Floating Hem-o-Lok Clips in the Bladder without Stone Formation after Robot-Assisted Laparoscopic Radical Prostatectomy

Bladder Neck Contracture with Hem-o-Lok Clips Migration after Robotic-Assisted Radical Prostatectomy: A Case Report and Literature Review

Hem-o-lok clips are widely used in robotic-assisted radical prostatectomy (RARP). However, clips-related complications have been reported, including intravesical migration. Here, we share a 60-year-old male case with newly diagnosed prostatic adenocarcinoma. With an unfavorable intermediate risk, he was admitted for RARP. He was discharged from hospital without any immediate complications. However, he reported progressive dysuria and slow urine stream 6 months after surgery. Cystoscopy showed severe bladder neck contracture (BNC), and 2 Hem-o-lok clips were found intravesically and removed during bladder neck incision. Subsequently, fiberocystoscopy revealed another 2 clips near the bladder neck with mild BNC after another 6 months. These 2 clips were also removed during bladder neck dilatation. His urination status then improved without further obstruction. Clip migration after RARP is uncommon; however, clinicians must keep this in mind when patients present with new complaints such as lower urinary tract symptoms, hematuria, and recurrent urinary tract infections.

Late-onset Hem-o-Lok® migration into the bladder after robot-assisted radical prostatectomy

INTRODUCTION

Hem-o-Lok® clips are widely used in robot-assisted radical prostatectomy because of their ease of application and secure clamping. Although there have been some reports of their migration into the urinary tract, this usually occurs a few months after robot-assisted radical prostatectomy. Late-onset cases of Hem-o-Lok® clip migration, that is, after more than 1 year, are rare.

CASE PRESENTATIONS

We report three cases of delayed endourethral Hem-o-Lok® clip migration more than 2 years after robot-assisted radical prostatectomy. The Hem-o-Lok® clips were almost completely endoluminal, and were attached at one end to the vesicourethral anastomosis. We successfully removed them via transurethral surgery using a holmium laser.

CONCLUSION

This case series describes late-onset Hem-o-Lok® clip migration into the bladder more than 1 year after robot-assisted radical prostatectomy. Transurethral holmium laser surgery was very effective for Hem-o-Lok® clip removal. To avoid involvement of Hem-o-Lok® clips in the vesicourethral anastomosis, appropriate resection at the time of bladder neck transection is important.

Incidental discovery of endourethral clip migration 10 years after radical prostatectomy: A case report and review of the literature

INTRODUCTION

Surgical clips (SCs) have been widely used for a variety of surgical procedures over the years. Despite their advantages and proven effectiveness, several clip-related complications have been reported, creating dilemmas as to their optimal use.

CASE DESCRIPTION

Herein, we present a rare delayed and incidental discovery of two endourethral metallic SCs in a 77-year-old male seeking treatment for acute renal colic. The patient had undergone open radical retropubic prostatectomy 10 years ago, and had an uneventful postoperative recovery. Computed tomography scan revealed left-sided hydronephrosis secondary to proximal ureteral calculus, as well as SCs at the level of vesico-urethral (VUR) anastomosis. Flexible cystoscopy confirmed the imaging findings, showing two endourethral clips, partly obstructing the VUR. Firstly, a serial wire-guided dilation took place, followed by left ureteral double-J stent placement. Unfortunately, the clips could not be concurrently removed due to their firm attachment to the bladder neck. Hence, our patient was scheduled for transurethral resection of the bladder neck and simultaneous endoscopic clip removal.

CONCLUSIONS

To the best of our knowledge, this is the first report to highlight such a delayed incidental finding, 10 years after open retropubic radical prostatectomy (RRP), during a JJ stent insertion for obstructive uropathy without previous clip-induced lower urinary tract symptoms. Although rare, physicians should be aware of the potential clip-related complications arising either in the short- or long-term postprostatectomy setting.

Development of bioabsorbable zinc-magnesium alloy wire and validation of its application to urinary tract surgeries

PURPOSE

Metallic medical devices are typically constructed from non-bioabsorbable metals that remains in the body and causes considerable complications. Particularly in the urinary tract, calculus, intractable infection, and misdiagnosis as calculus are often caused by non-bioabsorbable metals. Here, we developed a zinc-magnesium alloy as a new bioabsorbable metal and sought to evaluate the bioabsorbable behavior of zinc and zinc-magnesium alloy in a rat bladder implantation model.

METHODS

We prepared zinc-magnesium alloy wires with various proportions of magnesium and investigated the strength, shape retention, formability, and absorbability of these novel materials. Then, we implanted zinc and zinc-magnesium alloy rings formed by the wires into rat bladder. Rats were euthanized at the end of the observation period, and the rings were removed for volume evaluation. Extracted bladder tissues were subjected to histological analysis.

RESULTS

The strength of the zinc wire was enhanced by more than fourfold upon the addition of magnesium, without loss of ductility. Linear reduction of ring volume in urine was observed based on the concentration of magnesium within the ring. Nearly all rings were covered with a thin layer of calculus. Histological findings of the transected urinary bladder tissues did not differ among groups.

