Gossypiboma (Retained Surgical Sponge) and Recurrent Bladder Neck Contracture After Radical Retropubic Prostatectomy and Bilateral Pelvic Lymph Node Dissection

Abstract

Retained foreign bodies after abdominal or pelvic surgery are rarely reported despite an estimated incidence of 1/1,500 cases.' While surgical removal is typically required, potential difficulties may not be appreciated and published guidelines are limited. We report on a patient with retained gauze sponges discovered incidentally 18 months after radical prostatectomy. CASE REPORT A 65-year-old white man presented with recurrent bladder neck contracture 18 months after radical retropubic prostatectomy and bilateral pelvic lymph node dissection performed elsewhere for pathological stage T2cNOMO Gleason grade 3+2 adenocarcinoma. Bladder neck dilation was required 1 and 3 months postoperatively followed by cold knife incision of the bladder neck 13 months after surgery. Prostate specific antigen remained undetectable and biopsy of the bladder neck demonstrated only fibrosis. The patient was instructed to perform clean intermittent self-catheterization on a tapering schedule. A total of 18 months after prostatectomy the patient reported recurrent obstructive symptoms. Following urethral dilation to 20F with filiforms and followers, an 18F Foley catheter was inserted. A pelvic radiograph performed to screen for surgical clips near the bladder neck revealed radiopaque thread consistent with retained surgical sponges in the obturator fossae bilaterally (fig. 1). Radiopaque contrast material was instilled via the indwelling urethral catheter, and pelvic computerized tomography showed encapsulated masses of variable attenuation lateral to the bladder base bilaterally and extending proximally along the psoas muscles (fig. 2). Attenuation values were consistent with fluid filled cavities surrounding the foreign material, suggesting possible lymphoceles or sterile abscesses. Cystoscopy with the patient under anesthesia demonstrated moderately dense fibrosis at the bladder neck and a polypoid mass adjacent to the bladder neck that acted as a ball valve. Excisional biopsy revealed proliferative cystitis, including nephrogenic adenoma and xanthogranulomatous inflammation with foreign body material. Exploratory laparotomy was performed via a midline infraumbilical incision. Moderately dense adhesions were noted in the space of Retzius and dissection was extended to the obturator fossae bilaterally with care taken to preserve