Abstract
Gossypiboma is a dreaded complication following mainly abdomino-pelvic surgeries. The clinical presentation varies widely and is strongly associated with two factors: localization of the textiloma and type of the tissue reaction. Intravesical gossypiboma migration is rare and usually presents as recurrent urinary tract infections. We report a case of gossypiboma migration into the bladder that was treated by endoscopic extraction. The purpose of this report is to remind the importance of the prevention which must be the challenge rather than the treatment modalities.
Keywords: Textiloma, Migration, Bladder, Prevention
1. Introduction
The term “gossypiboma” is a combination of the Latin word “gossipium” meaning cotton and the Swahili word “boma” meaning place of concealment.1 It refers to a retained non-absorbable surgical material accidently left inside a patient's body. The foreign material is most commonly a textile, hence the use of synonymous terms such as textiloma or gauzoma.2 Because of medico-legal consequences, the true incidence of gossypiboma is thought to be underreported. It was first described by Wilson in 18843 and has since become a dreaded complication following mainly abdomino-pelvic surgeries.4 The clinical presentation varies widely and is strongly associated with the type of the tissue reaction and localization of the gossypiboma. Intravesical gossypiboma migration is rare.5 We report a case of gossypiboma migration into the bladder that was treated by endoscopic extraction.
2. Case presentation
A 43-year-old patient with history of hysterectomy, consulted for recurrent irritative lower urinary tract symptoms and gross hematuria evolving for three months. Physical examination revealed a hypogastric tenderness. Cytobacteriological examination of urine found Escherichia coli, which was sensitive to amoxicillin and nitrofurantoin. Cystoscopy showed a gauze partially embedded on an inflammatory bladder's posterior wall (Fig. 1). The patient received antibiotics and endoscopic gauze extraction was performed (Fig. 2). We retrieved a surgical gauze of 20 cm of major axis (Fig. 3). The post-operative period was uneventful after 36-months follow-up period. Cystoscopic evaluations were normal.
Fig. 1.
Cystoscopy showing a gauze partially embedded on an inflammatory bladder's posterior wall.
Fig. 2.
Endoscopic extraction of the gauze: (A) rigid cystoscope being introduced and (B) the gauze being removed through the urethra.
Fig. 3.
Gauze after extraction.
3. Discussion
Gossypiboma is a dreaded complication, perhaps the least reported complication of surgery because of medico-legal consequences. The clinical presentation varies widely and can occur from one day to several years after the causative surgery.1,4 The symptoms are usually associated with the type of foreign-body reaction and the localization of the gossypiboma. Two types of foreign-body have been described: aseptic fibrinous response and exudative reaction.4, 5, 6 The aseptic fibrinous response creates adhesions and encapsulation, and leads to the formation of granuloma (pseudotumor). In this case, the gossypiboma usually remains asymptomatic.4 The exudative reaction, on the other hand, leads to abscess formation and therefore to more severe symptoms. The localization also plays a major role in the clinical presentation. Gossypiboma can be located anywhere in the peritoneal cavity. The small intestine is the most commonly affected site by intraluminal migration due to relatively large outer surface and its thin wall that offers the least resistance.4,5 That explains the frequence of intestinal perforation, obstruction or fistula.
Gossypiboma tends to migrate into the adjacent viscera.4 Because of the thick wall of detrusor, gossypiboma migration into the bladder is rare.5 Therefore, a long period of inflammation is required for the gossypiboma to penetrate into the bladder. Open surgery of the bladder or organs around it (uterus, ovary, rectum) is more likely to cause erosion of a foreign body into the bladder. Symptoms of intravesical gossypiboma include recurrent urinary tract infections, dysuria, hematuria, urinary retention.2,5,7, 8, 9 In our case, recurrent urinary tract infection was the main symptom. Imaging methods such as plain X-ray, ultrasound, CT scan, MRI and/or endoscopy can be helpful to the diagnosis. Cystoscopy is utilized to confirm the presence of intravesical foreign-body, the type and location.7,8 At the same time, extraction by cystoscopy is possible and should be tried initially as we made in our case. Due to urethral considerations in male patients, endoscopic extraction is more difficult but can be performed piecemeal using Double J stent removing forceps and a lithotrite.10 Management of cases non-treatable endoscopically requires extraction of the gossypiboma by laparoscopy or laparotomy, followed by intestinal resection if necessary and reparation of damaged organs.5
Therefore, prevention of gossypiboma must be a challenge rather than the treatment modalities. Care should be taken by the surgical team about the risk factors identified by Gawande et al. These factors include change in operating room staff, an emergency operation, an unexpected change in procedure, inadequate number of staff, long duration operations, hurried sponge counts, inexperienced staff, patient's unstable condition, excessive blood loss and a failure to count sponges. The three most important risk factors are emergency surgery, unplanned change in the operation and body mass index.11 It is recommended to educate the staff to systematically use the WHO checklist for all types of operation and perform a “standard surgical instrument and sponge count.4,6,11 The latter is a protocol involving a routine, audible pre-operative count of surgical sponges and instruments by at least two people, with the surgeons paying close attention. A second count is done before the closure of the surgical site and a third count at the completion of the entire procedure.6 Besides, surgeons must keep in mind that counts are not always sufficient. There are many cases of gossypiboma in which the final count was erroneously confirmed complete. To compensate the human fallibility, new technologies such as tagged, bar-coded or radio-opaque surgical sponges and automated counters have been developed.6 These technologies are not widespread in low-income countries, hence the importance of the WHO checklist.
