Intravesical migration of an intrauterine contraceptive device complicated by bladder stone: a report of six cases

Intrauterine contraceptive device is the most popular method of reversible contraception in developing countries due to its efficiency and low cost. However, this device is often inserted by paramedics of variable skills, and follow-up evaluations are irregular or absent which can be the source of major complications. The authors report six cases of intravesical migration of intrauterine contraceptive devices complicated by bladder stones. All the six cases were managed endoscopically with excellent outcome. The authors demonstrate that this major complication can be managed endoscopically with decreased morbidity for the patient.     

Urinary complications of migrated intrauterine contraceptive device

The study aimed to present diagnosis and management of urinary complications resulting from migration of intrauterine contraceptive device (IUD). Between May 2002 and January 2007, eight women were treated for urinary complications because of migrated IUD. Persistent lower urinary tract symptoms were the main complaint in five cases, while one patient presented with urinary incontinence and two had suffered from right loin pain. Diagnosis was established after performing noncontrast computed tomography (NCCT) in all cases. Intravenous urogram (IVU) was carried out for evaluation of hydronephrosis in two cases. Cystoscopy was performed before surgical intervention in six cases. The interval between insertion of IUD and onset of symptoms ranged from 1 week up to 2 years. NCCT revealed complete intravesical position of the IUD with calculus formation on top in four cases and partial bladder wall penetration in the fifth. Cystoscopy confirmed the site of the IUD as detected by NCCT. In the last two cases, retroperitoneal migration of IUD had led to fibrosis around the right pelvic ureter. Intravesical IUDs and stones were successfully retrieved using transurethral endoscopy while suprapubic retrieval of the device was followed by repair of vesicouterine fistula in the fifth case and ureteroneocystostomy in the last two cases. Persistent lower urinary tract symptoms in women with IUD should raise the suspicion of intravesical migration. Noncontrast CT permitted excellent depiction of the site of migrated IUD for selection of proper management. Endoscopic retrieval is feasible and safe in cases with intravesical migrated IUD.     

Rupture of urinary bladder secondary to bladder carcinoma with extensive abdominal gangrene: A case report

Introduction and importanceSpontaneous rupture of the urinary bladder is rare but potentially severe. It is unusually related to bladder tumours. The morbidity and mortality rate are very high in these groups of patients.Case presentationWe present a case of a 62-year-old man who was known to have a bladder tumour who presented with extensive gangrene of the anterior abdominal wall. Imaging showed an extraperitoneal urinoma extended to the anterior abdominal wall secondary to a bladder rupture with posterior bladder wall thickening suggesting a bladder tumour. After optimization of the patient’s condition, urinoma drainage and upper urinary tract drainage by bilateral nephrostomy, excision of all necrotic tissues and a biopsy of the bladder lesion was performed. At a multidisciplinary meeting, we opted for a transurethral resection of the bladder followed by palliative chemotherapy considering that the tumour was locally advanced and depending on the disease course and patient’s condition.Clinical discussionGangrene secondary to urinary bladder rupture caused by transitional cell carcinomas is a very rare disease with poor oncological and infectious prognoses. For these reasons, treatment is often palliative.ConclusionUrinary bladder rupture secondary to bladder carcinoma could rarely be complicated with abdominal gangrene. No standardized treatment is recommended seeing the extreme rarity of this disease and management should be discussed on a case-by-case basis.     

Idiopathic spontaneous pulmonary torsion of the lingula: A case report

IntroductionSpontaneous pulmonary torsion is an extremely rare event and is known to occur as a complication of thoracic surgery and traumatic injuries.Presentation of caseAn 18-year-old man presented to our hospital with pain in the left back region. Clinical examination, computed tomography and bronchoscopy are crucial for diagnosis of pulmonary torsion. During thoracotomy, the lingula segment was observed to be bent on the head side and turned 180° counterclockwise; subsequently, lingulectomy was performed.DiscussionSpontaneous pulmonary torsion may occur in pulmonary conditions such as pneumothorax, atelectasis, infection, pleural effusion, congenital defect, or tumor. Furthermore, it can be speculated that torsion of the segment is possible only in the patients with an accessory fissure or those who have undergone a segmentectomy.ConclusionWe have reported an extremely rare case with respect to the fact that the pulmonary torsion occurred spontaneously in an unseparated segment, and that the etiological factor could not be identified.     

