Successful management of auto knotted intravesical infant feeding tube by minimal invasive technique.

We report a case of acute urinary retention due to intravesical auto knotting of infant feeding tube in a child treated successfully by endoscopic approach.

INTRODUCTION

Clean intermittent catheterization (CIC) is often utilized in neurogenic bladder.[1] Intravesical knotting is a rarely reported complication of CIC but it can cause significant morbidity.[2-4]

CASE REPORT

A four year old male child with neurogenic bladder was on regular clean intermittent catheterization (CIC) with infant feeding tube (5F) by the mother for the past six months. The child was brought to emergency with acute urinary retention following inability to withdraw infant feeding tube after introduction for drainage of bladder. An ultrasonography showed feeding tube knotted and impacted at bladder neck and a plain radiograph [Figure 1] confirmed the findings. The feeding tube was cut at urethral meatus and pushed into the urinary bladder with another 8F Foley's catheter and it was kept in situ for relief of urinary retention. Subsequently under general anesthesia, cystoscopy was done and the knotted infant feeding tube was identified [Figure 2]. A 5 mm laparoscopic port was introduced into the urinary bladder in the supra pubic region under cystoscopic guidance. The knotted part of feeding tube cut with laparoscopic scissors and unknotting done with Maryland forceps, followed by removal of two pieces of infant feeding tube through same port. The supra pubic port closed and child was catheterized after the procedure. The postoperative period was uneventful and the urethral catheter removed after 72 hours.

Figure 1

Anteroposterior view of plain X-ray pelvis showing impacted infant feeding tube in bladder neck

Figure 2

Cystoscopic picture showing knotted infant feeding tube in urinary bladder

DISCUSSION

CIC is commonly done in children with neurogenic bladder dysfunction. Infant feeding tube knotting is a very rare event.[5] It gets knotted when excessive length of flexible catheter is inserted in the bladder and forms a loop; subsequently as the catheter is withdrawn a knot can form and tightens on withdrawal leading to impaction of the catheter. Removal of infant feeding tube has been tried in many ways, e.g. supra pubic cystostomy, manual removal of catheter with gentle traction under local/general anesthesia or the infant feeding tube is uncoiled by passing a guide wire in infant feeding tube and straightening it, but fails if the knot is tight.[6]

It is best to prevent this problem by totally avoiding the use of infant feeding tube or by introducing only short length of feeding tube to drain the bladder. A 6-10F Foley's catheter may be better option. A high index of suspicion is required to diagnose knotting of infant feeding tube when it cannot be withdrawn easily. This will prevent traumatic urethral injury due to forcible removal and subsequent risk of urethral stricture.