Endoscopic Management of Free Lying Migratory Orthopedic Screw in Bladder.

75-year old gentleman presented with acute urinary retention. He had met with road traffic accident 15 years back and sustained pelvic fracture and bladder rupture, underwent bladder repair and open reduction and internal fixation of pubic symphsis. Imaging studies showed the free lying encrusted orthopedic screw in the bladder, which was removed per urethra using nephroscope. Migratory foreign bodies in the urinary bladder are rare. However there is a possibility of longstanding foreign bodies in adjacent structures to erode and perforate into the bladder. Inside the bladder these foreign bodies act as nidus for stone formation.

Introduction

Foreign bodies (FB) in urinary bladder can occur due to self introduction or migration. Intra-uterine contraceptive devices are the commonly reported free lying foreign body found in the bladder. Disruptions of the pelvic ring are associated with a 7% to 25% incidence of lower urinary tract injuries. Displaced fractures and dislocations of the pelvic ring and acetabulum are usually treated with open reduction and internal fixation with plate and screws. Loosening and migration of these plates and screws can occur. However to the best of our knowledge, this is the first report describing the migration of such a screw into the bladder and the implant staying in the bladder without spontaneous extrusion and removal using a nephroscope through the urethra.

Case presentation

75 year gentleman presented in September 2015, with frequency for 2 days followed by acute urinary retention (AUR). He had sustained a road traffic accident (RTA) in Oct 2000 and had pubic diastasis and bladder rupture. Bladder repair followed by open reduction and internal fixation of symphysis pubis were done with a single plate and four screws. Post operative period was un-eventful. In 2002 implant removal was attempted by the orthopedician but was unsuccessful. He was lost to follow-up till he returned with acute urinary retention in September 2015.

Management

Evaluation with ultrasound abdomen and CT scan pelvis (Fig. 1) revealed a mobile screw lying in the bladder with minimal calcification at the head of the screw. Cystoscopy was done using a 26 Fr nephroscope (Fig. 2). Nephroscopic grasper was used to disintegrate the encrustation at the head end of the screw (Fig. 3). The screw was held at the pointed tip (Fig. 4) and removed in to-to with the sheath engaged in the urethra thereby protecting the urethral mucosa from damage. The diameter of the head was 7 mm and the length was 5 cm. Patient voided well after the procedure and is asymptomatic now.

Figure 1

Computed tomography showing intravesical screw.

Figure 2

Cystoscopic view showing encrusted screw in bladder.

Figure 3

Free lying screw in the bladder after encrustation removal.

Figure 4

Screw being removed with nephroscope by holding the pointed tip.

Disscussion

Only 2 cases of orthopedic implants,1, 2 getting dislodged and spontaneous passage occurring urethrally have been reported in literature. This patient presented with AUR, without any bothersome symptoms of migration of the screw to the bladder. Possible risk factor for the intravesical migration of the screw could be loosening of the screw during the failed attempt at removal of the plate. Nephroscope has a circular sheath with an offset lens and would be better as the circular head of the screw could be engaged within the lumen of the nephroscope sheath. This is presented for the rarity of migration of an entire orthopedic screw into the bladder and the use of a nephroscope to retrieve the screw. To our knowledge this is the first report of cystoscopic removal of a free lying intravesical screw.

Conflict of interest

None.