Stesura Seveso Archivio Italiano di Urologia e Andrologia 2014; 86, 2108 ORIGINAL PAPER Management of bladder stones associated with foreign bodies following incontinence and contraception surgery Abdulmuttalip Simsek 1, Faruk Ozgor 1, Mehmet Fatih Akbulut 1, Erkan Sönmezay 1, Bahar Yuksel 2, Omer Sarılar 1, Ahmet Yalcın Berberoglu 1, Zafer Gokhan Gurbuz 1 1 Haseki Research and Education Hospital, Department of Urology, Istanbul, Turkey; 2 Istanbul Medical Faculty, Gynecology and Obstetric Department, Istanbul, Turkey. Aim of the study: To investigate success of endoscopic lithotripsy for bladder stone following stress urinary incontinance surgery and contraception surgery. Materials and methods: Charts of patients admitted in two centers between January 2006 and March 2013 were retrospectively reviewed and seven women were enrolled in our study. Patients demographic parameters including age, main complaint(s), previous surgery type, time to diagnosis were analyzed. Also operative time, hospitali- sation lenght, perioperative and postoperative complica- tion(s) were evaluated. Results: Five patients had undergone tension free vaginal tape procedure and one patient had undergone transobtu- rator tape procedure. Median age was 62 (50-71) years. In one patient bladder stone formed around an intrauter- ine device. Dysuria (85%), hematuria (57%) and recur- rent urinary tract infection (57%) were the main com- plaints. The median diagnosis time was 44.1 months. Abdominal ultrasonography and non contrast enhanced computer tomography were performed for five and two patients respectively and diagnosis was confirmed cysto- scopically. Endoscopic lithotripsy using Holmium laser lithotripter or pneumatic lithotripter was used for all cases. The mean operation time was 41.2 minutes (20-70) and success was 100%. There was no intraoperative complication. Only one patient had fever higher than 38ºC postoperatively and was treated by appropriate antibiotic. The median hospitalisation time was 1.57 day. Conclusion: In conclusion endoscopic lithotripsy is a safe and effective approach to manage bladder stone associat- ed with mid-urethral synthetic slings and intrauterine devices. KEY WORDS: bladder stone; Endoscopic cystolithotripsy; Intrauterine device; Mid urethral synthetic sling. Submitted 17 September 2013; Accepted 5 October 2013 Summary INTRODUCTION Bladder stones (BS) are rare in women and consist 5% of all cases (1). Generally stone formation in the bladder is No conflict of interest declared. related with an underlying pathology such as neurogenic bladder, pelvic organ prolapse or foreign bodies (2). Benefits of intrauterin devices (IUD) and mid-urethral syn- thetic slings (MUSS) were well described in contraception and stress urinary incontinence, respectively (3-4). Migration of IUD and MUSS into the bladder leads to dysuria, urgency, pelvic pain, recurrent urinary tract infection and BS (5). When BS occur, removal of BS and foreign body is mandatory. Several Authors have defined different approaches to solve this medico-legal problem. Despite acceptable success rate of all techniques, open approaches as cystotomy and partial cystectomy are associated with new incision scar, painful post operative period and longer hospitalisation time when compared with endoscopic treatment modalities (6-7). In this paper we aim to present our experience about BS associated with IUD and MUSS. MATERIALS AND METHODS We conducted an observational study through chart review of patients who were treated for BS. From January 2006 to May 2013, eighteen patients were treated for BS in Sultangazi Goverment Hospital and Haseki Training And Research Hospital. Seven women had BS associated with IUD or MUSS and were enrolled in the study. Diagnosis was confirmed by imaging studies (ultra- sonography or non-contrast enhanced computer tomog- raphy) and endoscopically. The operative procedure was similar for all patients. Endoscopic cystolithotripsy was perfomed using Holmium-Yag laser or pneumatic lithotripter to expose IUD or MUSS (Figure 1). To disconnect the MUSS from the bladder wall, endoscopic scissors and transurethral resection (TUR) with monopolar diathermy were used. When the foreign body was completely separated from the wall of the bladder, an endoscopic forcep was used to remove the IUD or MUSS. Patients’ age, main complaints, diagnosis method and time from surgery to diagnosis were evaluated. Also operative time, treatment modality and lenght of hospitalization were analyzed. Median diagnosis time was defined as the DOI: 10.4081/aiua.2014.2.108 109Archivio Italiano di Urologia e Andrologia 2014; 86, 2 Management of bladder stones associated with foreign bodies following incontinence and contraception surgery period from incontinence or contraception surgery to diagnosis of BS. All patients charts were rewieved by two author (FO and AS). Variables were defined before data collection. Microsoft Excel 2010 software (Microsoft Corporation, Redmond, WA) was used for data entry. RESULTS Demographic characteristics of the patients are present- ed in Table 1. Median age was 62 years. Six patients had undergone stress incontinance surgery including tension free vaginal tape (TVT) and trans obturator tape (TOT). One patients had an history of IUD insertion (Figure 2). All patients were symptomatic and had more than one complaint. Main complaints were dysuria (85%), hema- turia (57%) and recurrent urinart tract infection (UTI) (57%). Patients also reported urgency, frequency and pelvic pain. The median diagnosis time was 44.1 months (range from 9 to 218 months). Pelvic x-ray was per- formed all patients. To evaluate upper urinary system and perivesical area abdominal ultrasonography was also performed in 5 patients and non contrast enhanced com- puter tomography was performed in other 2 patients (Figure 3). Median operative time was 41.2 minutes (range from 20 minutes to 70 minutes) and median hospitalisation time was 1.57 day (range from 1 day to 4 days). Holmium laser was