Cystolitholapaxy is a usually straightforward procedure that usually poses minimal challenges to endourologists. However occasionally endourologists may encounter surprises and unexpected intraoperative findings that may change the course of the procedure. In our case we encountered a large and intact whole piece of Gauze encrusted with stone and although converting to cystotomy and extrusion of foreign body is a plausible option that many urologists may resort to we sought to attempt to remove it purely endoscopically. This is the first study to demonstrate different endoscopic approaches to treat a bladder stone formed over a retained gauze.

A 57 year old male with history of muscle invasive bladder cancer who underwent cystoprostatectomy and neobladder urinary diversion in 2017, foley dependent due to urinary incontinence presented to us with a large bladder stone > 4 cm. We performed cystoscopy using a 22-French sheath and 30-degree telescope. On cystoscopy the urethra was normal and prostate was absent. There was large 4 cm stone in neobladder with leucoplakia on posterior wall. The ureteric orifices were not identified. We proceeded to fragment his stone with Holmium:YAG laser 2 J x 60 Hz. As we proceeded to fragment the shell of the stone a huge gauze was discovered inside the stone. Multiple different techniques were employed in attempt to remove it including the endoscopic stone grasper, laparoscopic grasper, Tri-prong grasper, Lumenis® VersaCut morcellator, and laparoscopic scissors.

The procedure began with cystolithotripsy of the stone shell with Holmium:YAG laser at 2 J x 60 Hz that revealed a gauze inside the stone. We implemented different techniques in manipulating and breaking the foreign body including the endoscopic stone grasper, laparoscopic grasper, three pronged grasper and Tri-prong grasper. Next, we proceeded to use the VersaCut morcellator on the gauze. Lastly we resorted to using laparoscopic scissors to cut and breakdown the retained gauze and eventually succeeded in completing the procedure. Operation time was 263 min, and estimated blood loss was 5cc. The patient was discharged home on post-operative day 1 with no intra-operative or post-operative complications and failed voiding trial on 2 weeks follow up due to urinary incontinence. The stone was composed of 70% struvite and 26% of calcium phosphate

Endoscopic treatment of bladder stones with an unexpected large foreign body can be difficult, time consuming and inefficient with the use of one modality. Improvisation and varying techniques are very important for endourologists to tackle difficult surgical challenges and enhance endoscopic efficiency.