\u003eIQR= interquartile range\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSD= standard deviation\u003c/p\u003e\n\u003cp\u003eOR= odds ratio\u003c/p\u003e\n\u003cp\u003eCI= confidence interval\u003c/p\u003e\n\u003cp\u003eB= regression coefficient\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eMH \u0026Ouml;zbilen:\u003c/strong\u003e Protocol/project development, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eMC Karabacak:\u0026nbsp;Data collection or management\u003c/p\u003e\n\u003cp\u003eT Tığlı:\u0026nbsp;Data collection or management\u003c/p\u003e\n\u003cp\u003eM Yoldaş:\u0026nbsp;Data analysis\u003c/p\u003e\n\u003cp\u003e\u0026Uuml; Uysal:\u0026nbsp;Data analysis\u003c/p\u003e\n\u003cp\u003eMZ Keskin:\u0026nbsp;Protocol/project development\u003c/p\u003e\n\u003cp\u003eG Ko\u0026ccedil;:\u0026nbsp;Protocol/project development\u003c/p\u003e\n\u003cp\u003eZG G\u0026uuml;rb\u0026uuml;z:\u0026nbsp;Protocol/project development\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of potential conflicts of interest\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The author(s) received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e The study protocol was approved by\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ethe ethics committee of Health Sciences University Izmir Tepecik Health Practice and Research Hospital \u0026nbsp;(IRB: 2022/04-14).The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u0026nbsp;\u003c/strong\u003eInformed consent form was obtained from all patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSchwartz BF, Stoller ML (2000) THE VESICAL CALCULUS. Urologic Clinics of North America 27(2):333-346. https://doi.org/10.1016/S0094-0143(05)70262-7\u003c/li\u003e\n\u003cli\u003ePapatsoris AG, Varkarakis I, Dellis A, Deliveliotis C (2006) Bladder lithiasis: from open surgery to lithotripsy. Urol Res 34(3):163-167. https://doi.org/10.1007/S00240-006-0045-5\u003c/li\u003e\n\u003cli\u003ePhilippou P, Moraitis K, Masood J, Junaid I, Buchholz N (2012) The management of bladder lithiasis in the modern era of endourology. Urology 79(5):980-986. https://doi.org/10.1016/j.urology.2011.09.014\u003c/li\u003e\n\u003cli\u003eGangkak G, Yadav SS, Tomar V, Vyas N, Jain D (2016) Pneumatic cystolithotripsy versus holmium:yag laser cystolithotripsy in the treatment of pediatric bladder stones: a prospective randomized study. Pediatr Surg Int 32(6):609-614. https://doi.org/10.1007/S00383-016-3876-3\u003c/li\u003e\n\u003cli\u003eCicione A, Denunzio C, Manno S, Damiano R, Posti A et al (2018) Bladder stone management: An update. 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Front Immunol 13:842008. https://doi.org/10.3389/FIMMU.2022.842008\u003c/li\u003e\n\u003cli\u003eChapelle C, Lavall\u0026eacute;e E, Vall\u0026eacute;e M, Descazeaud A (2024) Bicentric retrospective study comparing the postoperative outcomes of patients treated surgically for bladder stones with or without concomitant surgery for BPH. World J Urol 42(1):1-7. https://doi.org/10.1007/S00345-023-04699-Z/METRICS\u003c/li\u003e\n\u003cli\u003ePhilippou P, Volanis D, Kariotis I, Serafetinidis E, Delakas D (2011) Prospective comparative study of endoscopic management of bladder lithiasis: is prostate surgery a necessary adjunct? Urology 78(1):43-47. https://doi.org/10.1016/J.UROLOGY.2010.10.035\u003c/li\u003e\n\u003cli\u003eChilds MA, Mynderse LA, Rangel LJ, Wilson TM, Lingeman JE et al (2013) Pathogenesis of bladder calculi in the presence of urinary stasis. Journal of Urology 189(4):1347-1351. https://doi.org/10.1016/J.JURO.2012.11.079\u003c/li\u003e\n\u003cli\u003eHuang Foen Chung JWNC, De Vries SH, Raaijmakers R, Postma R, Bosch JLHR et al (2004) Prostate Volume Ultrasonography: The Influence of Transabdominal versus Transrectal Approach, Device Type and Operator. Eur Urol 46(3):352-356. https://doi.org/10.1016/J.EURURO.2004.05.002\u003c/li\u003e\n\u003cli\u003eAron M, Goel R, Gautam G, Seth A, Gupta NP (2007) Percutaneous versus transurethral cystolithotripsy and TURP for large prostates and large vesical calculi: refinement of technique and updated data. Int Urol Nephrol 