Day Case Surgery Research Articles

Pregabalin/celecoxib versus midazolam/celecoxib as pre-emptive analgesia for minor day-case surgery

Background Surgical stress is one of the most common causes of perioperative anxiety and postoperative pain. Pregabalin and celecoxib (P/C) have different mechanisms of analgesia demonstrated after a variety of surgical procedures. This study was designed to evaluate the efficacy, sedation, and postoperative pain control using combination of P/C as against midazolam and celecoxib (M/C) as a premedication. Patients and methods Sixty adult patients (20-60 years of age), ASA physical status I and II, of either sex scheduled to undergo elective minor day-case surgeries were randomly allocated into two groups of 30 patients each in this prospective study. Group I (P/C) received oral pregabalin (150 mg) and celecoxib (200 mg) 1 h before surgery, whereas group II (M/C) received oral midazolam (7.5 mg) and celecoxib (200 mg) 1 h before surgery. Preoperative sedation level was assessed using the Ramsay sedation scale. Intraoperative and postoperative analgesic consumption, the time to first analgesic requirement, and postoperative pain were recorded using visual analog scale. Adverse events were also recorded. Results Preoperative sedation level and intraoperative hemodynamic parameters were significantly higher in the M/C group compared with the P/C group. Intraoperative and postoperative analgesic consumption were significantly higher in the M/C group, whereas the time for first analgesic requirement was significantly higher in the P/C group compared with the M/C group. Conclusion Premedication using combination of P/C in day-case surgery decreased analgesic consumption and had a good sedative level with limited adverse effects.

Efficacy of intravenous dexketoprofen trometamol compared to intravenous paracetamol for postoperative pain management after day-case operative hysteroscopy: randomized, double-blind, placebo-controlled study

Adequate pain management following day-case surgery allows early ambulation of patients. In this study, we aimed to compare postoperative analgesic efficacy of intravenous (iv) dexketoprofen vs. iv paracetamol following day-case operative hysteroscopy. One hundred and fourteen American Society of Anesthesiologists (ASA) I-II patients scheduled for day-case operative hysteroscopy were recruited and randomized to three groups in the study. Group D received 50 mg iv dexketoprofen trometamol, Group P 1000 mg iv paracetamol and Group C normal saline solution. Visual Analogue Scale (VAS) pain intensity, pain relief, sedation, nausea-vomiting, other side effects, and additional opioid analgesic requirement were noted at postoperative 15 minutes (min), 30 min, 1 hour (h), 2 h, and 3 h. Patients with VAS>=40 mm received meperidine 0.25 mg/kg as rescue analgesic medication. VAS scores at 15 min, 30 min, 1 h, and 2 h were significantly lower in Group D compared to Group C. VAS scores at 15 min and 30 min were significantly lower in Group D compared to Group P. The percentages of patients who required opioid treatment were 34%, 60%, and 63% in Groups D, P and C, respectively (p<0.05). Total delivered opioid dose was 0.10±0.16 mg/kg, 027±0.33 mg/kg and 0.28±0.25 mg/kg in Groups D, P and C, respectively (p<0.05). Pain relief score was significantly better in Group D at postoperative 15 min when compared with Group C (p<0.05). Our study demonstrated that iv dexketoprofen has superior efficacy for postoperative pain management following day-case operative hysteroscopy when compared with paracetamol and placebo.

Intrathecal chloroprocaine vs. lidocaine in day-case surgery: recovery, discharge and effect of pre-hydration on micturition

This randomised, double blind prospective study compares intrathecal lidocaine with chloroprocaine in day-case surgery and the influence of a 500 ml pre-load intravenously. We tested the hypothesis that chloroprocaine provides faster recovery and discharge in day-case surgery. Secondary we studied the influence of a preload compared with fluid restriction on discharge time and micturition problems. One hundred patients undergoing day-case arthroscopy were randomised to receive either lidocaine (L) 60 mg or chloroprocaine (CP) 40 mg intrathecally and this with (L+, CP+) or without (L−, CP−) a 500 ml pre-load of crystalloid. Block characteristics, micturition and discharge times were registered. Bladder volumes were monitored by ultrasound. Micturition problems received a micturition score. Onset and quality of the block were comparable between groups. Time to regain Bromage 1 and L2 regression were shorter for the CP group compared with the L group. Voiding (168 ± 44 min) and discharge (178 ± 52 min) were approximately 40 min faster for the CP group compared with the L group. Pre-load provided faster bladder filling but there were no differences in voiding time within the CP or L group. The CP+ group (166 ± 36 min) was discharged faster than both L groups (226 ± 57 min, 227 ± 59 min). More serious micturition problems occurred in the L+ group compared with both CP groups. Chloroprocaine is suitable for day-case surgery because of faster block regression and discharge than lidocaine. A 500 ml pre-load may not affect discharge but did not increase micturition problems for chloroprocaine.