used in 3 cases and pneumatic lithotripter was used in 4 cases. There was no intra operative complica- tion. Post operative period was uneventfully for six patients. Only one patient had fever > 38ºC on the first day of operation and ceftriaxone was started empirically at the dose of 2 g/day. In urine culture, ceftiraxone sensi- tive ESBL producing Escherichia coli was isolated. The patient was discharged at the 4th day after operation. In follow up, endoscopy was performed in six patients who underwent TUR. Cystoscopy revealed recovered bladder mucosa without protrusion of the tape into the bladder in each patient. Recurrent stress urinary inconti- nence was developed in two patients but both of them refused new surgical manipulation. DISCUSSION Bladder stones are uncommon in women and mostly result of pathological conditions such as neurogenic bladder, bladder diverticulum and foreign material. During storage of urine a foreign body is an ideal nidus for stone formation and encrustation by calcium oxalate. Also infection in bladder accelerate the process (8). Most of foreign bodies are related with complications of urog- ynecologic procedures. Suture materials from bladder suspension procedures, sling procedures or IUD inser- tion are the most common source of an intravesical foriegn body (9). Insertion of MUSS or IUD into the bladder leads to the development of significant symtomps and impact nega- tively on quality of life. Dysuria, hematuria, urgency, fre- quency, resistant and recurrent UTI are the most com- mon symptoms (10). On the other hand stone formation requires time. It should be questioned why why the patients were not admitted to hospital despite they com- Figure 1. Bladder stone formed on TVT sling. Pneumatic lithotripter was used to fragment the stone. Figure 2. Image of IUD and fragmented stones after operation. Endoscopic forceps was used to remove IUD. Figure 3. Image of bladder stone at non-contrast enhanced computer tomography. Archivio Italiano di Urologia e Andrologia 2014; 86, 2 A. Simsek, F. Ozgor, M. Fatih Akbulut, E. Sönmezay, B. Yuksel, O. Sarılar, A. Yalcın Berberoglu, Z. Gokhan Gurbuz 110 plaints and why the diagnosis was so delayed. That may be explained by socio-cultural conditions of the country. All these symptoms are mostly considered as a natural sign of aging by patients. Furthermore in rural areas its difficult to achieve health care and physicians tend to treat the symptoms without investigating underlying pathology. To prevent further complications, it is very important to recognize intraoperatively bladder injury during stress incontinance surgery. Cystoscopy is a part of TVT proce- dure and the best method to evaluate the presence of bladder injury (11). Nevertheless in this paper we pres- ent five cases who underwent TVT procedure. Two hypothesis can explain the unfortunate event: sling mesh in the bladder was missed at cystoscopy or mesh was placed in the submucosal area close but outside to the bladder mucosa. Experience of surgeon can affect recog- nizement of bladder injury at cystoscopy. To increase the accuracy of cystoscopy, bladder must be filled with at least 300 mL of fluid to have better vision and use of 7º or 12º optics allows a more extensive view (12). Cystoscopy is not routinely performed after TOT because of the low risk of bladder injury (13). Tayrac et al. and Abdel-Fattah et al. found less than 1% incidence of lower urinary tract injury mostly associated with out- in technique (14-15). Due to longer operative time and requirement of endoscopic instruments, cystoscopic inspection after TOT is not accepted by most surgeons. To avoid injury emptying the bladder completely is very important. We perform cystoscopy only if hematuria occurs intraoperatively or for persistance of irritative bladder symptoms. Due to their safety and efficacy, IUDs are the most pre- ferred method of reversible contraception all over the world (16). However insertion of IUD by paramedics and irregular follow- up evaluations can lead to serious com- plications such as uterine perforation (17). Harrison et al. emphased on the experience of the surgeon to prevent uterine perforation (18). After perforation, IUD could be found in any extrauterine location as rectum, omentum, peritoneum or wall of iliac vein but migration into the bladder is very rare (19-20). Pathophysiology is still unknown but some authors believe that uterine and bladder contractions have a sig- nificant role in the migration of IUD into the bladder. Also uterin atrophy contributes to movement of IUD (21). Misplacement of IUD can cause pain, bleeding and loss of its contraception ability. In our case, the patient was 32 years-old when the T-shape IUD was placed. She had no pregnancies after insertion and symptoms were accepted as normal by the patient. Treatment options are variable according to the experience of the physician and can be divided in open and endo- scopic procedures. Open cystotomy is an alternative for big and hard stones to shorten operation time. If the mesh or IUD is very adherent and it is impossible to remove the foreign body from the bladder wall partial cystectomy may be performed (10). Pikaart et al. performed laparoscopic stone removal by following the steps of open surgery (22). With the application of technological advances in medi- cine, endoscopic treatments is become equally effective and more comfortable than open surgeries. Tyzortis et al. presented two case of bladder stone associated with TVT and both stones were treated endoscopically (23). Also Mustafa et al. used transurethral mesh resection and pneu- motic lithotripsy for the same problem (24). Feiner et al. used Holmium laser to fragment bladder stones after TOT procedure (25). Endoscopic therapies are the first choice for us because most of bladder stones are easily fragment- ed. Furthermore endoscopic manipulations are not affect- ed from body mass index of the patient and by previous surgeries. 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