Special Feature 223Urology Journal Vol 5 No 4 Autumn 2008 Intravesical Foreign Bodies Review and Current Management Strategies Muhammad Rafique Introduction: The aim of this study was to evaluate the cause, diagnosis, and management of intravesical foreign bodies in patients treated at our hospital and to review and update management of intravesical foreign bodies reported in the current literature. Materials and Methods: Sixteen patients had been treated for intravesical foreign bodies at Nishtar Medical College Hospital, Multan, Pakistan during a 5-year period. Records of these patients were analyzed retrospectively for etiology, presentation, diagnosis, and management. Results: The age of the patients ranged from 14 to 70 years and 10 of them were men. Seven patients (43.8%) had iatrogenic intravesical foreign bodies, 5 (31.3%) had migrated foreign bodies from the adjacent organs, and 4 (25.0%) had self-introduced foreign bodies into the bladder. The objects included copper wire, carrot, lead pencil, intrauterine device, surgical gauze, pieces of Foley catheter, and teflon beak of resectoscope sheath. The most common presenting symptoms were urinary frequency and dysuria. Endoscopic retrieval was possible in 8 (50.0%) patients, and the remaining underwent open cystostomy. Conclusion: Intravesical foreign bodies should be included in the differential diagnosis of patients with chronic lower urinary tract problems. Radiological evaluation is necessary to determine the exact size, number, and nature of them. The most suitable method for removal of intravesical foreign bodies depends on the nature of the foreign body, age of the patient, and available expertise and equipment. Most intravesical foreign bodies can be retrieved with minimally invasive techniques. Urol J. 2008;5:223-31. www.uj.unrc.ir Keywords: foreign bodies, bladder, foreign-body migration, urinary tract infections, hematuria, intrauterine devices, cystoscopy Department of Urology, Nishtar Medical College, Multan, Pakistan Corresponding Author: Muhammad Rafique, FRCS, FRCS, Dip Urol, FEBU No 5, Altaf Town, Tariq Rd, Multan, Pakistan Tel: +92 61 457 1544 E-mail: rafiqanju@hotmail.com Received October 2007 Accepted July 2008 INTRODUCTION During the past few decades, reports of intravesical foreign bodies have increased in the literature. A review of the literature on this subject reveals that almost any conceivable object has been introduced in to the urinary bladder. Introduction into the bladder may be self-insertion (through the urethra), iatrogenic, migration from adjacent organs, or a results of penetrating trauma.(1-4) Patients present with either acute or chronic symptoms due to complications. Each foreign body poses a challenge to the urologist and treatment has to be individualized according to the size and nature of the foreign body and age of the patient.(5) Previously, endoscopic extraction with or without perineal urethrotomy or open cystotomy were the only treatment options, but with the advent of newer minimally invasive Intravesical Foreign Bodies—Rafique 224 Urology Journal Vol 5 No 4 Autumn 2008 techniques, most intravesical foreign bodies can be removed endoscopically without resorting to open surgery.(6-9) This paper presents our experience of diagnosis and management of various intravesical foreign bodies at our hospital. In addition, the discussion focuses on reviewing and updating the knowledge on management of intravesical foreign bodies reported in the current literature. MATERIALS AND METHODS Hospital records of patients who had received treatment for intravesical foreign bodies during a period from January 2001 to December 2005 at the department of urology, Nishtar Medical College Hospital, Multan, Pakistan, were retrospectively analyzed. The patients’ age and sex, clinical presentation, diagnosis, and offered treatment were reviewed. The study was approved by the hospital’s ethics committee. RESULTS There were 16 patients who had received treatment of intravesical foreign bodies at our hospital during the studied period. Their age ranged from 14 to 70 years (median age, 33 years). Ten patients were men and 6 were women (male- female ratio, 1.7:1). They had presented with variable urinary symptoms (Table 1). The most common symptoms were urinary frequency and dysuria. Hematuria, difficulty with micturition, and urinary retention were the other complaints at presentation. Seven patients (43.8%) had iatrogenic foreign bodies including