Introduction
Iatrogenic bladder injury (IBI) is one of the most common urogenital tract injuries and divided into two groups as external and internal injuries [1]. Internal IBI usually occurs during transurethral resection of bladder tumors and there are two types of perforations; intra and extra-peritoneal types. External injuries are associated with pelvic procedures and mostly seen in obstetric and gynecologic operations, followed by general surgical and urologic interventions. Bladder stones occur among patients who are bedridden, have a urethral catheter, or with bladder outlet obstruction and infection [2]. The X-ray film of kidney-ureter-bladder (KUB) shows the radiopaque stones, which usually move when the patient is repositioned. A radiolucent and stationary bladder stone may be visualized by ultrasonography, instead of KUB. Foreign bodies such as surgical sutures may act as a nidus of bladder stones [3]. These bladder stones are non-mobile and present like fixed echogenicity in the ultrasonographic examination. We present a case of a woman with bladder stone associated with suture 4 years after the gynecologic procedure.
Case Report
A 69-year-old woman admitted to our urology policlinic with urge incontinence and pain on voiding during a year. She had a history of hysterectomy and bilateral salpingo-ooferectomy 4 years ago. In physical examination; she has a scar regarding her previous operation on abdomen and external genitalia was normal. Laboratory results revealed that serum creatinine, blood urea nitrogen levels were 0.5 ng/ml and 10 mg/dl. The urinalysis showed hematuria and pyuria. Urine culture was sterile. The x-ray film of KUB was normal. There was 27*9 mm bladder lesion was detected in ultrasonographic examination suggested as bladder mass with calcification. Computed tomography revealed the bladder stones of 1 cm and 2 cm’s (Fig. 1).
Cystoscopy showed the bladder stones associated with prolene suture (Fig. 2). Transurethral resection of sutures was performed and the stones were fragmented using the laser. The patient discharged 2 days after the operation. The urge incontinence continued and tolterodine, an anticholinergic drug (Detrusitol 4 mg SR, Pfizer) was administered. The patient had no problem during the 3 months follow up period.
Discussion: Bladder stones are the results of either migration of the stones from kidney or urinary stasis in the bladder [3]. Urinary stasis is usually associated with bladder outlet obstruction, cystocele, neurogenic bladder or foreign body in the bladder. Some authors reported that mesh migration or migration of intrauterine contraceptive devices to the bladder can act as a nidus of bladder stones [4, 5]. There are reporting data of bladder stones associated with a foreign body among the patients who had a pelvic organ surgery previously [6]. The foreign body is a risk for encrustation and stone formation. Bladder stone has been reported using exposed non-absorbable sutures and mesh. Additionally, the authors reported a patient with lower urinary tract symptoms associated absorbable suture after myomectomy [6]. Incidental bladder injury during surgical interventions may promote bladder wall erosion especially using non-absorbable sutures [2]. We think that this foreign body is a remnant of surgery 4 years ago. The patient underwent the hysterectomy in another hospital. Neither the patient nor the documents reported no complication. Due to the gynecologists commonly use non-absorbable sutures for fascia tissues, we think that an iatrogenic injury that had been occurred during fascia closing, and using non-absorbable sutures had played a role as a foreign body for bladder stones. A small probability is a scenario, that bladder injury occurred and the surgeon repaired the bladder without consultation with a urologist.
The clinical presentation of the patients is lower urinary tract symptoms such as dysuria, voiding difficulties, weak micturition and hematuria [6]. Some patients may be asymptomatic with normal values in the urinalysis [2]. The patient was presented with incontinence in the current study.
Although KUB radiography can show only radiopaque bladder stones, radiolucent stones are missed [2]. Ultrasonography plays important role in the diagnosis of bladder stones. These stones are non-mobile and present like hanging fixed echogenicity in the ultrasonographic examination [3]. Cystoscopy is very useful for the diagnosis of these patients [6]. Ultrasonography revealed bladder lesion suggesting as calcified bladder tumor in our patient. Computed tomography showed the bladder stones with atypical localization. Cystoscopy confirmed the diagnosis of bladder stones associated with non-absorbable sutures.
The sutures and bladder stones are usually removed using endoscopic techniques successfully [2]. When comparing open surgery, endoscopy has minimal patient morbidity and shorter hospital stay [6]. The patients are treated with transurethral excision of the sutures and laser for stone fragmentation, like in our case.
Finally, the patients who had a history of pelvic surgery previously and present with lower urinary tract symptoms should be evaluated for the foreign body-associated disorders. The clinicians should consider that non-absorbable suture can be potential risk for bladder stone formation in the future.
Conflict of Interest
The authors have been no conflict of interest relevant of this article.
