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Neovesical-Urethral Anastomotic Stricture Due to External Suture Migration
Images in Clinical Urology Neovesical-Urethral Anastomotic Stricture Due to External Suture Migration Andrea Mogorovich, Maurizio De Maria, Francesca Manassero, Gianluca Giannarini, and Cesare Selli We report on the endoscopic appearance and subsequent treatment of a neovesical-urethral anastomotic stricture caused by migration of a nonabsorbable suture originally placed for retropubic hemostasis. UROLOGY 73: 1002, 2009. © 2009 Elsevier Inc.
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68-year-old man, who had undergone radical cystectomy with an ileal orthotopic neobladder 11 months previously, was referred for voiding difficulty and serum creatinine elevation. Ultrasonography showed moderate hydronephrosis and severe neobladder dilation, and urethral catheterization was unsuccessful. Urethroscopy revealed the presence of a partially calcified suture at the level of the neovesicalurethral anastomosis (Fig. 1), which allowed passage of only a 4F ureteral catheter (Fig. 2). Endoscopic suture removal was performed using rigid biopsy forceps, followed by cold knife incision of the stricture. An 18F catheter was left in place for 2 weeks, and then the patient was instructed to use continuous intermittent catheterization. Neovesical-urethral anastomosis has an incidence of 2.7%-8.8%.1 Its causes include healing disruption, prolonged catheterization, and failure of mucosal apposition.2 Risk factors include diabetes, vascular disease, smoking, and blood loss. Treatment options range from catheterization to endoscopic incision. In our case, we postulated that migration of an external 3-0 Prolene suture used for difficult retropubic hemostasis resulted in prolonged inflammation, leading to anastomotic stricture. From the Unit of Urology, Department of Surgery, University of Pisa, Pisa, Italy Reprint requests: Andrea Mogorovich, M.D., Unit of Urology, Department of Surgery, University of Pisa, Via Roma 67, Pisa, Italy. E-mail: [email protected] Submitted: October 14, 2008, accepted (with revisions): December 1, 2008
Figure 1. Endoscopic view of suture loop that migrated at level of neovesical-urethral anastomosis.
It has been documented that nonabsorbable sutures next to the urinary tract can migrate inside it3; however, to the best of our knowledge, this is the first case of neovesicalurethral anastomosis caused by suture migration. References 1. Patel SG, Cookson MS, Clark PE, et al. Neovesical-urethral anastomotic stricture after orthotopic urinary diversion: presentation and management. Br J Urol. 2007;101:219-222. 2. Huang G, Lepor H. Factors predisposing to the development of anastomotic strictures in a single-surgeon series of radical prostatectomies. BJU Int. 2006;97:255-258. 3. Athanasopoulos A, Liatsikos EN, Perimenis P, et al. Delayed suture intravesical migration as a complication of a Stamey endoscopic bladder neck suspension. Int Urol Nephrol. 2002;34:5-7.
Figure 2. (A,B) Progressive introduction of 4F ureteral catheter into pinhole-size anastomosis. 1002
© 2009 Elsevier Inc. All Rights Reserved
0090-4295/09/$34.00 doi:10.1016/j.urology.2008.12.010
A
68-year-old man, who had undergone radical cystectomy with an ileal orthotopic neobladder 11 months previously, was referred for voiding difficulty and serum creatinine elevation. Ultrasonography showed moderate hydronephrosis and severe neobladder dilation, and urethral catheterization was unsuccessful. Urethroscopy revealed the presence of a partially calcified suture at the level of the neovesicalurethral anastomosis (Fig. 1), which allowed passage of only a 4F ureteral catheter (Fig. 2). Endoscopic suture removal was performed using rigid biopsy forceps, followed by cold knife incision of the stricture. An 18F catheter was left in place for 2 weeks, and then the patient was instructed to use continuous intermittent catheterization. Neovesical-urethral anastomosis has an incidence of 2.7%-8.8%.1 Its causes include healing disruption, prolonged catheterization, and failure of mucosal apposition.2 Risk factors include diabetes, vascular disease, smoking, and blood loss. Treatment options range from catheterization to endoscopic incision. In our case, we postulated that migration of an external 3-0 Prolene suture used for difficult retropubic hemostasis resulted in prolonged inflammation, leading to anastomotic stricture. From the Unit of Urology, Department of Surgery, University of Pisa, Pisa, Italy Reprint requests: Andrea Mogorovich, M.D., Unit of Urology, Department of Surgery, University of Pisa, Via Roma 67, Pisa, Italy. E-mail: [email protected] Submitted: October 14, 2008, accepted (with revisions): December 1, 2008
Figure 1. Endoscopic view of suture loop that migrated at level of neovesical-urethral anastomosis.
It has been documented that nonabsorbable sutures next to the urinary tract can migrate inside it3; however, to the best of our knowledge, this is the first case of neovesicalurethral anastomosis caused by suture migration. References 1. Patel SG, Cookson MS, Clark PE, et al. Neovesical-urethral anastomotic stricture after orthotopic urinary diversion: presentation and management. Br J Urol. 2007;101:219-222. 2. Huang G, Lepor H. Factors predisposing to the development of anastomotic strictures in a single-surgeon series of radical prostatectomies. BJU Int. 2006;97:255-258. 3. Athanasopoulos A, Liatsikos EN, Perimenis P, et al. Delayed suture intravesical migration as a complication of a Stamey endoscopic bladder neck suspension. Int Urol Nephrol. 2002;34:5-7.
Figure 2. (A,B) Progressive introduction of 4F ureteral catheter into pinhole-size anastomosis. 1002
© 2009 Elsevier Inc. All Rights Reserved
0090-4295/09/$34.00 doi:10.1016/j.urology.2008.12.010