= Solution
\b[Choose the method that can remove the whole <bladder stone> with the least overall danger in that patient.] Here <lithotomy> means cutting into the <urinary bladder> to extract the stone; <lithotrity> means instrumental crushing through the <urethra>. The latter is not the later technique of external shock-wave treatment, and “no incision” does not mean “no tissue injury”.
\b[The stone.] A small, accessible, freely movable stone that can be grasped and broken without excessive force favours <lithotrity>. Great bulk, great hardness, an awkward shape, several substantial stones or a stone fixed in a recess increases the difficulty of fragmentation and complete clearance. The amount of debris matters: pieces left in the <urinary bladder> can irritate it, obstruct the passage or provide material for further growth. A historical comparison must count the burden of manipulation and clearance, not imagine that pulverization makes the stone disappear. No single size threshold can be specified independently of the instrument, the stone and the patient.
\b[The access passage and the <urinary bladder>.] <Urethral stricture>, inadequate urethral calibre, an existing false passage or difficult prostatic obstruction can make introduction of a useful crushing instrument unsafe. A <urinary bladder> that tolerates exploration, holds a reasonable volume and empties effectively is more favourable than one with marked <cystitis>, bleeding, extreme irritability or retention of <urine>. The operator must also consider <kidney> function, active <infection> and general reserve. A severely ill patient should not be exposed to a prolonged elective sequence of instrumentation merely because the stone itself seems crushable.
\b[Age and anatomy.] In a small child, the <urethra> may not admit an adequately strong instrument, which helps explain the historical preference for <lithotomy> in many children. Age is a proxy for anatomy and tolerance, not an absolute law: small instruments and different modern access routes change the comparison. In an older man, the <prostate>, <urinary bladder> emptying and general illness can be more important than age alone. In a woman, easier access through a shorter <urethra> may favour an endoscopic route, but forceful dilation or extraction can still damage the continence mechanism.
\b[The operation and its operator.] Cutting risks <haemorrhage>, urinary leakage, injury and postoperative <infection>; crushing risks injury from the instrument and retained or impacted fragments. Each method requires skill, appropriate apparatus and aftercare. A contemporary 1859 lecture explicitly contrasts older complicated drilling apparatus with the curved crushing instrument then in use. That is evidence that the available instrument was part of the decision, rather than a timeless property of “<lithotrity>”. <Lithotrity instrument lecture in the British Medical Journal (1859)>[8 January 1859, p. 23, contrast of earlier drilling and later curved crushing apparatus]{ref}
\b[Practical selection.] With a modest stone, passable <urethra>, tolerably healthy <urinary bladder>, effective emptying and suitable expertise, <lithotrity> has a strong rationale. When the stone is too large or resistant for safe fragmentation, access is unsafe or fragments cannot reasonably be cleared, extraction through another route becomes preferable. At the same time, poor general health may make either operation hazardous, so the preliminary task can be stabilization and management of associated disease rather than immediate choice of an instrument.
Modern guidance usually favours transurethral endoscopic fragmentation where feasible, offers a percutaneous route when transurethral treatment is unsuitable, and retains open <surgery> as an option for very large stones. In children, urethral injury risk can determine the route. These current options illustrate the same anatomical trade-offs but must not be imported wholesale into an 1865 recommendation. Nor should a historical preference for cutting in children be treated as a modern rule. <Bladder Stones in the EAU Guidelines on Urolithiasis>[Interventions and recommendations: transurethral, percutaneous and open approaches; patient and access factors]{ref}
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