retained surgical gauze (namely gossypiboma) in 5, a piece of a Foley balloon catheter in 1, and Teflon beak of a resectoscope sheath in 1 patient. All of the patients with surgical gauze had undergone open transvesical prostatectomy at peripheral hospitals and presented at variable intervals after the primary surgical operation. A piece of the Foley catheter in 1 patient had probably been left in the bladder when the balloon of his “stuck” catheter was suprapubically punctured. One patient had transurethral resection of the prostate carried out 6 weeks before presentation, when the Teflon beak of the resectoscope sheath became detached and was incidentally left in the bladder. He presented with hematuria. In 5 patients (31.3%), the foreign bodies had migrated into the urinary bladder from the Patient Age Sex Foreign Body Cause Presentation Time to Presentation Treatment 1 60 M Surgical gauze Iatrogenic Acute urinary retention 3 months Cystoscopy 2 70 M Surgical gauze Iatrogenic Frequency, dysuria, difficulty with micturition 6 years Open cystotomy 3 70 M Surgical gauze Iatrogenic Difficulty with micturition, recurrent UTI 3 years Open cystotomy 4 67 M Surgical gauze Iatrogenic Difficulty with micturition 3 weeks Cystoscopy 5 65 M Surgical gauze Iatrogenic Urinary retention 4 months Open cystotomy 6 30 M Piece of Foley balloon catheter Iatrogenic Recurrent UTI 6 months Cystoscopy 7 60 M Teflon beak of TUR sheath Iatrogenic Hematuria, difficulty with micturition 6 weeks Cystoscopy 8 28 F Calculus on IUD Migration Recurrent UTI 5 years Cystoscopy and litholopaxy 9 32 F Calculus on IUD Migration Hematuria 5 years Open cystotomy 10 35 F Calculus on IUD Migration Frequency, dysuria 3 years Open cystotomy 11 40 F Calculus on IUD Migration Hematuria, dysuria 2 years Cystoscopy and litholopaxy 12 14 F Metal wire Migration Hematuria, dysuria 3 weeks Open cystotomy 13 25 M Copper wire Self-insertion Hematuria 3 weeks Open cystotomy 14 28 F Carrot Self-insertion Hematuria 2 weeks Cystoscopy and TUR resection 15 18 F Lead pencil Self-insertion Hematuria, dysuria 4 weeks Cystoscopy 16 16 F Ball pen Self-insertion Recurrent UTI 6 months Open cystotomy Table 1. Patients Presented With Intravesical Foreign Bodies* *M indicates male; F, female; UTI, urinary tract infection; TUR, transurethral resection; and IUD, intrauterine device. Intravesical Foreign Bodies—Rafique Urology Journal Vol 5 No 4 Autumn 2008 225 surrounding structures. In 4 of them, intrauterine device (IUD) had migrated into the bladder, and these patients presented between 2 and 5 years after insertion of the device when calculi had been formed over the IUDs (Figure 1). A mentally disabled boy who had swallowed a 3-in long metal wire 6 weeks earlier presented with hematuria and dysuria, and the metal wire was found to be lying in the bladder. In 4 patients (25.0%), the foreign bodies had been self-introduced into the bladder for sexual pleasure. These included a copper wire (Figure 2), a carrot, a lead pencil (Figure 3), and a ball pen. These patients were rather young with the ages ranged between 14 and 28 years. All of the patients had undergone ultrasonography of the urinary tract and plain abdominal radiography of the kidney, ureters, and bladder (KUB) at the time of admission to our hospital. In 15 patients (93.8%), ultrasonography had detected the presence of an echogenic object in the bladder; however, only in 6 (37.5%), the presence of vesical foreign bodies had been correctly reported by the radiologist. Nine of the cases (52.3%) had been erroneously reported to be bladder calculi. In 1 patient ultrasonography had failed to diagnose the presence of a piece of Foley balloon catheter. Plain KUB had revealed the presence of a foreign body in 7 patients (43.8%), while in 2 patients (12.5%), who had a surgical gauze in the bladder, a faint radio-opaque shadow in the bladder area had been reported. In 2 patients who had transvesical prostatectomy, cystography had been performed that had strongly suggested the presence of a foreign body in the bladder by showing contrast material in some areas of filling defect. Eight intravesical foreign bodies (50.0%) had been removed endoscopically, and the remaining, by open surgery. The operation had been carried out by different surgeons and surgeons in training. The number of the foreign bodies removed endoscopically could have been higher had the required endoscopic equipment and Figure 1. Pelvis radiography shows calculus