bladder calculi in older men are commonly associated with prostatomegaly causing chronic bladder outlet obstruction . in most cases , these stones are removed endoscopically with transurethral disintegration employing mechanical , ultrasonic , or electrohydraulic lithotripsy , swiss lithoclast , and holmium : yag laser . for patients with multiple or large stones , alternative approaches including combination percutaneous and transurethral cystolithotripsy , and percutaneous cystolithotomy have also recently been reported . these procedures invariably require anesthesia and hospitalization , and occasionally result in bladder perforation or postoperative urethral strictures . robotic - assisted radical prostatectomy ( rarp ) using the da vinci system ( intuitive surgical , inc , sunnyvale , ca ) has become increasingly popular as primary therapy for early prostate cancer , accounting for over 70% of all radical prostatectomies performed in the united states in 2008 . in these patients , concomitant vesical stones single - stage retrieval of vesical calculi may be easily performed robotically upon opening the bladder neck . with seven degrees of freedom afforded by the patented endowrist robotic instruments , stone manipulation and handling is greatly facilitated with minimal trauma to the bladder mucosa , minimizing the risk of postoperative hematuria and clot retention that is associated with prolonged cystolithotripsy or cystolitholapaxy in the setting of large or multiple stones . we present a case of a 64-year - old male with gleason 3 + 4 prostate cancer with concomitant multiple asymptomatic bladder stones diagnosed on preoperative endorectal magnetic resonance imaging of the prostate , the largest measuring 16 mm . our technique of athermal nerve - sparing robotic prostatectomy with anatomic restoration of the vesicourethral junction has been previously described . we employ a six - port transabdominal approach using the da vinci surgical system ( intuitive surgical inc , sunnyvale , ca ) . after the bladder was dissected off the pelvis , the contours of the vesicoprostatic junction were visualized and bladder neck transection was commenced anteriorly . given the prominent median lobe of the prostate encountered [ figure 1a ] , posterior bladder neck transection was completed after visual identification of both ureteral orifices with the aid of intravenous indigo carmine . the vasa deferentia were ligated and divided between clips , and both seminal vesicles dissected from their pedicles . ( a ) prominent median lobe of prostate noted on bladder neck transection during robotic - assisted radical prostatectomy . ( b ) bladder stone retrieval using endowrist prograsp forceps while bladder neck held open with endowrist maryland forceps . ( d ) the bladder inspected for residual calculi  the mucosa appears trabeculated and inflamed from chronic outlet obstruction the right - sided endowrist hot shear scissors on the right robotic arm was then exchanged for a robotic prograsp forceps . holding open the bladder neck with the left - sided maryland forceps , the prograsp forceps were used to manually retrieve the bladder stones one at a time [ figure 1b ] . each stone was deposited into an endocatch gold laparoscopic entrapment sac ( covidien inc . , the bladder was then inspected for residual stones using both graspers to manipulate the transected bladder neck , and bladder irrigation with normal saline performed repeatedly to ensure complete stone clearance [ figure 1d ] . thereafter , robotic prostatectomy and vesicourethral anastomosis was completed in our usual fashion , and the specimen with bilateral lymph nodes removed with the entrapped stones in the same endocatch gold sac . final pathologic assessment confirmed gleason 3 + 4 adenocarcinoma of the prostate , weighing 61 g . the patient was discharged home on the first postoperative day , and his foley urethral catheter removed on the seventh postoperative day . the patient reported passage of two tiny stone fragments after catheter removal , with significantly improved urinary stream . flexible cystoscopy at 6 weeks follow - up showed no evidence of residual stones in the bladder , with the patient using one pad a day for continence . vesical calculi are seen in 2530% of patients with bladder outlet obstruction , and in the setting of retained or infected urine arises from supernaturation and nucleation around a nidus . bladder stone composition varies geographically , being predominantly of calcium oxalate origin in the united states , while uric acid or urate stones predominate in europe . in patients with large , hard , or multiple stones with prostatic hyperplasia , single - setting transurethral cystolithotripsy or cystolitholapaxy with resection of prostate , albeit desirable , has been reported to be technically challenging and associated with morbidities that included significant hematuria , urethral stone impaction , sepsis , and incomplete stone clearance with need for repeated or staged procedures . for these patients , open cystolithotomy remains the most expeditious approach for swift and complete stone eradication . we were able to achieve complete stone clearance using the prograsp forceps [ figure 2a ] , which are best suited for smooth flat or rounded stones , while smaller stones with jagged and irregular surfaces may be handled using the serrated inner jaws of the endowrist cobra forceps ( intuitive surgical inc . , the graptor forceps afforded extended length for securing the stone between its jaws [ figure 2c ] . although not required in our case , bladder neck incision may be easily extended to facilitate retrieval of very large bladder stones , followed by racquet handle closure prior to vesicourethral anastomosis construction . a separate laparoscopic entrapment sac may be required for these sizable stones . in patients with stones in bladder diverticuli , concomitant robotic diverticulectomy should be performed to ameliorate the possibility of recurrent stone formation due to urinary stasis . ( courtesy of intuitive surgical inc . , sunnyvale , ca . ) ensuring complete stone clearance may be difficult in a capacious chronically distended bladder . we employed direct vision of the bladder interior while holding the neck wide open with both forceps , followed by saline irrigation until bladder distension . this can indeed be challenging especially with the patient in the trendelenburg position where the stones will tend to gravitate toward the bladder dome ; however , dissection of vasa deferentia and seminal vesicles permits the bladder neck to be manipulated in various directions , making it easier to access the bladder dome and other hidden regions for subsequent stone retrieval and laparoscopic inspection . on - table passage of a flexible cystoscope under robotic guidance into the bladder followed by saline distension or passage of a basket / grasper for direct stone removal was an alternative approach we had considered for ensuring stone clearance , but is ergonomically challenging given the sizable footprint of the robotic platform and arms . in summary , single - stage cystolithotomy during robotic radical prostatectomy is easy to perform given the augmented dexterity and repertoire of the available robotic grasping instruments , causes minimal morbidity , and obviates the need for prior transurethral cystolithotripsy or cystolitholapaxy that could potentially result in urethral stricture formation and compromise of continence return .
asymptomatic concomitant vesical calculi are an occasional finding on routine radiologic staging and evaluation of patients with early prostate cancer . 
 we report the first case of single - stage robotic cystolithotomy for multiple bladder stones in a 64-year - old man undergoing robotic - assisted radical prostatectomy , and discuss the approaches available for ensuring complete stone clearance in this unique setting . 
 we show that concomitant bladder stone extraction during robotic - assisted radical prostatectomy is feasible and does not add significantly to operative time . 
 this technique avoids the need to undergo additional general anesthetic procedures with potential complications such as bleeding , urethral stricture formation , and bladder perforation , prior to the prostatectomy .