CONCLUSIONS

Zinc-magnesium alloy is a promising candidate for use as a bioabsorbable medical device in the urinary tract.

Silent invasion of Hem-O-Lok clip

A 58-year-old man underwent laparoscopy-assisted distal gastrectomy (LADG) with Billroth I gastroduodenostomy due to early gastric cancer. During surgery, the perigastric vessels were ligated with Hem-o-Lok clips. Esophagogastroduodenoscopy (EGD) 6 months later showed a fungating mass at the anastomosis site. Repeat EGD 1 year after LADG showed a Hem-o-Lok clip at the fungating mass lesion. Because the patient was asymptomatic, with no major abnormalities on clinical examination, and endoscopic removal of the clip would have been difficult due to the presence of adhesions and inflammation, no attempt was made to remove the clip. The patient remained well after the exposed Hem-o-Lok clip was identified. A third EGD 6 months later showed that the clip had disappeared from the anastomosis site, and that this site was covered with normal mucosa surrounding the scar.

Incidental detection of asymptomatic migration of Hem-o-lok clip into the bladder after laparoscopic radical prostatectomy

Hem-o-lok clips have been widely used in laparoscopic or robot-assisted surgery. We report a case of an incidentally discovered Hem-o-lok migration into the bladder after laparoscopic radical prostatectomy. The patient was a 75-year-old man with localized prostate cancer who underwent laparoscopic radical prostatectomy in July 2009. At 3 postoperative years, follow-up ultrasonography revealed a small round mass in the bladder. No lower urinary tract symptoms were reported, and urinalysis results had never indicated hematuria or pyuria. Cystoscopy revealed a Hem-o-lok clip in the bladder, near the vesicourethral anastomotic site. We could not remove it with forceps in the outpatient clinic, so we performed the procedure again under general anesthesia and successfully removed the Hem-o-lok clip. To our knowledge, this is the first report of an asymptomatic Hem-o-lok migration into the bladder.

An update on best practice in the diagnosis and management of post-prostatectomy anastomotic strictures

Postprostatectomy vesicourethral anastomotic stenosis (VUAS) remains a challenging problem for both patient and urologist. Improved surgical techniques and perioperative identification and treatment of risk factors has led to a decline over the last several decades. High-level evidence to guide management is lacking, primarily relying on small retrospective studies and expert opinion. Endourologic therapies, including dilation and transurethral incision or resection with or without adjunct injection of scar modulators is considered first-line management. Recalcitrant VUAS requires surgical reconstruction of the vesicourethral anastomosis, and in poor surgical candidates, a chronic indwelling catheter or urinary diversion may be the only option. This review provides an update in the diagnosis and management of postprostatectomy VUAS.

Migration of clips to the colon after laparoscopic partial nephrectomy

A 78-year-old man was treated with laparoscopic partial nephrectomy for a 4 cm tumour in the lower pole of the left kidney. The patient was discharged 2 days postoperatively. Preoperatively there was no sign of metastasis; the pathology indicated complete removal of the tumour, a renal cell carcinoma. 53 days postoperatively the patient had acute onset of rectal bleeding. A colonoscopy revealed necrosis and three clips on the wall of the colon corresponding to where the descending colon passes over the left kidney. The patient was treated conservatively. Clip migration has been reported previously, but to our knowledge we present the first case of clip migration to the colon after laparoscopic partial nephrectomy. Suggestions to avoid the presented complication are made.

[INTRAVESICAL MIGRATION OF A HEM-O-LOK CLIP AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY: A CASE REPORT]

The Hem-o-lok clips (HOLC) is frequently used for hemostasis of the lateral pedicles in robot-assisted prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP). We report a rare post-operative complication, the migration of a HOLC into the bladder leading to calculus formation after RARP. A 54 year-old man underwent RARP with nerve- sparing procedure with HOLCs in the left neurovascular bundle. Three months later, he was referred to our hospital for pollakisuria and spontaneous hematuria. Abdominal ultrasonographic examination and computed tomography (CT) demonstrated a bladder stone that was 7 mm in diameter. On cystourethroscopy, he was noted to have a yellow-colored stone at 9 o'clock position of vesicourethral anastomosis. A cystolithotripsy for a bladder stone was performed until the surface of it was broken. A HOLC with a calculus was revealed and retrieved by stone forceps through the urethra. Since then, Intravesical migration of a HOLC has not been observed.

Three Types of Intravesical Hem-o-Lok Clip Migration After Laparoscopic Radical Prostatectomy

BACKGROUND

Hem-o-Lok® clips (HOLCs) (Weck® Surgical Instruments, Teleflex Medical, Durham, NC) are widely used for controlling the lateral pedicles in laparoscopic radical prostatectomy, but intravesical HOLC migrations have been reported in more and more studies. This study aimed to summarize clinical presentations, management, and outcomes of these patients.