formation on an intra-uterine device. Figure 2. Pelvis radiography shows a coiled-up metal wire in the bladder area. Figure 3. Ultrasonography shows a straight echogenic foreign body (lead pencil; arrow) and balloon of a Foley catheter in the bladder. Intravesical Foreign Bodies—Rafique 226 Urology Journal Vol 5 No 4 Autumn 2008 expertise be available at the time of treatment of all cases. Postoperatively, 2 patients had fever with rigors that settled with appropriate intravenous antibiotic therapy. One patient who had open surgical removal of a surgical gauze developed superficial wound infection. No other complications were recorded. DISCUSSION Intravesical foreign bodies are an important consideration in the differential diagnosis of lower urinary tract problems. Usually, foreign bodies are self-introduced, result of medical errors, migrated from the surrounding organs, or result of a penetrating injury. The variety of foreign bodies inserted in to bladder defies imagination and includes any types of objects. The most common motive associated with intravesical insertion of foreign bodies is sexual gratification. In some cases, it may be a consequence of a psychiatric illness. It is therefore surprising that objects as diverse as light bulbs, electric wire, glass rod, thermometer, battery, and blue tack have been self-introduced by patients.(2,9-12) Occasionally, a foreign body is inadvertently inserted into the female urethra in an attempt to procure abortion or prevent conception. (13) Furthermore, thermometers are frequently reported to slip into the female bladder during the patient’s attempts to determine the temperature in the vulva or urethra.(14,15) Rarely, living objects, leech for instance, may enter the urinary bladder through the urethra.(16) A variety of objects have been reported to migrate into the urinary bladder from the surrounding pelvic organs, including IUD, vaginal pessary, artificial urinary sphincter, prosthetic slings, nonabsorbable sutures used in Stamey procedures, surgical gauze, etc.(17-22) Almost any foreign body placed in the vicinity of the bladder has a potential of migration into the urinary bladder. Calculus formation may develop on such foreign bodies. Catheters and endoscopic instruments are the most common objects introduced into the bladder by urologists. Thus, fragments of these instruments are the most common iatrogenic foreign bodies remaining in the bladder. Catheter tips, parts of catheter balloon, bougies, and beak of resectoscope sheath are some of the reported iatrogenic foreign bodies recovered from bladder.(7,23-26) In addition, urethral stents used in reconstructive urological procedures such as hypospadias repair may migrate into the bladder. (27) Retained suture material or staples used in bladder surgeries are of other iatrogenic objects, which may subsequently present as bladder calculi.(28) Occasionally, surgical gauze or sponge (gossypiboma) may be left in the bladder.(29,30) Recently, transvaginal tape has become one of the common procedures performed for the treatment of female stress incontinence. Perforations of the bladder during the placement of transvaginal tape are relatively common, but are usually noted on cystoscopy and corrected intraoperatively. Undetected bladder perforation may result in several complications including recurrent urinary tract infections, bladder calculus formation, and pelvic pain.(31,32) Symptoms of intravesical foreign bodies are usually those of acute cystitis including urinary frequency, dysuria, hematuria, and strangury. Some patients may present with swelling of the external genitalia, poor urinary stream, and urinary retention. More importantly, patients occasionally present with no symptoms or complaint of minimal discomfort.(23) However, signs that should raise the physician’s suspicion include undue anxiety during sexual history taking or attempts to avoid genital or rectal examination. Previous bladder surgery or surgery on the adjacent organs may well be relevant.(1) Radio-opaque intravesical foreign bodies can usually be detected on KUB radiography. Intravenous urography or retrograde urethrography may provide additional information and occasionally reveal surprising findings and unexpected radiolucent objects.(1) The use of abdominal and transvesical ultrasonography has been reported for the detection of non-radio-opaque intravesical foreign bodies.