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Migration of left hip pin with involvement of left ureter
MIGRATION
OF LEFT HIP PIN WITH
INVOLVEMENT
OF LEFT URETER
STEVEN
Z. KLEINMAN,
LESTER
A. RUSSIN,
M.D.
M.D.
From the Departments of Urology and Orthopedics, Mount Sinai Medical Center, Miami Beach, Florida
ABSTRACT - This patient had hematuria and a history of hip fusion many years before. It was found that a left hip pin had broken, and its sharpened portion had migrated through the head of the femur into the adventitia of the left ureter. During exploratory surgery, a bonecutter was employed to cut off the tip of the pin flush with the pelvic wall. The patient has had no recurrence of hematuria. Review of the literature disclosed no report of a similar case.
This case illustrates the potential migratory pins following hip fusion.
danger
of
Case Report A seventy-three-year-old man was seen on July 24, 1974, because of dark, muddy, reddish urine for one week prior to the visit. This hematuria was painless. The patient had no nocturia. There was no prior history of calculi, urinary retention, or other urinary problems. Past surgical history revealed hip fusion many years before; medical records for this procedure were not available. The patient’s medical history was negative, and he had no known allergies. On physical examination the kidneys and bladder were not palpable. Rectal examination revealed a benign prostate (2+). The genitalia were normal. There were no hernias. Routine urinalysis showed a full field of red cells with occasional white cells. In view of the gross total painless hematuria, the patient was admitted to Mount Sinai Medical Center on July 25, 1974. He underwent an intravenous pyelogram (IVP), cystoscopy, and biopsy of suspicious areas of the bladder to rule out bladder or renal tumors and calculi as causes of the bleeding. Results of this evaluation were negative. However, the IVP showed the
396
presence of a broken left hip pin (Fig. 1). The sharpened portion of the pin apparently had migrated through the head of the femur. It was pointing to the distal portion of the left lower ureter, with possible involvement of the bladder wall. During cystoscopy, a urethral stricture was found and was dilated with filiforms and followers to 24 F. With completion of the dilation, panendoscopic examination enabled visualization of the stricture. The prostatic urethra revealed mild trilobar obstructive hypertrophy. Cystoscopy revealed no evidence of bleeding sites within the bladder or bladder neck and no tumors. No bleeding was seen from the left ureteral orifice, although a slight discoloration of the e&x from the left ureter signified possible bleeding. This discoloration was more marked on over-distention of the bladder. Some small stones were visualized and easily irrigated out. These were analyzed as 100 per cent calcium oxalate monohydrate. A retrograde pyelogram was not performed because the IVP visualized well the entire left collecting system, including the calyces, pelvis, and ureter. In view of the good IVP results, it was thought that a retrograde view would not yield additional information.
UROLOGY
/ OCTOBER
1980
/
VOLUME
XVI, NUMBER 4
FIGURE 1. Preoperative IVP: .shotoing (A) fracture of pin and relationship of pin to ureter filled and partially
bladder, and (B) sharp point of pin in periureteral tissue deviating ureter medially.
KUB (anteroposterior FIGURE 2. Postoperative view) showing pin cut fEush to bone surface. Postoperatively, orthopedic consultation was obtained because of the evidence of migration of a left hip pin. The consultant believed that the pin could be involving either the lateral portion of the bladder or the lower left ureter. It was therefore decided to explore surgically to modify or remove the pin and to evaluate any pathologic findings in the bladder. The patient underwent the exploratory surgery on August 2, 1974, through a Pfannen-
UROLOGY
/ OCTOBER1980
/ VOLUMEXVI.
NUMBER4
stiel extraperitoneal incision, perivesical in nature, exposing the left perivesical area of the retroperitoneum with the ureter well visualized to its insertion in the bladder. The point of the pin was identified and found to be penetrating, but not perforating, the adventitia of the left ureter. When the bladder was filled with fluid, the upper portion of its left lateral wall also pressed against the sharp point of the pin. The orthopedic team decided not to remove the entire pin because of its position in the bone (Fig. 1). Instead, a bonecutter was used to cut off the tip of the pin flush with the pelvic wall (Fig. 2). Postoperatively, the patient did well and has had no recurrence of hematuria. Comment Review of the literature failed to reveal any similar case reported. We believed that this pin, if allowed to remain, would have migrated through the ureter and bladder, probably causing perforation with massive extravasation. 945 Arthur Godfrey Road Miami Beach, Florida 33140 (DR. RUSSIN)
397
OF LEFT HIP PIN WITH
INVOLVEMENT
OF LEFT URETER
STEVEN
Z. KLEINMAN,
LESTER
A. RUSSIN,
M.D.
