The incidence of benign prostate hyperplasia (BPH) combined with bladder stones is more than 10% [1]. The traditional method advocates cystotomy and stone extraction with prostatectomy, and some scholars have used the combination of suprapubic cystotomy and stone extraction + transurethral prostatic electrocautery [2], but the patient’s hospitalization time is long, the complications are many, the trauma is big, the recovery is slow, and it has certain limitations. With the progress of endoluminal urology and the accumulation of clinical experience, simultaneous prostatectomy and endoluminal lithotripsy have become the main treatment for BPH combined with bladder stones, but the need to change the surgical equipment during the operation not only prolongs the operation time, but also increases the number of times the equipment goes in and out of the urethra, which is prone to lead to urethral stenosis, and at the same time, the blurring of vision due to the lifting up of the stone-crusher powder during lithotripsy is prone to injury to the bladder. To solve this problem, we made full use of plasma electrosurgical equipment from January 2008 to December 2011, and treated 205 cases of benign prostatic hyperplasia accompanied by bladder stones in the same period without replacing the sheath of plasma electrosurgical equipment, which not only simplified the surgical process and kept the surgical field clear, but also achieved good surgical results. It is reported as follows. I. Data and methods 1. Patient data From January 2008 to December 2011, a total of 205 cases of prostatic hyperplasia with bladder stones received surgical treatment. All cases had a history of dysuria and lower urinary tract symptoms (LUTS), 30 cases had hematuria, 12 cases had urinary retention, and all of them had a history of elevated PSA. All of them underwent prostate aspiration biopsy to exclude prostate cancer. The average age of the patients was 71±9 years (63-80 years), the average duration of the disease was 5.1 years (3-13 years), the average prostate volume determined by ultrasound was 58 ml (32-81 ml), the average diameter of bladder stones was 2.3 cm (0.8-4.8 cm), the International Prostate Symptom Score (IPSS score) was 23.8±5.6, the quality of life score was 4.2±1.4 The maximum urinary flow rate was 6.3±1.7 ml/s, and the average residual urine was 62 ml (33-105 ml). 26 cases of hypertension, 4 cases of chronic bronchitis and 10 cases of diabetes mellitus were combined. 2.Treatment Complications: those with medical comorbidities should correct their medical diseases first; patients taking anticoagulant drugs should stop taking anticoagulant drugs for 5-7 days before surgery; those with combined infections should control their infections before surgery. Instrumentation: Olympus plasma diathermy scope from Japan, Holmium laser lithotripsy system from Dormier Company of Germany, Olympus camera monitoring system for lithotripsy. Methods: Epidural anesthesia or general anesthesia, taking the lithotomy position, under the monitoring of the imaging system, the plasma catheteroscope was inserted into the bladder via the urethra, observing the urethral prostate, bladder wall, stone size, number, and shape, and then a 5F ureteral catheter, which was cut in front, was inserted through the plasma catheteroscope at the point of placing the electrocutaneous loop, which was used as a fiber-optic channel of the holmium laser, and then holmium laser was used for lithotripsy to crush the stones as much as possible when it saw them. The stone is broken down as much as possible, and the broken stone is aspirated out with the Ellik flosser. After that, a 5F ureteral catheter was taken out, and an electrocutaneous loop was installed, and transurethral plasma resection of the prostate was performed. Postoperatively, a three-lumen balloon catheter was left in place for drainage, and saline was continuously flushed until the flushing fluid was clear, and the urinary catheter was removed in 5-6 days. Antibiotics were routinely applied for 3 days to prevent infection. 3.Statistical methods Paired t-test was performed on patients’ IPSS score, quality of life score, maximum urine flow rate, serum sodium and hemoglobin before and after surgery. Results: All 205 cases were successfully operated in one operation, the lithotripsy time was 10-40 min, average 25 min; the prostate electrocautery time was 15-50 min, average 35 min; no intraoperative complications such as electrocautery syndrome and bladder perforation occurred. No residual stones were found in KUB plain film or ultrasonography before extubation, and the stone removal rate was 100%. There was no difficulty in urination after removal of the urinary catheter at 5 d. Two cases developed anterior urethral stenosis at 4 weeks after surgery, and five cases developed temporary urinary incontinence, which was cured after treatment. Three months after surgery, the International Prostate Symptom Score (IPSS) decreased from 23.8±5.6 to 6.6±2.3 (P<0.01), the maximal urinary flow rate (UFR) increased from 6.3±1.7 ml/s to 17.3±2.8 ml/s (P<0.01), and the quality of life score (QOL) decreased from 4.2±1.4 to 2.2±0.8 (P<0.01). The changes of hemoglobin and serum sodium before and after surgery were not statistically significant (P>0.05). III.DISCUSSION Bladder stones are the most common lower urinary tract stones, accounting for about 5% of the urinary tract stones [1], usually due to lower urinary tract obstruction factors: such as prostatic hyperplasia urethral stenosis primary or secondary neurogenic bladder caused by long-term obstruction of the bladder outlet urinary retention, or the bladder for a long period of time foreign body retention, the bladder foreign body bacterial mass of inflammation necrotic tissue and pus block become the core of the stone, inducing the crystalline material precipitated on its surface, the This leads to bladder stone formation [3]. In elderly men, the