- Email: [email protected]
Encapsulated Paravesical Foreign Body
0022-534 7/ 90/ 1435-1004$02.00/ 0 Vol. 143, May
THE JOURNAL OF UROLOGY Copyright © 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
ENCAPSULATED PARAVESICAL FOREIGN BODY KIMIO FUJITA
AND
TOKUJI ICHIKAWA
From the Department of Urology, National Medical Center Hospital, Tokyo, Japan
ABSTRACT
A large, round, paravesical mass was surgically removed from a 65-year-old man. The mass was an encapsulated aseptic granuloma surrounding a gauze that was left in situ 10 years previously at hernioplasty. (J. Ural., 143: 1004-1005, 1990) A patient with a large mass simulating a cyst arising from the left seminal vesicle is described. The seminal vesicles were normal on vesiculography and the mass was suspected to be parenchymal in nature by nuclear magnetic resonance imaging (MRI) and computerized tomography (CT). Preoperative diagnosis was benign teratoma. At operation an encapsulated gauze was found that had been left behind 10 years previously at hernioplasty. The appearance of this classical surgical complication on modern diagnostic imaging was interesting and instructive. CASE REPORT
A 65-year-old man complained of vague pain in the left lower abdomen and was referred to our hospital after a huge mass in the bladder was detected by abdominal echography. The patient had a history of left hernioplasty 10 years previously. He was
FIG. 2. A, CT scan of pelvic cavity shows bladder with contrast medium in its base compressed by thick walled mass, which seems to be cystic. B, echogram reveals gauze within mass, although appearance was difficult to explain preoperatively. C, nuclear MRI clearly differentiates bladder, abnormal mass and prostate.
FIG. 1. IVP combined with vesiculography. Contrast medium injected from seminal vesicle canal revealed that mass did not arise from seminal vesicle. Intravenous contrast material did not visualize mass, which suggests that it had no communication with urinary tract. Bladder was markedly compressed from left side. Accepted for publication December 18, 1989.
afebrile and laboratory examinations were within normal limits. Cystoscopy revealed no mass within the bladder but the left wall was markedly compressed from the outside. The mass was soft on bimanual palpation. Excretory urography (IVP) demonstrated the compressed bladder and a slightly dilated left caliceal system. A cyst arising from the left seminal vesicle was suspected but the seminal vesicle was normal and only compressed slightly by the mass on vesiculography (fig. 1). The delayed film of the IVP performed in conjunction with vesiculography confirmed that the mass was isolated from the seminal vesicle and urinary tract (fig. 1). Echography suggested that the mass was not homogeneous but the nature of the conspicuous abnormality within the mass was difficult to explain (fig. 2, B). CT revealed cystic changes with a thick, irregular wall (fig. 2, A) . However, nuclear MRI suggested a parenchymal nature (fig. 2, C). Preoperative diagnosis was benign teratoma.
1004
1
,----
1005
E NCAP S ULATED PARAVESICAL FOREIGN BO DY
paque marker was identified in the gauze. Microscopically, fibrous tissue with infiltrating cells surrounded the foreign body. Convalescence was uneventful and the patient was discharged from the hospital 8 days postoperatively. DISCUSSION
In recent years the incidence of gauze sponges and laparot-
6
8
9
20
21
22
23
FIG. 3. Surgical specimen, with retained gauze encapsulated by thick wall of fibrous tissue and intermingled with fatty tissue.
At operation the bladder wall and peritoneum were not hard to separate. The ureter and seminal canal were compressed upwards. There were dense adhesions of the mass to the pelvic wall. Although the iliac vessels could be separated, subcapsular dissection was necessary in areas. The mass contained no fluid and yellow, fatty tissue was observed inside the thick capsule. The specimen was approximately 9 cm. in diameter (fig. 3). Within the mass, there was a mottled gauze that apparently was left behind at hernioplasty 10 years previously. No radio-
J
omy pads retained at operation probably has decreased as the result of routine sponge counts and the use of radiopaque markers. Most patients in whom these materials are retained in the abdomen will have complications within weeks or a few months. However, in our patient the gauze was retained outside the peritoneal cavity and became a huge aseptic granuloma without causing severe symptoms. It is interesting that the granuloma developed so intimately with the bladder that it separated the bladder wall and the seminal vesicle. Although CT and nuclear MRI revealed the dimensions of the mass, it is not easy to recognize retained surgical materials on roentgenograms unless radiopaque markers are used.' Echography was useful to identify the gauze within the mass,2 although it was not recognized as such preoperatively. REFERENCES
J. A.: Gossypibomathe problem of the retained surgical sponge. Radiology, 129: 323, 1978. 2. Sekiba, K., Akamatsu, N. and Niwa, K.: Ultrasound characteristics of abdominal abscesses involving foreign bodies (gauze). J. Clin. Ultrasound, 7 : 284, 1979. 1. Williams, R. G., Bragg, D. G. and Nelson,
THE JOURNAL OF UROLOGY Copyright © 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Printed in U.S.A.
