Lower urinary tract dysfunction resulting from a 10-year retained intravesical absorbable suture from a uterine myomectomy

Abstract

Intravesical foreign bodies may be a result of migration from adjacent organs or penetrative injury, or they may be self-introduced or iatrogenic from medical or surgical procedures. Urinary tract infections, abnormal biochemistry, abnormal urinary tract anatomy, and the presence of foreign bodies within the urinary tract have been identified as risk factors for bladder stone formation [1]. There have been reports of bladder stones associated with a foreign body in patients who had a pelvic organ surgery previously [2] .T he foreign body acts as a site for encrustation and calculi formation [3]. Patients may be asymptomatic or may show some mild discomfort. Common symptoms are hematuria, dysuria, voiding difficulties, increased urinary frequency, and a weak urinary stream. A 50-year-old patient presented to our unit with complaints of intermittent lower abdominal pain. She complained of lower urinary tract symptoms, predominantly a weak urinary stream and voiding difficulties. Ten years earlier, she had a uterine myomectomy. However, postoperatively, she developed complications due to tuboovarian abscess that required a re-laparotomy. She also had a history of hypertension that was well controlled with medications. She had had three vaginal deliveries with no complications. Her body mass index was 38.2 kg/m 2 . Upon pelvic examination, no abnormal findings were noted. A urine culture did not show infection. An upright abdominal and pelvic X-ray revealed a radio-opaque density or calcification over the right ureteric orifice (Fig. 1). There was also mild scoliosis of the lumbar spine. We performed a scheduled cystoscopic examination. We removed a 1.5 cm 0.9 cm bladder stone and noted an abnormal foreign body at the bladder dome. The features of the foreign body were suggestive of a potential mesh material (Fig. 2). The patient’s symptoms improved after the cystoscopy, but prior to any further intervention, we performed further evaluation of the foreign body with a computed tomography scan of the pelvis. The results showed normal pelvic organs with no evidence of a foreign body. We counseled the patient, and she underwent another cystoscopic examination. Transurethral removal of the suture with endoscopic forceps was performed while the patient was under general anesthesia. No complications were encountered. The bladder mucosa was inspected (Fig. 3). The foreign body disintegrated upon examination. A histological analysis confirmed the foreign body as a suture material with granulomatous reaction and inflammatory granulation tissue. The patient had an indwelling bladder catheter for 1 day and had an excellent recovery. At the 2 months’ postprocedure follow-up, the patient was symptom free, and a repeat cystoscopic examination revealed normal findings. In animal and clinical studies, it has been reported that foreign bodies can act as a nidus for stone formation [4]. Bladder stone formation has been reported to occur on exposed nonabsorbable sutures and mesh [2,3,5]. There are very few reported cases of stone formation on absorbable sutures [1,6]. In our case, it may be possible that during surgery for the uterine myomectomy or during the second surgery, the suture was passed inadvertently into the bladder dome. The removed foreign body was confirmed to be a suture material. We believe that this foreign body is a remnant of the suture used in the patient’s surgical procedure 10 years ago. In this case, the suture may be a contributing factor to the development of bladder calculi and may be the cause of the