Lorazepam does not improve the quality of recovery in day-case surgery patients

In day-case surgery, the effects of the anxiolytic lorazepam as premedication on the quality of postoperative recovery are unknown. To evaluate whether lorazepam as a premedication beneficially affects quality of recovery (primary outcome) and psychological manifestations (secondary outcome) after day-case surgery. A randomised, double-blind, placebo-controlled clinical trial. Single tertiary centre. day-case surgery; age at least 18 years. insufficient knowledge of the Dutch language; intellectual disability; ophthalmology surgery; extracorporeal shock wave lithotripsy; endoscopy; botulinum toxin A treatment; abortion; chronic pain treatment; preceding use of psychopharmaceuticals; contraindication to lorazepam. Lorazepam (1 to 1.5 mg) intravenously vs. NaCl 0.9% as a premedication prior to surgery. Quality of Recovery-40 (QoR-40) score. State-Trait Anxiety Inventory (STAI-State/Trait); State-Trait Anger Scale (STAS-State/Trait); Multidimensional Fatigue Inventory (MFI); Hospital Anxiety and Depression Scale (HADS). Timing of evaluation: T0: preoperatively (all scales); T1: before discharge (STAI-State/Trait); T2: first postoperative working day (QoR-40); T3: 7th day after surgery (all scales). Robust regression analysis was applied. Statistical analyses were adjusted for the corresponding baseline value and sex. Four hundred patients were randomised; 398 patients were analysed. Postoperative mean QoR-40 scores were similar in both groups at T2 (174.5 vs. 176.4, P = 0.34) and T3 (172.8 vs.176.3, P = 0.38). Postoperative mean STAI-State/Trait scores decreased less in the group with lorazepam at T1 (32.3 vs. 29.3, P < 0.0001; 32.7 vs. 30.8, P = 0.0002). STAI-Trait and HADS-Anxiety decreased less in the group with lorazepam at T3 (31.1 vs. 30.0; P = 0.03, 3.3 vs. 2.5, P = 0.003). STAS-State increased in the group with lorazepam at T3 (10.8 vs. 10.3, P = 0.04). In day-case surgery, lorazepam as a premedication did not improve quality of recovery. Furthermore, this premedication may delay the decrease in postoperative anxiety and aggression. ClinicalTrials.gov identifier: NCT01441843.

A UK experience of daycase cochlear implant surgery

ObjectivesThis study aims to assess the safety of daycase cochlear implant surgery.MethodsA retrospective review was conducted on all patients who underwent cochlear implant surgery at a teaching hospital in Oxford, UK between September 2008 and February 2012.ResultsOne hundred and sixteen patients underwent cochlear implant surgery. This included 73 adults and 43 children. Twenty-six patients underwent the procedure as a daycase procedure. There were no readmissions.DiscussionThe demand ‘to do more with less’ has led to increasing drives for efficiency and cost-effectiveness. Therefore, the role of daycase surgery is becoming increasingly widespread. Daycase surgery has been shown to be advantageous for both patients and hospitals.ConclusionDaycase cochlear implant surgery is feasible and can be safely conducted in a select group of patients.

Elective day-case laparoscopic cholecystectomy: a formal assessment of the need for outpatient follow-up.

Elective laparoscopic cholecystectomy (LC) is performed routinely as day-case surgery. Most hospital trusts have a policy of no routine postoperative outpatient follow-up although there are no formal guidelines on this. The aim of this retrospective study was to identify the incidence of complications, the degree of symptom resolution and patient satisfaction with a view to formally appraising the need for outpatient follow-up. Patients who underwent LC in the period between February 2011 and June 2012 were contacted retrospectively by telephone. A standardised questionnaire was used to ascertain the incidence of surgical site infection (SSI), other complications, symptom resolution and patient satisfaction. A total of 211 responses were collected. The rate of SSI was 7.6% (n=16), with the only specific risk factor being smoking (p=0.027). All other complications had a combined incidence of 7% (n=15). There was complete resolution of symptoms in 64% of patients. Of the 36% of patients with residual symptoms, 45% described abdominal discomfort or pain, 41% described reflux symptoms and 14% complained of diarrhoea. Patient satisfaction was very high (96%), yet 33% of patients visited their general practitioner postoperatively in relation to their surgery. Patients are highly satisfied with elective day-case LC. However, SSI is not uncommon, occurring in 1 in 13 patients. Although the majority of patients experience complete symptom resolution, a significant proportion do not. In our experience, routine outpatient follow-up is not required. Nevertheless, the lack of formal follow-up may prove a missed learning opportunity, potentially resulting in inappropriate patient selection for surgery.

