Open Cystolithotomy Under Local Anesthesia in a High-Risk Patient With a Giant Bladder Stone and Unilateral Lung Collapse: A Case Report.

Abstract

Introduction: Giant bladder stone is rare in current scenarios. When patients also have severe pulmonary disease, anesthesia becomes high risk. This case illustrates how open cystolithotomy under local anesthesia can be a viable option in such medically compromised patients.

Case presentation: A 60-year-old male from rural Eastern Nepal presented after prolonged history of lower urinary tract symptoms, hematuria, and progressive shortness of breath. Chest imaging revealed a collapsed left lung. Abdominal imaging showed a giant bladder stone (11 ^∗8 cm). Given the patient's severely reduced pulmonary reserve, he underwent open cystolithotomy under local anesthesia with mild sedation. The stone was removed successfully with no major perioperative complications.

Discussion: In patients with a collapsed left lung, the anesthetic risk associated with general or spinal anesthesia is significantly high. In such circumstances, local anesthesia with sedation, although uncommon for open bladder surgery, may be considered when the patient's clinical condition mandates it. Adequate preoperative optimization, including chest physiotherapy and careful perioperative monitoring, is essential. Management requires balancing the risks of anesthesia against the risks of leaving the stone untreated, such as infection, renal damage, and bladder dysfunction.

Conclusion: Open cystolithotomy under local anesthesia with mild sedation may be a feasible alternative in high-risk cases with giant bladder stone where general/regional anesthesia is contraindicated. Early detection, multidisciplinary management, and resource allocation are essential especially in rural and under-resourced regions for prevention and management of these cases.