Elsevier

Urology

Volume 72, Issue 1, July 2008, Pages 158-161
Urology

Oncology
Bladder Neck Contractures Related to the Use of Hem-O-Lok Clips in Robot-Assisted Laparoscopic Radical Prostatectomy

https://doi.org/10.1016/j.urology.2007.11.105Get rights and content

Objective

Recently, several large series of robot-assisted laparoscopic radical prostatectomy (RALP) have described a low incidence of bladder neck contractures (BNC). We have had a similar experience at our institution. Our objective is to describe our experience with BNC after RALP and a novel relationship to the use of Hem-o-lok Clips (HOLC).

Methods

We reviewed a database of patients who underwent RALP at our institution from January 2004 to September 2007 and identified patients with BNC or complications related to the use of HOLC. We performed a retrospective chart review to attempt to determine the cause of each BNC. We also performed a PubMed search and review of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database.

Results

Of 524 patients undergoing RALP, 4 had a BNC develop, 2 of the BNCs were associated with HOLC migration and erosion into the vesicourethral anastomosis, and 1 was found to have HOLC migration within the bladder. A fifth patient had an anastomotic leak develop secondary to a HOLC that migrated into the bladder neck. Two similar cases of HOLC-related migration have been reported to MAUDE.

Conclusions

When early BNC or unexplained urinary retention occurs after RALP, one should have a high index of suspicion for migration of HOLC. Clip use should be minimized on tissue immediately adjacent to the anastomosis, and every effort should be made to retrieve loose clips after the procedure.

Section snippets

Material and Methods

The robotic program at our institution was initiated in January 2004. We have since maintained a prospective database of clinical, surgical, and pathologic parameters. For this study, we retrospectively reviewed our database of complications to identify all patients who had a BNC develop. We also performed a search of the United States Food and Drug Administration Manufacturer and User Facility Device Experience Database (MAUDE) to identify reported failures of HOLC between July 2005 and June

Results

Between January 2004 and September 2007, 524 consecutive patients underwent RALP at our institution by 2 surgeons (H.A.F., J.D.E.). The average follow-up time for the entire cohort was 10.78 months. We identified 4 patients with BNC within the cohort (0.76%), 2 of the BNCs were found to have HOLC migration into the urinary tract. A fifth person has been identified also with HOLC migrated into the bladder but no associated BNC.

Patients 1 and 2 had obstructive lower urinary tract symptoms with

Comment

Long et al.17 reported on a metal clip migration causing vesicourethral stricture after radical prostatectomy after multiple episodes of urinary retention and several failed urethrotomies. To our knowledge, our series is the first case report describing Weck HOLC migration into the vesicourethral anastomosis. Our experience brings to light questions regarding the use of foreign bodies in close proximity to the vesicourethral anastomosis during RALP.

Our review demonstrates several interesting

Conclusions

On the basis of these findings, we recommend minimizing the use of HOLC on tissue immediately adjacent to the anastomosis during RALP, specifically the vasa and seminal vesicles, and every effort should be made to retrieve any loose clips after the procedure. These clips are prone to migration and may cause, or significantly contribute to, BNC formation after RALP. Migration of HOLC into the vesicourethral anastomosis should be considered in patients with symptoms consistent with BNC after RALP.

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