Elective day-case laparoscopic cholecystectomy: a formal assessment of the need for outpatient follow-up

Introduction Elective laparoscopic cholecystectomy (LC) is performed routinely as day-case surgery. Most hospital trusts have a policy of no routine postoperative outpatient follow-up although there are no formal guidelines on this. The aim of this retrospective study was to identify the incidence of complications, the degree of symptom resolution and patient satisfaction with a view to formally appraising the need for outpatient follow-up. Methods Patients who underwent LC in the period between February 2011 and June 2012 were contacted retrospectively by telephone. A standardised questionnaire was used to ascertain the incidence of surgical site infection (SSI), other complications, symptom resolution and patient satisfaction. Results A total of 211 responses were collected. The rate of SSI was 7.6% (n=16), with the only specific risk factor being smoking (p=0.027). All other complications had a combined incidence of 7% (n=15). There was complete resolution of symptoms in 64% of patients. Of the 36% of patients with residual symptoms, 45% described abdominal discomfort or pain, 41% described reflux symptoms and 14% complained of diarrhoea. Patient satisfaction was very high (96%), yet 33% of patients visited their general practitioner postoperatively in relation to their surgery. Conclusions Patients are highly satisfied with elective day-case LC. However, SSI is not uncommon, occurring in 1 in 13 patients. Although the majority of patients experience complete symptom resolution, a significant proportion do not. In our experience, routine outpatient follow-up is not required. Nevertheless, the lack of formal follow-up may prove a missed learning opportunity, potentially resulting in inappropriate patient selection for surgery.

Elective day-case laparoscopic cholecystectomy: a formal assessment of the need for outpatient follow-up

The painful total hip arthroplasty requires careful evaluation and investigation. This is usually focused on the prosthesis and adjacent anatomical structures. We present a case report of a 64-year-old man who had a Birmingham hip resurfacing procedure for primary osteoarthritis. His hip pain worsened following the procedure and was under systematic investigation for this. Subsequent investigation for vascular disease revealed a total infrarenal aortic occlusion. An aortobifemoral bypass improved the hip pain and function dramatically, and the patient now has an excellent quality of life.

Can we consider day-case laparoscopic cholecystectomy for acute calculous cholecystitis? Identification of potentially eligible patients

BackgroundDay-case laparoscopic cholecystectomy has not yet been validated for acute cholecystitis. We sought to identify a subgroup of acute cholecystitis patients having been hospitalized overnight after laparoscopic cholecystectomy but who could have been eligible for day-case surgery. MethodsWe identified patients treated for acute cholecystitis with laparoscopic cholecystectomy in our university medical center between May 1, 2010, and May 31, 2012, and who lacked contraindications for day-case surgery. In a second step, we assumed that patients hospitalized for <3 d would have been eligible for day-case surgery. We then compared patients hospitalized for ≤3 d with those hospitalized for >3 d in terms of demographic data, laboratory test results, and surgical procedures. ResultsThe study population comprised 86 men and 82 women (median age: 57 y; age range: 18–90 y). Contraindications for day-case surgery were identified preoperatively in 23% of the cases (39 of 168) and intraoperatively in another 23% of the cases. The proportion of patients hospitalized for <3 d was 41% (69 of 168) when considering the intention-to-treat population and 57% (51 of 90) when considering patients with no contraindications to day-case surgery. Forty percent of the patients hospitalized for ≥3 d (16 of 39) suffered from postoperative pain that was poorly controlled by oral analgesics. Abdominal drainage was the only predictive factor for hospitalization <3 d (odds ratio [95% confidence interval] = 0.13 [0.02–0.71]; P = 0.01). ConclusionsDay-case laparoscopic may be feasible in selected patients with mild or moderate acute calculous cholecystitis. Our present results may be of use in designing a study of day-case surgery for acute calculous cholecystitis and related changes in the management of these patients.