(33-35) The degree of the echogenicity of a foreign body is dependent on the difference in acoustic impedance between the foreign body and surrounding tissues. Hence, the ultrasonographic appearance of intravesical foreign bodies will vary Intravesical Foreign Bodies—Rafique Urology Journal Vol 5 No 4 Autumn 2008 227 depending on their nature.(36) To confirm the presence of intravesical foreign body cystoscopy is utilized. In addition, cystoscopy will identify the type and location of the foreign body, as well as being the most adequate method for treatment.(2) Complications of intravesical foreign bodies consist of chronic and recurrent urinary tract infections, acute urinary retention, calcification, obstructive uropathy, scrotal gangrene, vesicovaginal fistula, squamous cell carcinoma, and even death of sepsis.(37-44) Initial management of patients with intravesical foreign bodies should consists of providing pain relief and control of irritative voiding symptoms by prescribing analgesics and anticholinergic drugs, respectively. Antibiotics will be required for the control of urinary tract infection and prevention of sepsis in infected patients. Definitive management of intravesical foreign bodies is aimed at providing complete removal of the foreign body with minimal complications such as trauma to the bladder and urethra, peritonitis, urinary tract infection, hematuria, etc. On rare occasions, foreign bodies may be spontaneously expelled from the bladder during urination.(45) Most foreign bodies in the bladder may be removed either complete or after fragmentation via the endoscopic approach. However, the optimal technique is dictated by the patient’s condition, associated urinary tract injuries and size, and shape and nature of the foreign body. Table 2 gives a brief summary of various authors’ experiences of management of intravesical foreign bodies recorded in the current literature.(1,3,7-11,13,16-18,24,45-80) Conventionally, grasping forceps and retrieval baskets are used for removal of a foreign body. In some cases, grasping an object with an alligator or calculus forceps increases the effective diameter of that object and may make removal difficult and hazardous. In the past few decades, several modifications of endoscopic instruments and devices have been developed, especially for removing foreign bodies. Reportedly, cylindrical foreign bodies and thermometers have been removed via transurethral route using rigid and flexible cystoscopy, respectively.(46,47) Wise and King(48) reported magnetic extraction of a metallic foreign body (hair pin) from the bladder by specially designed magnetic retriever. In recent years, because of their larger diameter and straight and strong design, the use of percutaneous instruments has been suggested for removing longer and stiff intravesical foreign bodies.(49) Younesi and colleagues(6) reported a similar technique for removal of a fragile glass foreign body (a lidocaine carpule) from the bladder. While Marshall and associates(50) reported the use of a specially constructed prolene snare intra-operatively to facilitate safe and rapid extraction of an intravesical metallic pipe by cystoscopy. Metal wires introduced into the bladder usually get curled up due to bladder contractions. In some cases, a wire can be removed endoscopically(12); however, in most cases, open surgery is required to minimize urethral trauma during perurethral extraction. Ejstrud and Poulsen(51) reported the use of intravesical laparoscopy to untie a complete knot of an electric wire. The bladder was distended with 100 mL of saline during the procedure. Paraffin objects such as candles and crayons are frequently introduced into the bladder. In the past, various solvents like xylol, benzene, and kerosene had been used for minimally invasive treatment of such objects. Since these solvents are known to be carcinogenic, their use is no longer suitable. Endoscopic removal of wax and paraffin objects is often complicated by their characteristic of floating on water. This problem may be solved by infusing gases such as carbon dioxide for cystoscopic examination and removal.