M.D.
From the Departments of Urology and Orthopedics, Mount Sinai Medical Center, Miami Beach, Florida
ABSTRACT - This patient had hematuria and a history of hip fusion many years before. It was found that a left hip pin had broken, and its sharpened portion had migrated through the head of the femur into the adventitia of the left ureter. During exploratory surgery, a bonecutter was employed to cut off the tip of the pin flush with the pelvic wall. The patient has had no recurrence of hematuria. Review of the literature disclosed no report of a similar case.
This case illustrates the potential migratory pins following hip fusion.
danger
of
Case Report A seventy-three-year-old man was seen on July 24, 1974, because of dark, muddy, reddish urine for one week prior to the visit. This hematuria was painless. The patient had no nocturia. There was no prior history of calculi, urinary retention, or other urinary problems. Past surgical history revealed hip fusion many years before; medical records for this procedure were not available. The patient’s medical history was negative, and he had no known allergies. On physical examination the kidneys and bladder were not palpable. Rectal examination revealed a benign prostate (2+). The genitalia were normal. There were no hernias. Routine urinalysis showed a full field of red cells with occasional white cells. In view of the gross total painless hematuria, the patient was admitted to Mount Sinai Medical Center on July 25, 1974. He underwent an intravenous pyelogram (IVP), cystoscopy, and biopsy of suspicious areas of the bladder to rule out bladder or renal tumors and calculi as causes of the bleeding. Results of this evaluation were negative. However, the IVP showed the
396
presence of a broken left hip pin (Fig. 1). The sharpened portion of the pin apparently had migrated through the head of the femur. It was pointing to the distal portion of the left lower ureter, with possible involvement of the bladder wall. During cystoscopy, a urethral stricture was found and was dilated with filiforms and followers to 24 F. With completion of the dilation, panendoscopic examination enabled visualization of the stricture. The prostatic urethra revealed mild trilobar obstructive hypertrophy. Cystoscopy revealed no evidence of bleeding sites within the bladder or bladder neck and no tumors. No bleeding was seen from the left ureteral orifice, although a slight discoloration of the e&x from the left ureter signified possible bleeding. This discoloration was more marked on over-distention of the bladder. Some small stones were visualized and easily irrigated out. These were analyzed as 100 per cent calcium oxalate monohydrate. A retrograde pyelogram was not performed because the IVP visualized well the entire left collecting system, including the calyces, pelvis, and ureter. In view of the good IVP results, it was thought that a retrograde view would not yield additional information.
UROLOGY
/ OCTOBER
1980
/
VOLUME
XVI, NUMBER 4
FIGURE 1. Preoperative IVP: .shotoing (A) fracture of pin and relationship of pin to ureter filled and partially
bladder, and (B) sharp point of pin in periureteral tissue deviating ureter medially.
KUB (anteroposterior FIGURE 2. Postoperative view) showing pin cut fEush to bone surface. Postoperatively, orthopedic consultation was obtained because of the evidence of migration of a left hip pin. The consultant believed that the pin could be involving either the lateral portion of the bladder or the lower left ureter. It was therefore decided to explore surgically to modify or remove the pin and to evaluate any pathologic findings in the bladder. The patient underwent the exploratory surgery on August 2, 1974, through a Pfannen-
UROLOGY
/ OCTOBER1980
/ VOLUMEXVI.
NUMBER4
stiel extraperitoneal incision, perivesical in nature, exposing the left perivesical area of the retroperitoneum with the ureter well visualized to its insertion in the bladder. The point of the pin was identified and found to be penetrating, but not perforating, the adventitia of the left ureter. When the bladder was filled with fluid, the upper portion of its left lateral wall also pressed against the sharp point of the pin. The orthopedic team decided not to remove the entire pin because of its position in the bone (Fig. 1). Instead, a bonecutter was used to cut off the tip of the pin flush with the pelvic wall (Fig. 2). Postoperatively, the patient did well and has had no recurrence of hematuria. Comment Review of the literature failed to reveal any similar case reported. We believed that this pin, if allowed to remain, would have migrated through the ureter and bladder, probably causing perforation with massive extravasation. 945 Arthur Godfrey Road Miami Beach, Florida 33140 (DR. RUSSIN)
397