Paediatric adenotonsillectomy as a daycase for obstructive sleep apnoea: How we do it in a tertiary unit

BackgroundPaediatric adenotonsillectomy is a common ENT operation. Daycase surgery for uncomplicated, elective procedures is encouraged in order to improve efficiency in healthcare. For patients with obstructive sleep apnoea (OSA), most units advocate an overnight stay for adenotonsillectomy, a procedure usually performed as a daycase in other contexts. MethodsA retrospective casenote review was carried out from 1st December 2011 to 1st December 2012 for all children undergoing daycase adenotonsillectomy for treatment of OSA at Bart's Children's and the Royal London Hospital. Results250 children underwent adenotonsillectomies for OSA as daycase procedures over twelve months. 6% had immediate, unplanned overnight admissions. 3% were readmitted within 30 days. No patients readmitted required surgical intervention. ConclusionFor an appropriately selected child, adenotonsillectomy can be safely performed as a daycase procedure in a tertiary centre.

Safe Single‐Dose Administration of Propofol in Patients with Established Brugada Syndrome: A Retrospective Database Analysis

Propofol is an anesthetic drug with a very attractive pharmacokinetic profile, which makes it the induction agent of choice, especially in day-case surgery. Data on its potential proarrhythmic effects in patients with Brugada syndrome (BS) patients are still lacking. The aim of our study was to investigate whether a single dose of propofol triggered any adverse events in consecutive high-risk patients with BS. All consecutive patients with BS having undergone an implantable cardiac defibrillator implantation under general anesthesia were eligible for this study. The anesthetic chart of each patient was reviewed, and the occurrence of malignant arrhythmic events as well as the need for defibrillation during induction and maintenance of anesthesia was investigated. Further monitoring of the patient comprised five-lead electrocardiogram (ECG), pulse oxymetry, and continuous carbon dioxide monitoring through side sampling from the ventilator tubes. Anesthesia was induced with propofol and sufentanyl. Injection of propofol occurred in a single-shot bolus-as often performed by most anesthetists-over a few seconds. Anesthesia was maintained with volatile anesthetics (sevoflurane or desflurane) in an oxygen-air mixture. From 1996 to 2011, 57 high-risk patients with BS (35 males; mean age: 43 ± 16 years) underwent an automated implantable cardioverter defibrillator implantation at our center using propofol as induction drug of general anesthesia. Three patients had a history of spontaneous type I ECG, three had aborted sudden death, and 51 had a history of recurrent or unexplained syncope. The induction dose ranged between 0.8 mg/kg and 5.0 mg/kg (2.2 ± 0.7 mg/kg). Only one case received propofol to maintain anesthesia. The surgical procedure involved an anesthetic period of 75 ± 25 minutes. No patient developed a malignant rhythm during induction and maintenance of anesthesia. All patients were then safely discharged from the postanesthetic care unit after 1 hour. No adverse events were noticed during the recovery phase. In our study, administration of a single-dose propofol in patients with BS was safe. Nevertheless, extreme caution is still recommended when conducting general anesthesia in patients with BS, especially if BS patients are sedated with propofol for longer periods.

Hyperparathyroidism: imaging for successful surgery and patient outcome

Purpose: In primary hyperparathyroidism, positive concordance of sestamibi scintigraphy and ultrasound scanning gives a high success rate of pathological parathyroid gland localisation. This facilitates focussed, minimally-invasive surgery, permitting single gland excision, day-case surgery and faster recovery. This study aims to assess outcome in patients with concordant and discordant imaging.

Achieving Day-Case Laparoscopic Nissen Fundoplication: An Analysis of Patient and Operative Factors

Day-case laparoscopic Nissen fundoplication has been described; however, its achievability and limitations in the setting of a busy Foundation Trust hospital are unclear. A retrospective cohort study of all cases undergoing laparoscopic Nissen fundoplication between January 1, 2009 and December 31, 2010 at three hospitals in the largest and the least densely populated Trust in the United Kingdom was undertaken. Primary end points of planned and achieved day-case surgery were compared with logistic regression analysis. Secondary end points were unplanned re-admission and complications. During the study period 126 consecutive patients underwent laparoscopic Nissen fundoplication. There were 64 female patients and 62 male patients. Primary surgery was undertaken in 115 patients and revisional surgery in 11. The age range was 21-73 years. Patients had traveled up to 52.3 miles or 80.2 minutes for their surgery. The median length of stay was 0 days in the planned day-case cohort and 1 day in the inpatient cohort. Day-case surgery was planned in 85 (68.55%). Successful day-case discharge was achieved in 71 cases (83.5%). There was no difference in age, geographical remoteness, surgeon volume, or length of surgery between planned and achieved day-case surgery. Patients were more likely to need unplanned admission if their American Society of Anesthesiologists grade was 2, when undergoing revisional surgery, and if the operation was completed after 1300 hours (1 p.m.). After multivariate regression analysis only operation completion time remained significant (P≤.05). The rate of unplanned re-admission related to surgery was 3/126 (2.38%). Day-case laparoscopic Nissen fundoplication can be achieved in the majority of patients. Unplanned admission is to be expected in approximately 15% of planned cases and cannot be predicted.

