International Urology and Nephrology 34: 5–7, 2002. © 2002 Kluwer Academic Publishers. Printed in the Netherlands.
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Delayed suture intravesical migration as a complication of a Stamey endoscopic bladder neck suspension Anastasios Athanasopoulos, Evangelos N. Liatsikos, Petros Perimenis & George A. Barbalias Department of Urology, University of Patras, School of Medicine, Patras, Greece
Abstract. We report our experience with two cases of late migration of the suture and bolster occurring 2 years after a modified Stamey endoscopic bladder neck suspension. Delayed migration of the suture and bolster after an endoscopic bladder neck suspension across tissue planes, with subsequent erosion into the bladder, is uncommon. Recurrent urinary tract infection and mild suprapubic discomfort were the only symptoms. Cystoscopy was the only helpful diagnostic tool and should be considered early in the evaluation of this kind of patients. The mechanism of migration of the cuff and the operative technique are discussed. Key words: Migration, Stamey procedure, Stress incontinence, Suture
Introduction
Case reports
Stamey first described in 1973 the technique of needle suspension of the vesical neck. Since then there have been a variety of reported modifications in the literature [12]. Endoscopic bladder neck suspension has been recognized as safe and effective in the treatment of stress incontinence and this kind of procedure is associated with few significant complications. Less than twenty cases of delayed suture and bolster migration into the urinary bladder are described in the international literature [2, 3, 4, 6, 8, 13, 14]. The majority of vesical calculi are due to urinary stasis secondary to bladder outlet obstruction and less than 2% of vesical calculi occur in women and, thus their presence should generate careful assessment of their etiology [5]. We report two cases of intravesical migration of the suture and bolster after a combined vaginal hysterectomy and modified Stamey endoscopic bladder neck suspension [1]. The encrustated foreign bodies were identified several months after the operations were performed as the first symptoms were presented late and were very mild.
Case 1 A 62-year old woman presented to our urology clinic with recurrent urinary tract infections and mild suprapubic discomfort. In her previous medical history she reported a vaginal hysterectomy combined with a modified Stamey endoscopic bladder neck suspension before eighteen months. The previous operation was performed by one of the authors (A.A.), and a meticulous cystoscopic control at the end of the procedure did not reveal any sites of perforation by the suspension sutures nor was there any evidence of submucosal location of sutures. Physical examination was unremarkable. Multiple urine cultures were positive for Klebsiella and despite continuous appropriate antibiotic therapy she continued to complain of bladder irritative symptoms. Ultrasonography, bladder scan and KUB did not reveal any abnormality. Cystoscopy revealed a calculus-like formation adherent on the right bladder wall (Figure 1). Endoscopic litholapaxy was attempted but was unsuccessful as we realized that the calcification was adherent to a nylon suture tied around a silicone bolster. Removal of the foreign body was achieved with the aid of the endoscopic semi lunar knife. The suture loop was then cut and with a grasping
6 Discussion
Figure 1. Calculus-like formation adherent on the bladder wall.
forceps the bolster was removed. The urethrotome was then reinserted and the proximal end of the suture was incised. Further inspection of the bladder did not reveal any additional findings. The postoperative course of the patient was uneventful. Six months after the removal of the suture and the bolster, the urine culture was sterile and the patient remained continent. Case 2 A 54-year old woman presented to our urology clinic with a history of recurrent urinary tract infections and moderate suprapubic discomfort for the past 3 months. She also reported a vaginal hysterectomy in combination with a modified Stamey endoscopic bladder neck suspension before fourteen months. Multiple urine cultures were positive for E.Coli and despite continuous appropriate antibiotic therapy she continued to have symptoms of cystitis. Bladder ultrasonography and KUB was unremarkable and cystoscopy was performed. The later revealed at the right bladder wall the presence of a calcified nylon suture. The same endoscopic procedure, as at the first case, was performed and the results were excellent, as at the first case. The combined approach of a vaginal hysteroscopy and endoscopic vesical neck suspension has been performed in 100 female patients at our institution. We have only observed the aforementioned 2 cases of delayed suture and bolster migration into the bladder.