39(1):173-177. https://doi.org/10.1007/S11255-005-0247-8\u003c/li\u003e\n\u003cli\u003eGrosse H (1990) [Frequency, localization and associated disorders in urinary calculi. Analysis of 1671 autopsies in urolithiasis]. Z Urol Nephrol 83(9):469-474. \u003c/li\u003e\n\u003cli\u003ePark S, Ryu JM, Lee M (2020) Quality of Life in Older Adults with Benign Prostatic Hyperplasia. Healthcare 8(2):158. https://doi.org/10.3390/HEALTHCARE8020158\u003c/li\u003e\n\u003cli\u003eHuang W, Cao JJ, Cao M, Wu HS, Yang YY et al (2017) Risk factors for bladder calculi in patients with benign prostatic hyperplasia. Medicine 96(32):e7728. https://doi.org/oi:10.1097/MD.0000000000007728\u003c/li\u003e\n\u003cli\u003eGadelkareem RA, Shalaby MM, Faddan AA (2023) Predictors of clinical and surgical characteristics of giant stones of the urinary bladder: a retrospective study. BMC Urol 23(1). https://doi.org/10.1186/S12894-023-01261-2\u003c/li\u003e\n\u003cli\u003eMill\u0026aacute;n-Rodr\u0026iacute;guez F, Errando-Smet C, Rousaud-Bar\u0026oacute;n F, Izquierdo-Latorre F, Rousaud-Bar\u0026oacute;n A et al (2004) Urodynamic findings before and after noninvasive management of bladder calculi. BJU Int 93(9):1267-1270. https://doi.org/10.1111/J.1464-410X.2004.04815.X\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Connor RC, Laven BA, Bales GT, Gerber GS (2002) Nonsurgical management of benign prostatic hyperplasia in men with bladder calculi. Urology 60(2):288-291. https://doi.org/10.1016/S0090-4295(02)01698-9\u003c/li\u003e\n\u003cli\u003eYoshida T, Kinoshita H, Nakamoto T, Yanishi M, Sugi M et al (2015) Conservative Treatment for Benign Prostatic Hyperplasia in Patients with Bladder Stones. Urology 86(3):450-453. https://doi.org/10.1016/J.UROLOGY.2015.04.022\u003c/li\u003e\n\u003cli\u003eHasan AM, AbdelRazek M, Ali AF, Alsaghier OM, Ahmed AA et al (2022) Synchronous transurethral cystolitholapaxy and TURP reveals better results than transurethral cystolitholapaxy plus medical therapy for BPH: a randomized prospective study on 100 patients with concomitant urinary bladder stone(s) and BPH. World J Urol 40(2):483-487. https://doi.org/10.1007/S00345-021-03882-4\u003c/li\u003e\n\u003cli\u003eMill\u0026aacute;n-Rodr\u0026iacute;guez F, Izquierdo-Latorre F, Montlle\u0026oacute;-Gonz\u0026aacute;lez M, Rousaud-Bar\u0026oacute;n F, Rousaud-Bar\u0026oacute;n A et al (2005) Treatment of bladder stones without associated prostate surgery: results of a prospective study. Urology 66(3):505-509. https://doi.org/10.1016/J.UROLOGY.2005.03.072\u003c/li\u003e\n\u003cli\u003eMaresca G, Mc Clinton S, Swami S, El-Mokadem I, Donaldson JF (2022) Do men with bladder stones benefit from treatment of benign prostatic obstruction? BJU Int 130(5):619-627. https://doi.org/10.1111/BJU.15761\u003c/li\u003e\n\u003cli\u003eSavin Z, Rahmani LD, Frangopoulos E, Gupta K, Durbhakula V et al (2025) Is Treating Bladder Outlet Really Needed when Removing Bladder Stones: Outcomes of Bladder Stones Removal Without Concomitant BPO Surgery. J Endourol 39(1). https://doi.org/10.1089/END.2024.0682\u003c/li\u003e\n\u003cli\u003eYoo TK, Cho HJ (2012) Benign prostatic hyperplasia: from bench to clinic. Korean J Urol 53(3):139-148. https://doi.org/10.4111/KJU.2012.53.3.139\u003c/li\u003e\n\u003cli\u003eFirasi AA, Soebadi MA, Himawan B, Diarsvitri W (2023) Age, Benign Prostatic Hyperplasia, Geography of Residence, and Occupation are Predictors of Bladder Calculi in Men: A Three-Year Data Analysis. Arch Esp Urol 76(2):145-151. https://doi.org/10.56434/J.ARCH.ESP.UROL.20237602.16\u003c/li\u003e\n\u003cli\u003eJung JH, Park J, Kim WT, Kim HW, Kim HJ et al (2017) The association of benign prostatic hyperplasia with lower urinary tract stones in adult men: A retrospective multicenter study. Asian J Urol 5(2):118. https://doi.org/10.1016/J.AJUR.2017.06.008\u003c/li\u003e\n\u003cli\u003eKim JW, Oh MM, Park HS, Cheon J, Lee JG et al (2014) Intravesical prostatic protrusion is a risk factor for bladder stone in patients with benign prostatic hyperplasia. Urology 84(5):1026-1029. https://doi.org/10.1016/J.UROLOGY.2014.06.038\u003c/li\u003e\n\u003cli\u003eLim