From February 2003 to May 2006, 43 patients with prostatic hyperplasia combined with bladder stones were treated by transurethral resection of the prostate (TURP) combined with nephroscopic pneumatic ballistics and ultrasonic lithotripsy for stone removal. 1 Data and methods 1.1 General data The 43 cases in this group, aged 53-86 years old, average 72 years old. All of them had typical clinical manifestations of prostatic hyperplasia, such as difficulty in urination and urinary frequency and urgency. Among them, 2 cases were combined with urinary retention. The International Prostate Symptom Score (IPSS) was 16-29, with an average score of 24. All cases were confirmed to have BPH by rectal examination and transrectal prostate ultrasound and PSA. Two cases were combined with unilateral lower ureteral stones. The presence of bladder outlet obstruction was confirmed by urodynamic examination in all cases, and no neurogenic bladder factor was present. The maximum urinary flow rate (Qmax) was 4-15 ml/s, with an average of 9 ml/s. 1.2 Treatment 1.2.1 Pre-operative preparation Pre-operative routine examination of the function of all important organs and treatment of combined medical diseases. Preoperative antibiotics should be used to prevent infection in the presence of urinary tract infection. In case of combined ureteral stones, KUB examination should be performed in the morning for final stone localization. 1.2.2 Surgical method All patients in this group were treated with continuous epidural anesthesia in the lithotomy position. In the case of combined ureteral stones, the ureter was firstly entered into the bladder via urethra under direct vision with F8/9.8WOLF ureteral rigidoscope, and the ureter was entered under the guidance of ureteral catheter, and the stone was found and connected to pneumatic ballistic lithotripsy system to break up the stone, and the D-J tube was left in place. For the management of bladder stones we used the new F20.8WOLF nephroscope (without a sheath) to enter the bladder via the urethra under direct vision. After stone discovery, EMS third generation pneumatic ballistic ultrasound lithotripter was used, including pneumatic ballistic lithotripter system with high performance ultrasound lithotripter system and negative pressure suction system. Either pneumatic ballistic lithotripsy or ultrasound lithotripsy can be used alone or in combination. For stones of higher hardness, the first use of pneumatic ballistic lithotripsy will break the stones into small pieces in a short period of time, and then use the combined ballistic and ultrasound systems, or use the ultrasound system alone to further crush and aspirate the stones; while for stones of lower hardness, the ultrasound or ballistic combined ultrasound lithotripsy system can be used directly to crush and remove the stones. After the examination, the bladder wall is free of stones and the TURP procedure is performed with the F24STORZ microscope, and the enlarged prostate lobes are removed sequentially up to the peritoneum. The prostate fragments were aspirated with Ellik, and the F22 triple-lumen balloon ureter was left in place for flushing. 1.2.3 Postoperative treatment The bladder was continuously flushed with saline for 1-2 days after surgery until the flushing fluid was clear. The urinary catheter was retained for 4-6 days and then removed. In the case of combined ureteral stones, the D-J tube was removed 1 month after surgery. 2 Results All 43 patients underwent a single successful operation, dealing with ureteral stones for about 10-20 min. bladder stone fragmentation and clearing time was 15-60 min, mean 30 min. prostate electrodesection time was 25-70 min, mean 55 min. bleeding volume was about 50-180 ml, mean 100 ml, and no one case had blood transfusion. No complications such as bladder perforation, TURP syndrome and serious infection occurred. In two patients with combined ureteral stones, the D-J tube was well positioned and the stones in the ureter were broken up. The urinary symptoms were significantly improved after removal of the ureter, and the hospital stay was 5-7 days. The maximum urinary flow rate was significantly higher than the preoperative rate at 14-25 ml/s with an average of 19 ml/s. The intraureteral stones were eliminated. 