Daycase Bariatric Surgery—Just How Much Experience Is Potentially Lost to Trainees?

Dear Sir, Recent changes prompted by the 2003 European Working Time Directive (EWTD) have impacted surgical training in a number of ways. Although the EWTD has decreased trainee fatigue and improved work–life balance, it has led to decreased theatre exposure for surgical trainees. The knock-on effect has been to reduce trainee opportunities to learn and consolidate their surgical technique. Bariatric surgery is complex, requiring a high level of skill with a laparoscopic approach at the heart of such operations. In order to ensure competence, trainees need to utilise all available opportunities to learn and perform parts or indeed all of the operation appropriate to their grade and ability. We reviewed electronic database records detailing daycase operations between 1 January 2007 and 1 January 2012 at a large NHS foundation trust, in order to investigate the availability of opportunities for trainees to develop laparoscopic skills in bariatric procedures. There were 92 daycase bariatric procedures performed during this time, including gastric band portreplacement and laparoscopic band-adjustment procedures. All these cases were performed by consultants with trainees assisting in only 20 % (n=18) of cases. Possible reasons for poor trainee participation include trainees not wishing to utilise such an opportunity or trainees being timetabled to attend other activities. Relatively minor operations such as daycase bariatric procedures provide trainees with opportunity to develop a solid technical foundation from which to progress to more complex procedures in the future. The laparoscopic skills developed by performing these subspecialty procedures are core and transferable to other surgical specialties. In order for standards of surgical excellence within the UK to be maintained, trainees must utilise all such available opportunities.

Chronic pain and quality of life (QoL) after transinguinal preperitoneal (TIPP) inguinal hernia repair using a totally extraperitoneal, parietalized, Polysoft ® memory ring patch

Little is known about both incidence of chronic pain and quality of life (QoL) after the transinguinal preperitoneal (TIPP) technique using a totally extraperitoneal, parietalized, memory ring patch. Among 622 (428 unilateral and 194 bilateral) hernia repairs (HR) in 525 patients, 92 % had a postoperative clinical control. Thereafter, two sets of postal self-assessed questionnaires were sent. A total of 531 HR were studied with a mean follow-up of 17 ± 8 months. Only one recurrence was detected. In 151 (28.4 %) HR the patients alleged various symptoms, but in only 10 (1.9 %) HR they considered their discomfort more bothersome than the hernia they had before, and in just 2 (0.4 %) HR they judged their result as bad (one patch removal for sepsis and one for hematoma). Only mild pain (including no painful discomfort such as a foreign body sensation) or moderate pain was frequent. Pain was self-graded as severe in four cases. None of them reported any regular consumption of antalgics. None of them judged their result as bad. Dysesthesia (numbness 19, paresthesia 20) mentioned in 39 HR (7 %), associated with pain in 16 HR, was said to be more bothersome than the hernia treated in just 3 HR (0.6 %). The results of the entire series were self-assessed as good or excellent in 97 % of the HR. In our TIPP series, both the incidence of recurrences (0.2 %) and that of severe chronic pain (≤0.7 %) were very low, as well as patients' QoL was excellent. In our experience, the postoperative course was as painless as that of laparoscopic TEP we had been performing previously, but TIPP appeared more suited to day-case surgery.

Occlusion of the round window: a novel way to treat hyperacusis symptoms in superior semicircular canal dehiscence syndrome

Conductive hyperacusis in superior semicircular canal dehiscence syndrome occurs due to the presence of a 'third window' created by the dehiscence. Reversible blocking of the round window can, in theory, cause a reduction in the compression-related volume displacement, and thereby minimise symptoms of conductive hyperacusis. This study describes a technique of permeatal blocking of the round window. The tympanomeatal flap is elevated and the round window niche is identified. The round window membrane is subsequently identified and occluded with bone wax, muscle and fascia, in three separate layers. Finally, the tympanomeatal flap is reflected, and an ear wick is inserted. Two patients who underwent the procedure reported a reduction in symptoms. Importantly, no Tullio phenomenon was reported post-operation. Blocking of the round window can be used to control symptoms of superior semicircular canal dehiscence syndrome in patients who present solely with symptoms of conductive hyperacusis. This technique provides an alternative to resurfacing techniques. The procedure is simple to perform, reversible and can be undertaken as day-case surgery.