MATERIALS AND METHODS

Six patients with intravesical HOLC migration were retrospectively identified from 750 consecutive patients who underwent robot-assisted laparoscopic prostatectomy between 2005 and 2014 performed by a single surgeon. The PubMed database was also searched for Hem-o-Lok clip migration after laparoscopic prostatectomy.

RESULTS

The incidence of intravesical HOLC migration in this study was 0.8% (6/750). In total, 22 patients were reported, including six from the current series. Three types of migrations were classified: Type I migration resulted in obstructive lower urinary tract symptoms 2-8 months after prostatectomy, whereas Type II migration led to stone formation, gross hematuria, or bladder spasm; in Type III migration, patients had spontaneous expulsion of the HOLC weeks after surgery.

CONCLUSIONS

Although the incidence of intravesical HOLC migration is relatively low, Type I migration with long-term sequelae remains a concern. The use of HOLCs adjacent to anastomosis should be minimized, and any loose clip must be retrieved to reduce complications.

Endourethral Migration of a Hem-o-Lok Clip after Robot-Assisted Laparoscopic Radical Prostatectomy

Hem-o-Lok clips (Weck Surgical Instruments, Teleflex Medical, Durham, North Carolina, USA) are widely used in robot-assisted laparoscopic radical prostatectomy because of their easy application and secure clamping. To date, there have been some reports of their migration into the urinary tract, causing urethral erosion, bladder neck contractures orcalculus formation. We report a case of endourethral migration of a hem-o-lok after robot-assisted laparoscopic prostatectomy. The hem-o-lok was almost completely endoluminal and attached to one end at the vesico-urethral anastomosis. The hem-o-lok was easily removed cystoscopically by using an endoscopic forceps.

Intraneobladder Hem-o-Lok Migration with Stone Formation after Orthotopic Neobladder Cystectomy

Introduction. Laparoscopic and robot-assisted laparoscopic surgery are widely performed in urology field, so Hem-o-Lok clips are thus extensively used in the laparoscopic procedures. We describe the first case of Hem-o-Lok clip which migrated into the neobladder with calculus formation 26 months after laparoscopic orthotopic neobladder cystectomy, which causes symptoms of gross hematuria and frequent urination. Case Presentation. A 57-year-old man with T2a muscle invasive bladder cancer underwent laparoscopic orthotopic sigmoid neobladder reconstruction after cystectomy which was complicated by intestinal anastomosis leak and peritoneal abscess requiring transverse colostomy and drainage 15 days postoperatively. Twenty-six months after cystectomy, he complained of gross hematuria and frequent urination. Computerized tomography and plain pelvic X-ray revealed a stone measuring approximately 2.8 cm in diameter in the neobladder. During cystoscopy, a closed whitish Hem-o-Lok clip was seen in the center of the calculi. No anastomotic leak or neoplasm was found during cystoscopy. Conclusion. Hem-o-Lok clip migration into the bladder after laparoscopic orthotopic neobladder cystectomy is a rare complication; the first reported case in the literature. To prevent Hem-o-Lok clip migration, it is recommended to avoid extensive use of Hem-o-Lok clip close to anastomosis site, and any loose Hem-o-Lok clip should be retrieved before closure.

Bladder neck contracture-incidence and management following contemporary robot assisted radical prostatectomy technique

Purpose:

Bladder neck contracture (BNC) is a well-recognized complication following robot-assisted radical prostatectomy (RARP) for treatment of localized prostate cancer with a reported incidence of up to 1.4%. In this series, we report our institutional experience and management results.

Methods:

A prospectively collected database of patients who underwent RARP by a single surgeon from 2006 to 2012 was reviewed. Watertight bladder neck to urethral anastomosis was performed over 18-French foley catheter. BNC was diagnosed by flexible cystoscopy in patients who developed symptoms of bladder outlet obstruction. Subsequently, these patients underwent cold knife bladder neck incisions. Patients then followed a strict self regimen of clean intermittent catheterization (CIC). We identify the patient demographics, incidence of BNC, associated risk factors and success of subsequent management.

Results:

Total of 930 patients who underwent RARP for localized prostate cancer was identified. BNC was identified in 15 patients, 1.6% incidence. Mean patient age and preoperative prostate-specific antigen was 58.8 years old and 7.83 ng/mL (range, 2.5–14.55 ng/mL) respectively. Mean estimated blood loss was 361±193 mL (range, 50–650 mL). Follow-up was mean of 23.4 months. Average time to BNC diagnosis was 5.5 months. In three patients, a foreign body was identified at bladder neck. On multivariate analysis, estimated blood loss was significantly associated with development of BNC. All patients underwent cystoscopy and bladder neck incision with a 3-month CIC regimen. Out of 15 index patients, none had a BNC recurrence over the follow-up period.

Conclusions:

BNC was identified in 1.6% of patients in our series following RARP. Intraoperative blood loss was a significant risk factor for BNC. In 20% of BNC patients a migrated foreign body was noted at vesicourethral anastomosis. Primary management of patients with BNC following RARP should be bladder neck incision and self CIC regimen.