4. Conclusion
Gossypiboma is a dreaded complication that can occur mainly after abdominopelvic surgery. Migration into the bladder is uncommon and usually presents as recurrent urinary tract infections. Despite all of the recommendations for the prevention, human mistake can persist. Therefore, intravesical gossypiboma should be considered in the differential diagnosis of patients with history of surgery and presenting recurrent irritative lower urinary tract symptoms.
Funding
The authors declare they have received no funding for the preparation of this document.
CRediT authorship contribution statement
Modou Ndiaye: Writing – review & editing, Validation, Resources, Investigation. Ibrahima Cissé: Writing – original draft, Methodology, Investigation, Conceptualization. Papa Mamadou Faye: Writing – review & editing, Validation, Methodology, Data curation. Oumar Gaye: Writing – review & editing, Validation, Supervision. Mouhamed Diallo: Resources, Methodology, Investigation. Papa Ahmed Fall: Validation, Supervision.
Declaration of competing interest
The authors report no declarations of interest.
References
- 1.Longo R., Amici S., Carillio G., Gasparini G. Diagnostic challenges in patients with tumors: case 2. Staphylococcal scalded-skin syndrome in a patient with extended small-cell lung cancer. J Clin Oncol. 2003 Oct 1;21(19):3702–3703. doi: 10.1200/JCO.2003.02.991. [DOI] [PubMed] [Google Scholar]
- 2.Javanmard B., Yousefi M.R., Fadavi B., Fallah Karkan M. Retained surgical gauze presenting with gross hematuria: a case report. Urol J. 2017 Aug 29;14(5):5027–5029. [PubMed] [Google Scholar]
- 3.Wilson C.P. 1884. Foreign Bodies Left in the Abdomen after Laparotomy; p. 15. (Medicine in the Americas, 1610-1920) [Google Scholar]
- 4.Sozutek A., Colak T., Reyhan E., Turkmenoglu O., Akpınar E. Intra-abdominal gossypiboma revisited: various clinical presentations and treatments of this potential complication. Indian J Surg. 2015 Dec;77(S3):1295–1300. doi: 10.1007/s12262-015-1280-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Mohammad M., Chukwuemeka A., Aji S., Tukur J., Diggol G., Ibrahim M. Intravesical migration of gossypiboma following vaginal hysterectomy: an unusual cause of acute urinary retention. Arch Int Surg. 2014;4(3):176. [Google Scholar]
- 6.Awowole I., Makinde O., Tijani A., Olasehinde O., Badejoko O. Thinking beyond gauze count at surgery: a reminder to surgeons on textilomas. Br J Med Med Res. 2014 Jan 10;4(32):5167–5173. [Google Scholar]
- 7.Rafique M. Intravesical foreign bodies: review and current management strategies. Urol J. 2008;5(4):223–231. [PubMed] [Google Scholar]
- 8.Singh P., Panaiyadiyan S., Nayak B. Pelvic gossypiboma with spontaneous intravesical erosion. BMJ Case Rep. 2017 Apr;11 doi: 10.1136/bcr-2016-219173. bcr-2016-219173. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Ahsaini M., Aboubakry S., El Ammari J., Tazi M.F., El Fassi M.J., Farih M.H. Un textilome intra-vésicale mimant une tumeur vésicale (pseudotumeur vésical): à propos d´un cas exceptionnel. PAMJ Clin Med [Internet] 2019;1 https://www.clinical-medicine.panafrican-med-journal.com/content/article/1/49/full/ [cited 2024 Feb 29] [Google Scholar]
- 10.Kansakar R., Hamal B.K. Cystoscopic removal of an intravesical gossypiboma mimicking a bladder mass: a case report. J Med Case Rep. 2011 Dec;5(1):579. doi: 10.1186/1752-1947-5-579. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Gawande A.A., Studdert D.M., Orav E.J., Brennan T.A., Zinner M.J. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003 Jan 16;348(3):229–235. doi: 10.1056/NEJMsa021721. [DOI] [PubMed] [Google Scholar]