Migrated Hem-o-lok clip in the bladder: A rare cause of bladder stone for cystolitholapaxy

Abstract

The bladder is the most common site of foreign bodies in the urinary tract. Most foreign bodies are self-inserted via the urethra due to exotic impulses, psychometric problems, or sexual curiosity. Here we present a rare case of bladder stones due to the migration of the Heme-o-lok clip. We present a case of a 76-year-old male with hematuria for 4 days. An abdominal computed tomography (CT) scan showed a 15 mm calculus noted in the urinary bladder. The patient underwent cystolitholapaxy which was successful. Foreign bodies inserted in the bladder pose a significant challenge and require timely intervention.

1. Introduction

Bladder migration of a Hem-o-loc® clip, which is a potential complication of robotic-assisted radical prostatectomy (RARP), is a late post-operative issue associated with robotic surgeries that may go undetected in the long term.¹ To minimize the risk of bladder and urethral injuries, minimally invasive procedures are generally recommended.

To our knowledge, there is currently no existing research on this topic conducted in Qatar, with only sporadic case reports being published.^2,3 In this study, we present a case of foreign body insertion during prostatectomy that occurred 9 years prior to the retrieval date.

2. Case presentation

We present a case of a 76-year-old male, with multiple comorbidities, who presented to the emergency department with Frank Hematuria of 4 days duration. The hematuria is total, intermittent with clear urine between the attacks and passage of clots along with dysuria and storage lower urinary tract symptoms including urgency and urge incontinence. The history of fever, chills, or rigor was negative. In addition to the absence of abdominal or flank pain, nausea, or vomiting. The patient did not show weight loss or any respiratory symptoms. He had a similar attack two months ago from presentation, which subsided spontaneously.

The patient had previously been diagnosed with hypertension, diabetes mellitus (DM) type 2, dyslipidemia, bilateral knee osteoarthritis, and morbid obesity. He had no previous history of foreign body insertion into the urethra. Family history was noncontributory.

Robotic prostatectomy with adjuvant radiotherapy for prostate adenocarcinoma with seminal vesical involvement and TNM staging T3bN0M0 was done in 2013. His last prostate-specific antigen (PSA) level was 0.01 in 2021.

The patient is a non-smoker, with no history of ethanol consumption, no drug or food allergies, and is not on any anti-platelets or anticoagulants. Upon physical exam, the patient's temperature was 36.1 °C when taken orally, heart rate of 66 beats/minute, respiratory rate of 18 breaths/minute, blood pressure was 156/71 mmHg, and SpO 2 was 97%. The patient was conscious, alert, and oriented to person, place, and time, and Glasgow Coma Scale (GCS) was 15/15 while lying comfortably in bed, not in pain or distress. The abdomen was soft lax, non-tender with no scars and no costovertebral angle tenderness. The scrotum displayed bilateral testes in a normal position, without any tenderness or swelling. The penis exhibited a normal circumcised state, with a regular meatal opening and no observed blood at the meatus. Lower limbs showed no edema and no signs of deep vein thrombosis (DVT).

Laboratory findings revealed microscopic hematuria and pyuria in routine urine analysis along with a positive nitrite test. Complete blood count (CBC) only showed slightly increased leukocytes. Electrolyte profiles and renal function were normal. A urinary tract CT scan showed a bladder stone in the urinary bladder measuring around 1.5 cm just lateral to the bladder neck as shown in Fig. 1. Accordingly, surgery was advised for its removal. The patient underwent transurethral cystoscopy for cystolitholapaxy and stone removal. The extraction procedure was carried out by the urology team under spinal anesthesia and the patient was put in a lithotomy position. Genitalia was prepped and draped in the usual sterile fashion.

Fig. 1.

CT scan showed a bladder stone about 1.5 cm in size near the bladder neck.

Cystoscopy showed normal urethra post robotic prostatectomy for prostate adenocarcinoma in 2013. The bladder mucosa showed a normal bladder wall, difficult to assess both ureteric orifices, stone adherent to the right bladder neck, and slight manipulation with the cystoscope released the stone with a surgical clip to which the stone is adherent as shown in Fig. 2. There was no active bleeding at the site of stone adherence. A stone punch was used to fragment the stone into fragments, and fragments were removed via the sheath (see Fig. 3). Cystoscopy after stone punch showed a normal bladder wall no injury was detected. Foley's catheter 16 Fr. was inserted and kept for 3 days.

Fig. 2.

Cystoscopy revealed a clear vision of a foreign body in the bladder (vascular clip) and successful removal of the foreign body was followed.

Fig. 3.

The foreign body (vascular clip) after successful removal with surrounded formed stone.

The postoperative period was uneventful, with good operation outcomes and no infections. The patient was put on an oral prophylactic antibiotics regimen for five days and was scheduled for an outpatient follow-up with the urology department. A follow-up evaluation in the urology department 4 days after the procedure showed no history of fever, pain, or hematuria, but rather discomfort with the Foley's tube. The patient Foley's catheter showed clear urine which was removed smoothly. Previous urine Culture showed Klebsiella pneumonia thus new culture was ordered.

Two weeks later the patient was seen again, with complaints of turbid urine but no hematuria. His urine culture result was pending as the patient give the urine culture late. Three weeks later the patient is stable, with no hematuria or new complaints. Urine Culture showed no growth and the post-void residual done for the patient was nil.

3. Discussion

Diagnosis of urinary bladder foreign bodies involves obtaining a comprehensive medical history and conducting clinical examinations. Some patients may exhibit signs of anxiety during sexual history-taking or exhibit reluctance toward genital or rectal examinations. Clinical presentations of urinary bladder foreign bodies can range from asymptomatic to experiencing symptoms such as dysuria, hematuria, frequency, poor stream, suprapubic pain, urinary retention, and chronic pelvic pain1.

In a retrospective study conducted by Bansal et al., 49 cases of foreign body retrieval from the urinary bladder were analysed over a span of 6 years. The study revealed that the circumstances of insertion varied, with iatrogenic factors accounting for 20 cases (40.8%), self-insertion for 17 cases (34.6%), sexual abuse for 4 cases (8.1%), migration from other organs for 4 cases (8.1%), and assault for 4 cases (8.1%).⁴ Another case report by Moser et al., of two cases in which patients with symptoms of bladder neck contracture (BNC) exhibited urethral erosion of Hem-o-Lok clips following robot-assisted laparoscopic prostatectomy.⁵

Typically, simple pelvic radiographic imaging is often sufficient to detect and characterize foreign objects in the urinary bladder. If further investigation is required, CT or ultrasound can be valuable and used as the next workup step. However, for accurate diagnosis, urethroscopy is considered the most reliable method. In the presented case, the patient sought medical attention early, before the inserted object could calcify or form stones, which increased the success rate of endoscopic retrieval.

It is also recommended to make every effort to extract loose clips located in the abdomen, as studies indicate their potential for migration.

Foreign bodies lodged in the urinary bladder pose a significant urological challenge and necessitate timely intervention. Gentle endoscopic intervention is the preferred and highly effective treatment approach for such cases.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Consent

Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by any related authority upon request.

Declaration of competing interest

The authors report no declarations of interest.