How I do it: percutaneous cystolitholapaxy for bladder stones with complex lower urinary tract anatomy.

While cystolitholapaxy for bladder stones is commonly performed using a transurethral approach, large or complex stone burdens in patients with complex lower urinary tract anatomy may make this inefficient or infeasible. Percutaneous cystolitholapaxy is a safe, effective, minimally invasive alternative for diverse indications, including patients with benign prostatic hyperplasia, urethral stricture disease, closed bladder neck, continent catheterized channel, or other urinary diversion. In this article, we review the indications for and advantages of percutaneous cystolitholapaxy and describe our step-by-step technique for this procedure, including representative imaging and favored equipment. We also discuss preoperative and postoperative considerations, management of potential complications, strategies to optimize clinical outcomes and patient safety, and comparisons with transurethral approaches. Finally, we report outcomes from our institutional series of percutaneous cystolitholapaxy cases to highlight the safety and efficacy of the procedure.