occurrence of bladder stones is often caused by lower urinary tract obstruction, and BPH is the most common cause [4], such patients, such as bladder stone removal alone, the symptomatic improvement is not as obvious as simultaneous bladder stone and prostate surgery, and some patients still need second-stage prostate surgery [5], so it is generally recommended that simultaneous surgery. Previously, suprapubic cystotomy and stone extraction combined with transurethral resection of the prostate was mostly used for treatment [6]. TURP combined with transurethral pneumatic ballistic lithotripsy [1], transurethral holmium laser lithotripsy [7-8], and percutaneous cystolithotripsy utilizing laparoscopic approaches [9] have also been used. Although the use of these methods can greatly reduce the chance of open surgery, they have limitations due to poor water circulation and unclear vision, as well as the fact that stones are not easily immobilized due to the increased amount of flushing fluid in the bladder, the large space for bladder movement, and the buoyant effect of water. At the same time, due to BPH combined with bladder stones patients are mostly elderly, often coexist with cardiovascular, endocrine, respiratory and other systemic diseases, surgical tolerance is poor, how to safely lift the bladder outlet obstruction and at the same time removing the stones is often encountered in the clinical work, urgently need to solve the problem. For patients with prostatic hyperplasia, with the development of plasma resection technology, transurethral plasma resection of the prostate has the advantages of high surgical safety, short learning curve, and fewer surgical complications compared with traditional TURP [10-11], and it has been widely used in clinical practice. We have previously used transurethral plasma resection of the prostate to treat high-risk prostatic hyperplasia and also achieved good results [12]. On this basis, we made full use of the structural characteristics of the Olympus plasma catheter, and placed a section of F5 ureteral catheter as a holmium laser fiber channel in the catheter at the position of the catheter loop during lithotripsy, which not only prevented the leakage of rinsing fluid from the catheter loop, but also facilitated the placement of the holmium laser fiber. At the same time, we utilize the water circulation system of Olympus plasma catheter to speed up the replacement of the rinsing fluid in the bladder, and flush the fine powder generated during the lithotripsy process out of the bladder in a timely manner, so as to maintain a clear view of the surgical field, which significantly reduces the risk of injury to the bladder due to the lack of a clear view of the bladder during surgery. Because of the smooth water circulation during lithotripsy, the surgical field of view is clear, avoiding the interruption of lithotripsy process due to unclear field of view, and after lithotripsy, the stone fragments will be flushed out of the bladder by using Ellik flushing device without repeated clamping to remove the stones, which can effectively shorten the lithotripsy time and increase the efficiency of lithotripsy of bladder stones. The average lithotripsy time for bladder stones in this group of cases was only 25 min, showing a high lithotripsy efficiency. At the same time, since the prostate surgery was performed at the same time, the blind spot in the field of view due to severe prostatic hyperplasia could be effectively solved, and bladder stones deposited between the middle lobe of the prostate and the deltoid region could not be easily missed. Since there is no need to change the sheath of the electrodesiccope during the procedure, the risk of urethral injury due to repeated insertion and removal of the sheath is minimized. Urethral stricture occurred in only two cases in our group, which is a relatively low incidence [13]. During the management of bladder stones, the following issues should be noted to minimize surgical complications. First, gentle movements should be made when entering the scope to reduce the damage to the urethral mucosa, and the scope should be entered under direct vision if patients with obvious prostatic mesophyll hyperplasia are encountered. Secondly, in the process of lithotripsy, the fiber optic is just enough to be able to directly against the stone, to avoid the stone slipping off during lithotripsy and damaging the bladder mucosa. At the same time, the speed of irrigation fluid should be controlled to keep the bladder moderately full, to avoid the movement of stones in the bladder and adsorption of bladder mucosa, in order to improve the efficiency of lithotripsy and shorten the operation time. During the procedure, bladder stones should be dealt with first and then the prostate. This is because lithotripsy before PKRP has less bleeding in the prostate area, clear vision, easy to perform lithotripsy, and also prevents the large trauma caused by electrolysis of the prostate first, which can cause bleeding in the later lithotripsy process and excessive inhalation of perfusate causing electrolysis syndrome. If the prostate is treated first, despite the increased space in the posterior urethra, the movement of the lens sheath during lithotripsy can lead to traumatic blood leakage affecting the field of view, and the need for traumatic hemostasis after lithotripsy, which will significantly prolong the operation time. In addition, if the prostate enlargement is treated first, the bacteria attached to the stone during lithotripsy can easily enter the bloodstream with the rinsing fluid through the prostate wound, which can easily lead to bacteremia or even severe sepsis. Simultaneous treatment of BPH combined with bladder stones using plasma electrosurgery can maximize the minimally invasive advantages of transurethral surgery, reduce surgical complications and improve surgical safety, which is a minimally invasive treatment worthy of promotion.