Betamethasone in hernia surgery: A randomized controlled trial

Post-operative pain and nausea may be a problem in day-case surgery. This study aims to investigate the effect of betamethasone on pain and nausea in inguinal hernia surgery. Patients aged 18-70 years scheduled for open inguinal hernia surgery at two Swedish hospitals, March 2005-December 2009, were eligible for inclusion. Patients were randomized, to either treatment with 12 mg betamethasone intravenously or placebo. Post-operative pain was assessed using a visual analogue scale on the recovery ward, each day the first post-operative week and at 1 month after surgery. One year after surgery, residual pain was estimated by the Inguinal Pain Questionnaire. A total of 398 patients were included (21 women, 377 men). Pain at rest on the day of surgery was significantly lower in the treatment group (p = 0.012). The pain was also significantly lower in the treatment group the day after surgery (p < 0.001), but not during the remaining part of the first post-operative week. Bleeding complications were reported by 17 patients (8.5%) in the Betamethasone group and seven (3.5%) in the placebo group (p = 0.028). One month after surgery, 21 out of 173 (12%) in the betamethasone group still had pain, compared to 33 out of 159 (21%) in the placebo arm (p = 0.049). After 1 year, no significant difference in pain was seen. A 12 mg betamethasone reduced pain during the first 24 h and at 1 month after inguinal hernia surgery. If combined with diclofenac, however, this dose may increase the risk for bleeding complications.

Day-case re-do varicose vein surgery

To assess whether re-do varicose vein surgery as a day case is feasible and safe. Data were collected retrospectively on 70 consecutive patients (77 legs) undergoing re-do sapheno-femoral or sapheno-popliteal ligation by consultant surgeons as day cases. Follow-up was by structured telephone interview. The 70 patients comprised 53 females and 17 males. Median age and body mass index were 47.5 years and 27, respectively. All patients were ASA Grade I or II. Median operating time was 75 min (range 25-140). Of the 70 patients intended to be treated as day cases, four (5.7%) were admitted overnight. There were no were re-admissions nor did any patient develop deep vein thrombosis. Eleven per cent developed wound infection and 4% transient lymphatic leakage. Overall, 91% of patients were pleased with the initial surgical result but this decreased to 81% in the longer term. Eighty-nine per cent would have their surgery performed again as a day case. Re-do sapheno-femoral or sapheno-popliteal can be performed safely as a day case.

Parental understanding of dosing instructions for paracetamol and ibuprofen suspension

AimsThis study was undertaken to identify whether parents and carers of children undergoing day-case surgery are able to read and understand the dosing instructions supplied with general sales list (GSL)...

Clinical Experience with the Swiss Lithoclast Master in Treatment of Bladder Calculi

Bladder calculi account for 5% of urinary tract calculi in the Western world, and many different treatment modalities have been presented throughout the decades. We report our clinical experience using the Swiss LithoClast® Master (SLM). The SLM is a rigid, hand-held endourologic probe including a pneumatic lithotriptor and an ultrasonic lithotriptor. Attached to the ultrasonic modality is a suction system. The two lithotriptor modalities are controlled by a footswitch and can be activated separately or simultaneously. The SLM is used via a rigid endoscope. Indications for treatment were medical complaints such as hematuria, lower urinary tract symptoms, pain, recurrent urinary tract infections, recurrent bursts of balloon in indwelling catheters, and difficulties performing clean intermittent self-catheterization. From August 1, 2009, to August 1, 2011, 27 patients were treated for bladder calculi (24 men). Five had a neurogenic voiding dysfunction, 3 had prostate cancer, and 19 had benign prostatic enlargement or detrusor muscle insufficiency. Median age was 74 years (range 45-86 years). Stone clearance was obtained in 26 (96%) patients. Stone burden was one or multiple bladder calculi. Median stone size of the largest stone in each patient was 20 (5-40) mm. Under the same anesthesia, two patients underwent a transurethral resection of the prostate because of a very large prostate. Median lithotripsy time was 60 (range 20-144) minutes. All patients were discharged within 24 hours. The method described is a safe and quick method for endoscopic lithotripsy of bladder calculi rendering the patients stone free in the vast majority of cases. The procedure can be performed as day-case surgery.