(1) Wyatt and Hammontree(8) reported the use of holmium:yttrium-aluminum-garnet laser to cut a foreign body, ie, a weed trimmer line, to facilitate its perurethral removal. They also tested many reported intravesical foreign bodies ex vivo and reported that most foreign bodies except glass appeared to be cut by the laser. As the glass object would not absorb laser energy, it was not fragmented. During the procedure, potential safety concerns about burns and exposure to byproducts of combustion appear to be mitigated by irrigation fluid. The authors suggest that many commonly reported intravesical foreign bodies are amenable to Intravesical Foreign Bodies—Rafique 228 Urology Journal Vol 5 No 4 Autumn 2008 treatment with laser. Habermacher and Nadler(7) reported the use of holmium laser to fragment a detached 26-F resectoscope sheath tip before its transurethral removal without any complications. Hong and colleagues(32) used holmium laser to remove bladder-penetrating polyester suture in an earlier sling surgery that could not be removed completely by conventional cystoscopic equipment. The use of laser for intravesical fragmentation and subsequent removal of large intravesical foreign bodies is a promising new technique for urological surgeons. Szlyk and Jarrett(52) described the use of 20-F rigid hysteroscope in urological practice to remove deeply embedded foreign bodies from the lower Reference Foreign Body Technique for Removal 55 IUD Cystoscopy 56,57 IUD Cystoscopy and suprapubic cystotomy 58 IUD Cystoscopy and transcervical removal 59 Calculus on IUD Cystoscopy/cystolithotripsy 16,60,61 Calculus on IUD Suprapubic cystostomy 62 Calculus on IUD Cystoscopy/electrohydraulic lithotripsy 63 Calculus on IUD Laparotomy 49 Pencil Percutaneous nephrolithotomy Sheath and forceps 13 Calculus on pencil cover Cystoscopy 1 Wax candle Cystoscopy, air insufflation, and endoscopic removal 22,64 Surgical gauze Cystoscopy and removal with forceps 65 Polypropylene mesh after laparoscopic hernioplasty Suprapubic cystostomy 66 Demobilization chain Suprapubic cystostomy 13 Bamboo stick Cystoscopy 67 Long plastic tube Cystoscopy 3,68 Electric wire Cystoscopy 51 Electric wire Intravesical laparoscopic undoing of knots & removal 69 Calculus on copper wire Suprapubic cystostomy 70 Calculus on metal wire Open cystostomy 8 Weed trimmer line Holmium:YAG laser 71 Stamey sutures Cystoscopy 72 Suture and pledget of bladder neck suspension Cystoscopy 31 Tension-free vaginal tape Suprapubically assisted Operative cystoscopy for Removal of mesh 32 Bladder penetrating polyester suture of sling operation Cystoscopy and holmium Laser removal 73,74 Polypropylene suture after anti-incontinence surgery Cystoscopy/holmium laser excision 75 Tampon Cystoscopy 76 Urethral incontinence plug Cystoscopy 47 Thermometer Flexible cystoscopy 77 Thermometer Percutaneous removal with rigid nephroscope and forceps 78 Aluminum rod Open cystostomy 48 Metallic hair pin Magnetic extraction with Magnetriever 17 Migrated AMS 800 urinary sphincter Transvesical removal 11 Battery Suprapubic cystostomy 7 Detached tip of resectoscope sheath Holmium laser fragmentation and cystoscopic removal 24 Calculus on a piece of Foley balloon catheter Tranurethral cystolitholapaxy cystoscopy 54 Retained catheter tip with inflated Foley balloon Cystoscopy, puncture of balloon with Sachse’s urethrotome knife, and endoscopic removal 79 calculus on ruptured Foley balloon fragment Cystoscopy 9 Blue tack Carbon dioxide insufflation cytoscopy for visualization and laparoscopic removal 80 Retained silastic catheter Cystoscopy for optical visualization and percutaneous removal with laparoscopic equipment 53 Toy frog Cystoscopic visualization and small open cystostomy Table 2. Reported Intravesical Foreign Bodies in the Literature and Techniques Used for Their Removal* *IUD indicates intrauterine device; YAG, yttrium-aluminum-garnet; and AMS, American medical systems. Intravesical Foreign Bodies—Rafique Urology Journal Vol 5 No 4 Autumn 2008 229 urinary tract of 3 patients in whom previous attempts with standard cystoscopic equipment had been unsuccessful. DeLair and coworkers(53) reported a technique for rapid extraction of a large foreign body from the bladder. In this technique, the intravesical foreign body was visualized by cystoscopy. Urinary bladder was entered through a small cystotomy using a cut- to-the-light approach, and the foreign body (a toy frog) was rapidly extracted under cystoscopic guidance. The authors claimed that combination of endoscopy and cystotomy is rapid, safe, and potentially applicable for the removal of large vesical calculi. Removal of the retained catheter tip of an inflated Foley catheter’s balloon is difficult and sometimes frustrating. The spherical latex rubber balloon with little amount of air makes it of lighter density than water. Therefore, it has tendency to