3 Discussion Approximately 10% of patients with prostatic hyperplasia (BPH) will also have bladder stones [1], which are formed mainly due to precipitation of particulate matter in the urine due to poor urination and excessive residual urine, combined with infection factors that eventually form stones. Due to the development of lumpectomy technology, open surgery is no longer used in many hospitals for patients with simple prostatic hyperplasia, and TURP has become the gold standard for the treatment of BPH [2]. However, once bladder stones are combined, open surgery has to be used to remove the stones and remove the enlarged gland at the same time by incising the bladder via the suprapubic bone. This method is very invasive, with slow recovery, long hospital stays, and sometimes complications such as wound infection and urinary fistula. If there is a way to remove the stones without opening the bladder, and then perform electrodesiccation of the prostate in one stage, the patient will benefit greatly. Therefore, there are vigorous lithotripter lithotripsy, extracorporeal shock wave lithotripsy, liquid electrolysis system, pneumatic ballistic lithotripsy system and laser lithotripsy system. Since the 1980s, our hospital has been using these methods to treat bladder stones. Although some patients have been spared the pain of open surgery, they are often limited by the size and hardness of the stones, and various complications occur. The forceps lithotripsy is only suitable for stones <2.5 cm and can cause bladder wall damage and even perforation if not done carefully, sometimes necessitating open surgery. Although electrohydraulic lithotripsy is less costly, it is not efficient, takes longer to lithotripsy, is more likely to damage the bladder, and requires more flushing fluid, and is generally only suitable for stones under 4 cm. The laser lithotripsy system is expensive and not easily promoted at the primary level, and the high cost of surgery is not easily accepted by patients. The system can only break up the stones, but cannot aspirate them at the same time, and needs to be replaced by an electrosurgery mirror to aspirate them via Ellik. In recent years, our hospital introduced the third generation of pneumatic ballistic lithotripsy combined with ultrasonic lithotripsy and adsorption device, which combines pneumatic ballistic lithotripsy system, high performance ultrasonic lithotripsy system and negative pressure adsorption system, each system can be used separately or simultaneously, which can not only break the stones quickly, but also suck out the stones at the same time, and without changing the instruments or equipment. In vitro studies have shown that the device is significantly more efficient in crushing and removing stones than single pneumatic ballistics or ultrasound lithotripsy [3, 4]. In clinical application, the device was found to significantly shorten the operation time and improve the stone removal rate per unit time, and it has good comminution effect on stones of different compositions, which significantly improved the clinical efficacy [5, 6]. Summarizing the experience of 43 cases, we believe that there are several other advantages of treating bladder stones with pneumatic ballistics combined with ultrasound and adsorption system before TURP: (i) the stones are crushed while the stones are adsorbed, and the stone fragments are sucked out of the body along the probe, and the stones do not run around during the whole process, which saves a lot of time. ② In the past, after the stone was crushed, it was necessary to switch to the electrodesiccope and aspirate it with Ellik. When a large stone could not be aspirated by Ellik, it would be replaced by a nephroscope and re-fractured. Sometimes this process needs to be repeated several times, which is not only tedious but also easy to damage the urethra. With the ultrasonic adsorption system, the problem can be completely solved with a single nephroscope placement. Sometimes, the stone fragments adhere to the bladder mucosa or are embedded in the mucosa, which cannot be extracted by Ellik, and can only be scraped off by electrodesiccation ring, which is easily damaged. The ultrasonic adsorption system is extremely easy to handle. ④ If there is a blood clot in the bladder that affects the visual field, this system can quickly aspirate the blood clot and keep the visual field clear. ⑤ With saline as the rinsing fluid, there is no complication of water absorption and TURP will not be affected by prolonged lithotripsy. ⑥ In case of combined ureteral stones, the device can be applied under ureteroscopy for simultaneous treatment. In conclusion, TURP combined with nephroscopic pneumatic ballistic and ultrasonic lithotripsy for the treatment of prostatic hyperplasia combined with bladder stones is an ideal method for the treatment of prostatic hyperplasia combined with bladder stones without surgical incision, less trauma, less pain, faster recovery, safe and efficient, and worthy of promotion.