ENCAPSULATED PARAVESICAL FOREIGN BODY KIMIO FUJITA
AND
TOKUJI ICHIKAWA
From the Department of Urology, National Medical Center Hospital, Tokyo, Japan
ABSTRACT
A large, round, paravesical mass was surgically removed from a 65-year-old man. The mass was an encapsulated aseptic granuloma surrounding a gauze that was left in situ 10 years previously at hernioplasty. (J. Ural., 143: 1004-1005, 1990) A patient with a large mass simulating a cyst arising from the left seminal vesicle is described. The seminal vesicles were normal on vesiculography and the mass was suspected to be parenchymal in nature by nuclear magnetic resonance imaging (MRI) and computerized tomography (CT). Preoperative diagnosis was benign teratoma. At operation an encapsulated gauze was found that had been left behind 10 years previously at hernioplasty. The appearance of this classical surgical complication on modern diagnostic imaging was interesting and instructive. CASE REPORT
A 65-year-old man complained of vague pain in the left lower abdomen and was referred to our hospital after a huge mass in the bladder was detected by abdominal echography. The patient had a history of left hernioplasty 10 years previously. He was
FIG. 2. A, CT scan of pelvic cavity shows bladder with contrast medium in its base compressed by thick walled mass, which seems to be cystic. B, echogram reveals gauze within mass, although appearance was difficult to explain preoperatively. C, nuclear MRI clearly differentiates bladder, abnormal mass and prostate.
FIG. 1. IVP combined with vesiculography. Contrast medium injected from seminal vesicle canal revealed that mass did not arise from seminal vesicle. Intravenous contrast material did not visualize mass, which suggests that it had no communication with urinary tract. Bladder was markedly compressed from left side. Accepted for publication December 18, 1989.
afebrile and laboratory examinations were within normal limits. Cystoscopy revealed no mass within the bladder but the left wall was markedly compressed from the outside. The mass was soft on bimanual palpation. Excretory urography (IVP) demonstrated the compressed bladder and a slightly dilated left caliceal system. A cyst arising from the left seminal vesicle was suspected but the seminal vesicle was normal and only compressed slightly by the mass on vesiculography (fig. 1). The delayed film of the IVP performed in conjunction with vesiculography confirmed that the mass was isolated from the seminal vesicle and urinary tract (fig. 1). Echography suggested that the mass was not homogeneous but the nature of the conspicuous abnormality within the mass was difficult to explain (fig. 2, B). CT revealed cystic changes with a thick, irregular wall (fig. 2, A) . However, nuclear MRI suggested a parenchymal nature (fig. 2, C). Preoperative diagnosis was benign teratoma.
1004
1
,----
1005
E NCAP S ULATED PARAVESICAL FOREIGN BO DY
paque marker was identified in the gauze. Microscopically, fibrous tissue with infiltrating cells surrounded the foreign body. Convalescence was uneventful and the patient was discharged from the hospital 8 days postoperatively. DISCUSSION
In recent years the incidence of gauze sponges and laparot-
6
8
9
20
21
22
23
FIG. 3. Surgical specimen, with retained gauze encapsulated by thick wall of fibrous tissue and intermingled with fatty tissue.
At operation the bladder wall and peritoneum were not hard to separate. The ureter and seminal canal were compressed upwards. There were dense adhesions of the mass to the pelvic wall. Although the iliac vessels could be separated, subcapsular dissection was necessary in areas. The mass contained no fluid and yellow, fatty tissue was observed inside the thick capsule. The specimen was approximately 9 cm. in diameter (fig. 3). Within the mass, there was a mottled gauze that apparently was left behind at hernioplasty 10 years previously. No radio-
J
omy pads retained at operation probably has decreased as the result of routine sponge counts and the use of radiopaque markers. Most patients in whom these materials are retained in the abdomen will have complications within weeks or a few months. However, in our patient the gauze was retained outside the peritoneal cavity and became a huge aseptic granuloma without causing severe symptoms. It is interesting that the granuloma developed so intimately with the bladder that it separated the bladder wall and the seminal vesicle. Although CT and nuclear MRI revealed the dimensions of the mass, it is not easy to recognize retained surgical materials on roentgenograms unless radiopaque markers are used.' Echography was useful to identify the gauze within the mass,2 although it was not recognized as such preoperatively. REFERENCES
J. A.: Gossypibomathe problem of the retained surgical sponge. Radiology, 129: 323, 1978. 2. Sekiba, K., Akamatsu, N. and Niwa, K.: Ultrasound characteristics of abdominal abscesses involving foreign bodies (gauze). J. Clin. Ultrasound, 7 : 284, 1979. 1. Williams, R. G., Bragg, D. G. and Nelson,