float in the urinary bladder and rest near the dome, almost hiding itself. Hemal and colleagues(54) reported 2 techniques to tackle such a situation. In the first technique, the bladder was evacuated of excess water and the balloon was trapped in the small space to be punctured with Sachse’s urethrotome knife before its removal. In the second technique, a fine hypodermic needle without its hub was mounted on the biopsy forceps to puncture the balloon. The removal of intravesical foreign bodies in children poses a great therapeutic challenge. In contrast to intravesical foreign bodies in adults, the size of the pediatric urethra may preclude safe transurethral removal. Reddy and Daniel(9) reported a novel method for tackling such a situation. Using cystoscopy as the optical device through the urethra, a 10-mm laparoscopic port was introduced suprapubically under the vision for extraction of the complex foreign body (ie, blue tack while the bladder remained insufflated with carbon dioxide at a pressure of 12 mm Hg. By avoiding the use of irrigating fluid, they claimed that irrigating fluid-induced hypothermia can be avoided. Percutaneous retrieval of intravesical foreign body in a 4-month-old infant using direct transurethral visualization has been reported by Hutton and Huddart.(80) CONCLUSION Intravesical foreign bodies are not uncommon and their presence should be included in the differential diagnosis of patients presenting with chronic lower urinary tract problems. Radiological evaluation is necessary to determine the exact size, number, and nature of foreign bodies. The most suitable method for removal of intravesical foreign bodies will depend on the nature of the foreign body, age of the patient, and the available expertise and equipment. Most intravesical foreign bodies can be retrieved with endoscopic and minimally invasive techniques without resorting to open surgery. CONFLICT OF INTEREST None declared. REFERENCES 1. Eckford SD, Persad RA, Brewster SF, Gingell JC. Intravesical foreign bodies: five-year review. Br J Urol. 1992;69:41-5. 2. Granados EA, Riley G, Rios GJ, Salvador J, Vicente J. Self introduction of urethrovesical foreign bodies. Eur Urol. 1991;19:259-61. 3. Pal DK. Intravesical foreign body. Indian J Surg. 1999;61:381-3. 4. Halkic N, Wisard M, Abdelmoumene A, Vuilleumier H. A large bullet in the bladder. Swiss Surg. 2001;7:139- 40. 5. van Ophoven A, deKernion JB. Clinical management of foreign bodies of the genitourinary tract. J Urol. 2000;164:274-87. 6. Younesi M, Ahmadnia H, Asl Zare M. An unusual foreign body in the bladder and percutaneous removal. Urol J. 2004;1:126-7. 7. Habermacher G, Nadler RB. Intravesical holmium laser fragmentation and removal of detached resectoscope sheath tip. J Urol. 2005;174:1296-7. 8. Wyatt J, Hammontree LN. Use of Holmium:YAG laser to facilitate removal of intravesical foreign bodies. J Endourol. 2006;20:672-4. 9. Reddy BS, Daniel RD. A novel laparoscopic technique for removal of foreign bodies from the urinary bladder using carbon dioxide insufflation. Surg Laparosc Endosc Percutan Tech. 2004;14:238-9. 10. Wenderoth U, Jonas U. Curiosity in urology? Masturbation injuries. Eur Urol. 1980;6:312-3. 11. Gogus C, Kilic O, Haliloglu A, Gogus O. A very unusual intravesical foreign body in a male. Int Urol Nephrol. 2002;34:203-4. 12. Pal DK, Bag AK. Intravesical wire as foreign body in urinary bladder. Int Braz J Urol. 2005;31:472-4. Intravesical Foreign Bodies—Rafique 230 Urology Journal Vol 5 No 4 Autumn 2008 13. Sharma UK, Rauniyar D, Shah WF. Intravesical foreign body: case report. Kathmandu Univ Med J (KUMJ). 2006;4:342-4. 14. Yiu MK, Yiu TF, Chan AY. Extraction of an intravesical thermometer using a flexible cystoscope. Br J Urol. 1995;76:143-4. 15. Riou PJ, Harris A. Intravesical thermometer: an unusual complication of vaginal temperature measurement. J Accid Emerg Med. 1998;15:432. 16. Mukherjee G. Unusual foreign body causing haematuria. J Indian Med Assoc. 1974;63:284-5. 17. Bartoletti R, Gacci M, Travaglini F, Sarti E, Selli C. Intravesical migration of AMS 800 artificial urinary sphincter and stone formation in a patient who underwent radical prostatectomy. Urol Int. 2000;64:167-8. 18. Tornero J, Palou J, Prados M, Salvador J, Vicente J. Bladder perforation caused by foreign body migration. Int Urol Nephrol. 2000;32:241-3. 19. Nouira Y, Rakrouki S, Gargouri M, Fitouri Z, Horchani A. Intravesical migration of an intrauterine contraceptive device complicated by bladder stone: a report of six cases. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:575-8. 20. Chamary VL. An unusual cause of iatrogenic bladder stone. Br J Urol. 1995;76:138. 21. Cardozo L. Recurrent intra-vesical foreign bodies. Br J Urol. 1997;80:687. 22. Grody MH, Nyirjesy P, Chatwani A. Intravesical foreign body and vesicovaginal fistula: a rare complication of a neglected pessary. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10:407-8. 23. Aliabadi H, Cass AS, Gleich P, Johnson CF. Self- inflicted foreign bodies involving lower urinary tract and male genitals. Urology. 1985;26:12-6. 24. Ohashi H. (A case of bladder calculus due to a ruptured balloon fragment of a Foley catheter). Hinyokika Kiyo. 1997;43:227-8. Japanese 25. Persad RA, Paisley A, Smith PJ. Retained catheter tip causing recurrent urinary tract infection in a 91-year- old man. Br J Urol. 1990;66:664. 26. Prasad S, Smith AM, Uson A, Melicow M, Lattimer JK. Foreign bodies in urinary bladder. Urology. 1973;2:258-64. 27. Wheeler RA, Malone PS, Griffiths DM, Burge DM. The Mathieu operation. Is a urethral stent mandatory? Br J Urol. 1993;71:492-3. 28. Ward HC. Surgical staples in bladder calculi after caecocystoplasty. Br J Urol. 1987;60:375. 29. Heffernan JP, Heidenberg HB, Irby PB, Moul JW. Gossypiboma (retained surgical sponge) and recurrent bladder neck contracture after radical retropubic prostatectomy and bilateral pelvic lymph node dissection. J Urol. 1997;157:1356-7. 30. Nishikawa K, Ohyama A, Kan E, et al. (Case report: a foreign body (gauze) in the bladder). Hinyokika Kiyo. 1991;37:287-9. Japanese. 31. Rosenblatt P, Pulliam S, Edwards R, Boyles SH. Suprapubically assisted operative cystoscopy in the management of intravesical TVT synthetic mesh segments. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16:509-11. 32. Hong SK, Kim KT, Shin JW, Kin SW, Paick JS. Endoscopic laser removal of a bladder-penetrating suture used in an earlier sling operation. Continence. 2005:1:58-60. 33. Lazar J, Asrani A. Sonographic diagnosis of a glass foreign body in the urinary bladder. J Ultrasound Med. 2004;23:969-71. 34. Barzilai M, Cohen I, Stein A. Sonographic detection of a foreign body in the urethra and urinary bladder. Urol Int. 2000;64:178-80. 35. Huang WC, Yang JM. Sonographic appearance of a bladder calculus secondary to a suture from a bladder neck suspension. J Ultrasound Med. 2002;21:1303-5. 36. Boyse TD, Fessell DP, Jacobson JA, Lin J, van Holsbeeck MT, Hayes CW. US of soft-tissue foreign bodies and associated complications with surgical correlation. Radiographics. 2001;21:1251-6. 37. Schnall RI, Baer HM, Seidmon EJ. Endoscopy for removal of unusual foreign bodies in urethra and bladder. Urology. 1989;34:33-5. 38. Loup J. (Foreign bodies of the urethra). Acta Urol Belg. 1987;55:462-6. 39. Bapat RD, Kamdar MS, Bhaktiani K, Jathar H. Obstructive uropathy due to a vesical calculus around a foreign body. J Postgrad Med. 1981;27:51-2. 40. Bhatt RI, Lau M, Ramani VAC. Renal failure secondary to a foreign body in the bladder. BJU Int. 2001;88:644-6. 41. Grumet GW. Pathologic masturbation with drastic consequences: case report. J Clin Psychiatry. 1985;46:537-9. 42. Mhiri MN, Amous A, Mezghanni M, Rekik S, Smida ML. Vesico-vaginal fistula induced by an intravesical foreign body. Br J Urol. 1988;62:271. 43. Wyman A, Kinder RB. Squamous cell carcinoma of the bladder associated with intrapelvic foreign bodies. Br J Urol. 1988;61:460. 44. Sivaloganathan S. Catheteroticum. Fatal late complication following autoerotic practice. Am J Forensic Med Pathol. 1985;6:340-2. 45. DiDomenico D, Guinan P, Sharifi R. Spontaneous expulsion of an intravesical bullet. J Am Osteopath Assoc. 1997;97:415-6. 46. Roemer KR, Das S. Transurethral endoscopic removal of cylindrical intravesical body. Urology. 1984;23:592-3. 47. Scriven JM, Patterson JE. Extraction of an intravesical thermometer using a flexible cystoscope. Br J Urol. 1995;76:815. 48. Wise KL, King LR. Magnetic extraction of intravesical foreign body. Urology. 1989;33:62-3. 49. Wegner HE, Franke M, Schick V. Endoscopic removal of intravesical pencils using percutaneous nephrolithotomy sheath and forceps. J Urol. 1997;157:1842. Intravesical Foreign Bodies—Rafique Urology Journal Vol 5 No 4 Autumn 2008 231 50. Marshall JS, Cardin AL, Palapattu G. A simple inexpensive snare for manipulation of intravesical foreign bodies. Can J Urol. 2008;15:3936-8. 51. Ejstrud P, Poulsen J. Laparoscopic removal of an electric wire from the bladder. Br J Urol. 1997;80:338. 