K Bin (2017) Epidemiology of clinical benign prostatic hyperplasia. Asian J Urol 4(3):148-151. https://doi.org/10.1016/J.AJUR.2017.06.004\u003c/li\u003e\n\u003cli\u003eAnil H, \u0026Uuml;nal U, Karamik K, Ortoglu F, Er\u0026ccedil;il H (2023) Bladder calculi concomitant with benign prostatic enlargement: is prostate surgery mandatory in patients who have never received medical therapy? Asian J Androl 25(5):604-607. https://doi.org/10.4103/AJA2022107\u003c/li\u003e\n\u003cli\u003eBansal A, Kumar M, Sankhwar S, Goel S, Patodia M et al (2016) Prospective randomized comparison of three endoscopic modalities used in treatment of bladder stones. Urologia 83(2):87-92. https://doi.org/10.5301/URO.5000171\u003c/li\u003e\n\u003cli\u003eAkram M, Cerrato C, Enikeev D, Tokas T, Somani BK (2024) Safety and efficacy of laser lithotripsy for treatment of bladder calculi: evidence from a systematic literature review. Curr Opin Urol. https://doi.org/10.1097/MOU.0000000000001250\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"bladder stones, benign prostatic obstruction, secondary intervention, cystolitholapaxy","lastPublishedDoi":"10.21203/rs.3.rs-6783314/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6783314/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo question the necessity of simultaneous BPO intervention with cystolitholapaxy in patients with BS due to BPO and to investigate the factors predicting secondary intervention.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 235 male patients over 40 years of age who underwent cystolitholapaxy,had a follow-up period longer than 12 months,and were thought to have BS secondary to BPO were included in the study.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e190 patients who did not require additional intervention were defined as group 1,and 45 patients who required secondary intervention were defined as group 2.Secondary surgical intervention was required at a rate of 19.5% with an average follow-up of 49 months.Mean peak urine flow rate(Qmax) was 11 m/s in group 1 and 8.6 m/s in group 2(p\u0026thinsp;\u0026lt;\u0026thinsp;0.001),postvoid residual urine volume(PVR) was 85.5 mL in group 1 and 115.3 mL in group 2(p\u0026thinsp;\u0026lt;\u0026thinsp;0.001),international prostate symptoms score(IPSS) was 16.7 in group 1 and 21.7 in group 2(p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).Total prostate volume (TPV)(p\u0026thinsp;=\u0026thinsp;0.015) and serum prostate specific antigen(PSA)(p\u0026thinsp;=\u0026thinsp;0.005) were also significantly higher in group 2.In the multivariate logistic regression analysis of factors predicting secondary intervention in patients undergoing cystolitholapaxy,low Qmax(odds ratio (OR)\u0026thinsp;=\u0026thinsp;0.783,95% confidence interval(CI):0.670\u0026ndash;0.915,p\u0026thinsp;=\u0026thinsp;0.002),high PVR(OR\u0026thinsp;=\u0026thinsp;1.019, 95%CI:1.008\u0026ndash;1.031,p\u0026thinsp;=\u0026thinsp;0.001),high IPSS(OR\u0026thinsp;=\u0026thinsp;1.230,95%CI:1.124\u0026ndash;1.345,p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and high PSA(OR\u0026thinsp;=\u0026thinsp;1.179,95%CI:1.026\u0026ndash;1.356,p\u0026thinsp;=\u0026thinsp;0.02) were found to be predictors for secondary intervention.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn patients with BS secondary to BPO,performing cystolitholapaxy offers a high likelihood of avoiding secondary intervention.Therefore, it would be more appropriate for urologists to decide on BPO surgery in addition to cystolitholapaxy by taking into account the parameters such as low Qmax,high PVR,high IPSS,and high PSA,which are predictors of secondary surgery in the preoperative period,with a patient-centered approach.\u003c/p\u003e","manuscriptTitle":"Is Cystolitholapaxy Sufficient in Patients with Bladder Stones Secondary to Benign Prostatic Obstruction?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-10 11:49:06","doi":"10.21203/rs.3.rs-6783314/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"54e0ae10-a88d-4304-b074-8e2eb149f3f1","owner":[],"postedDate":"June 10th, 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