The presence of intravesical foreign bodies should always be considered when investigating women with recurrent urinary symptoms and especially when they report previous surgical procedures for urinary incontinence [7] such as the Stamey endoscopic bladder neck suspension. The inability to sterilize urine after a course of appropriate antibiotic therapy should alarm the urologist and urge a thorough evaluation. A cystoscopic evaluation is deemed necessary and can certainly reveal the origin of the problem. In both of the cases reported here the use of the urethrotome demonstrated to be the appropriate endoscopic technique to address easily the problem of cutting the suture and remove by a grasping forceps the bolster. There are a variety of cases reported in the literature of bladder calcification formation on the cuff after endoscopic bladder neck suspension [2, 9, 14] but usually the migration of the suture and bolster occurred early. It is well documented in the literature that nonabsorbable suture material can migrate through the tissues reaching the bladder and can act as the nidus for stone formation [14]. Bihrle and Tarantino based on their experience with suture migration into the bladder after a retropubic bladder neck suspension suggested that an early erosion is usually due to an unrecognized intraoperative perforation of a sudmucosally placed suture [3]. It is certainly technically demanding to recognize such a lesion when it is located at the lateral bladder wall towards the dome. The need of a wide angle or a flexible scope is mandatory for visualization of such a foreign body. The delayed erosion of nylon suture after bladder neck suspension is rarely observed in the literature and the pathophysiologic explanation is somewhat theoretical. The presence of an inflammatory process may be one of the possible causes provoking adhesion to the bladder wall and finally migration of the bolster and suture into the bladder. This possible mechanism may mimic the behavior of other foreign bodies such as surgical needles, mesh and gauze pads which eventually find their way from the peritoneal cavity into the bladder lumen [10, 11]. An other possible cause of the delayed migration may be the excessive tension exerted on the sutures during the surgical procedure causing gradual ischemia and local necrosis of the surrounding tissues.
7 In addition the improper placement of the suspending sutures and the bolster may lead to their delayed intravesical migration and subsequent calcification. Thus, correct placement of the endoscopic bladder neck suspension suture at the vesical neck outside the bladder and its wall is crucial to the success of this procedure. The exact mechanism has not yet been clarified. In conclusion, women with the presence of recurrent cystitis should be meticulously evaluated with particular attention to the previous medical history, physical examination and urine culture results. In case of positive urine culture persistence despite appropriate antibiotic therapy, the suspicion of a foreign body into the bladder should arise especially if antiincontinence surgery has been previously performed.
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5. Drach GW. Urinary lithiasis. In: Walsh PC, Gittes RF, Perlmutter AD, Staney TA, eds. Campbell’s Urology 5th ed, Vol 1, sect VIII, Chapt 25, p. 1165. Philadelphia: WB Saundress Co, 1986. 6. Dwyer PL, Carey MP, Rosamilia A. Nonabsorbable intravesical sutures a significant cause of morbidity following bladder neck surgery for stress incontinence. Int Urogynecol J 1997; 8(abstract 0050): 542. 7. Echford SD, Persad RA, Brewster SF et al. Introvesical foreign bodies: five-years review. Br J Urol 1992; 69: 41–45. 8. Evans JWH, Chapple CR, Ralph DJ, Milroy EJG. Bladder calculus formation as a complication of stamey procedure. Br J Urol 1990; 65: 580–982. 9. Hargreave TB. The bladder in practical urological endoscopy 1988; 6: 103–104. Oxford: Blackwell scientific publications. 10. Irisawa C, Yamaguchi O, Shiraiwa Y et al. A case of foreign body in the urinary bladder. 11. Leppaniemi AK. Intravesical foreign body after inguinal herniotherapy. Scand J Urol Nephrol 1991; 25: 87–88. 12. Stamey TA. Cystoscopic suspension of the vesical neck for urinary incontinence. Surg Gynecol Obstet 1973; 136: 547. 13. Stamey TA. Urinary incontinence in the female: the Stamey endoscopic suspension of the vesical neck for stress urinary incontinence. In: Walsh PC, Retik AB, Vaughin ED Jr, Wein AJ, eds, ends Campbell’s Urology, 6th edn, pp. 2829–2850. 14. Zderic SA, Burros HM, Hanno PM et al. Bladder calculi in women after urethrovesical suspension. J Urol 1988; 139: 1047–1048.
Address for correspondence: G.A. Barbalias, Professor and Chairman of Urology, University Hospital, University of Patras Medical School, Rio, Patras, 26 500 Greece Phone: (061) 999364, 999385; Fax: (061) 993981 E-mail:
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