52. Szlyk GR, Jarrett TW. Use of rigid hysteroscope for extraction of foreign bodies embedded in lower urinary tract. J Endourol. 1999;13:47-8. 53. DeLair SM, Bernal RM, Keegan KA, Ellison LM. Ship in a bottle: rapid extraction of large intravesical foreign bodies. Urology. 2006;67:612-3. 54. Hemal AK, Taneja R, Sharma RK, Wadhwa SN. Unusual foreign body in urinary bladder: points of technique for their retrieval. Eastern J Med. 1998;3:30- 31. 55. Olaore JA, Shittu OB, Adewole IF. Intravesical Lippes loop following insertion for the treatment of Asherman’s syndrome: a case report. Afr J Med Med Sci. 1999;28:207-8. 56. Yilmaz Y, Bayrakli H, Cecen K, Gunes M. An unusual foreign body in the bladder. Eastern J Med. 2002;7:43-4. 57. Hoscan MB, Kosar A, Gumustas U, Guney M. Intravesical migration of intrauterine device resulting in pregnancy. Int J Urol. 2006;13:301-2. 58. Caspi B, Rabinerson D, Appelman Z, Kaplan B. Penetration of the bladder by a perforating intrauterine contraceptive device: a sonographic diagnosis. Ultrasound Obstet Gynecol. 1996;7:458-60. 59. Lu HF, Chen JH, Chen WC, Shen WC. Vesicle calculus caused by migrant intrauterine device. AJR Am J Roentgenol. 1999;173:504-5. 60. Maskey CP, Rahman M, Sigdar TK, Johnsen R. Vesical calculus around an intra-uterine contraceptive device. Br J Urol. 1997;79:654-5. 61. Dietrick DD, Issa MM, Kabalin JN, Bassett JB. Intravesical migration of intrauterine device. J Urol. 1992;147:132-4. 62. Yeni E, Unal D, Verit A. Migration of intrauterine contraceptive device as a cause of bladder stone. Braz J Urol. 2002;28:43-4. 63. Demirci D, Ekmekcioglu O, Demirtas A, Gulmez I. Big bladder stones around an intravesical migrated intrauterine device. Int Urol Nephrol. 2003;35:495-6. 64. Leppaniemi AK. Intravesical foreign body after inguinal herniorrhaphy. Case report. Scand J Urol Nephrol. 1991;25:87-8. 65. Bodenbach M, Bschleipfer T, Stoschek M, Beckert R, Sparwasser C. (Intravesical migration of a polypropylene mesh implant 3 years after laparoscopic transperitoneal hernioplasty). Urologe A. 2002;41:366-8. German. 66. Haakonsen P, Steinsvik E. (What nobody thought possible--a “demobilization chain” gone astray. Foreign body in the urinary bladder--a current differential diagnosis). Tidsskr Nor Laegeforen. 1995;115:1055-6. Norwegian. 67. Jani B, Aldujaily S, Katiyar N. Case report of a very long foreign body in urinary bladder. Internet J Urol (serial on the Internet). 2006 (cited 2008 Aug 12);4(1):(about 2 p.). Available from: http://www.ispub. com/ostia/index.php?xmlFilePath=journals/iju/vol4n1/ foreign.xml 68. Bukhari AS. Unusual foreign bodies in the urinary bladder. J Ayub Med Coll Abbottabad. 1999;11:65-6. 69. Davidov MI. (A case of the multiyear presence of a foreign body in the bladder). Urol Nefrol (Mosk). 199740-1. 70. Bird VG, Winfield HN. Removal of bladder stone with metal wire infrastructure. Can J Urol. 2002;9:1500-2. 71. Athanasopoulos A, Liatsikos EN, Perimenis P, Barbalias GA. Delayed suture intravesical migration as a complication of a Stamey endoscopic bladder neck suspension. Int Urol Nephrol. 2002;34:5-7. 72. Nabi G, Hemal AK, Khaitan A. Endoscopic management of an unusual foreign body in the urinary bladder leading to intractable symptoms. Int Urol Nephrol. 2001;33:351-2. 73. Giri SK, Drumm J, Flood HD. Endoscopic holmium laser excision of intravesical tension-free vaginal tape and polypropylene suture after anti-incontinence procedures. J Urol. 2005;174:1306-7. 74. Hodroff M, Portis A, Siegel SW. Endoscopic removal of intravesical polypropylene sling with the holmium laser. J Urol. 2004;172:1361-2. 75. Nthumba PM. Accidental insertion of a tampon into the bladder. East Cent Afr J Surg. 2005;10:72-3. 76. Modrau IS, Poulsen EU. Intravesical displacement and encrustation of urinary incontinence plugs. BJU Int. 2002;89:324. 77. Nishiyama K, Shimada T, Yagi S, Kawahara M, Nakagawa M. Endoscopic removal of intravesical thermometer using a rigid nephroscope and forceps. Int J Urol. 2002;9:717-8. 78. Bakshi GK, Agarwal S, Shetty SV. An unusual foreign body in the bladder. J Postgrad Med. 2000;46:41-2. 79. Juan YS, Chen CK, Jang MY, et al. Foreign body stone in the urinary bladder: a case report. Kaohsiung J Med Sci. 2004;20:90-2. 80. Hutton KA, Huddart SN. Percutaneous retrieval of an intravesical foreign body using direct transurethral visualization: a technique applicable to small children. BJU Int. 1999;83:337-8.