节育器异位致膀胱乙状结肠瘘及膀胱结石1例报告并文献复习

目的探讨宫内节育器异位致膀胱乙状结肠瘘及膀胱结石形成的原因、类型及诊治方法。方法报告1例节育器异位致膀胱乙状结肠瘘并形成膀胱结石的临床资料,结合文献讨论宫内节育异位致膀胱乙状结肠瘘及膀胱结石形成的原因、机制、临床特点及治疗方法。患者,女,31岁,因耻骨上膀胱切开取石术后5个月尿液中混有粪渣就诊,超声及KUB平片诊断为膀胱结石复发,行腔镜下碎石取石术,术中取出一个T型节育环,术后患者尿中仍有粪渣样物,经膀胱镜及肠镜检查诊断为膀胱乙状结肠瘘入我院。结果行剖腹探查术,术中发现子宫前壁有一穿孔瘢痕,膀胱顶壁及乙状结肠前壁有一瘘管,切除瘘管,分别修补膀胱及乙状结肠壁,术后患者排尿正常,尿中无粪渣,随访1年无复发。结论宫内节育器异位至膀胱并形成膀胱乙状结肠瘘是一种罕见的并发症,早期诊断需熟悉其发病机制并结合超声、子宫造影、CT等检查手段,早期治疗可防止严重并发症的发生。     

Peliosis lienalis with atraumatic splenic rupture in a patient with chronic myelomonocytic leukemia: A case report

IntroductionAtraumatic splenic rupture is a rare but life-threatening condition which may be associated with hematological malignancies.Presentation of caseWe present the case of a 63-year-old male patient with a history of chronic myelomonocytic leukemia and sarcoidosis under therapy with prednisone, who suffered an atraumatic splenic rupture with hemodynamic instability. He was managed with proximal splenic artery embolization and secondary open splenectomy. On pathology the diagnosis of peliosis lienalis was established.DiscussionPeliosis is a rare pathological entity, which presents with multiple blood-filled cavities within parenchymatous organs and is of unknown etiology and pathogenesis. In retrospect a rapid increase in splenomegaly and inhomogeneous parenchyma of the spleen on sonography was realized.ConclusionSonographic changes in size and parenchyma of the spleen in patients with hematological malignancies might help suspecting peliosis lienalis with impending splenic rupture and could alter clinical management towards a prophylactic splenectomy.     

Transobturator tape,bladder perforation,and paravaginal defect: a case report

Transobturator midurethral slings (TOT) have been shown to have less risk of vascular and visceral injury than tension-free midurethral slings. Routine cystoscopy has therefore not been felt to be necessary. A case of bladder perforation unrecognized at the time of TOT placement is presented. Findings at sling removal suggested that a clinically nonapparent paravaginal defect may have been instrumental in the injury. Consideration should be given to routine cystoscopy at the time of transobturator sling placement.     

Intravesical migration of intrauterine device resulting in pregnancy

Spontaneous migration of an intrauterine device into the bladder is very rare. A 29-year-old woman in whom an intrauterine device had been placed 6 years previously, presented complaining of chronic pelvic pain and recurrent irritative urinary tract symptoms. One year after insertion she had became pregnant and given birth without complications. Intravesical migration of the intrauterine device was confirmed by sonography and cystoscopy. The intrauterine device was removed by suprapubic cystostomy.     

Case report: The theory of post-ileocystoplasty spherical configuration in patients with low-capacity bladder

IntroductionBladder augmentation can be performed by detubularization of the small or large intestine. A large capacity bladder is necessary to avoid frequent urination; thus, the ileal sac must be able to store the maximum volume of urine with relatively low pressure and the shortest length of the intestine. The acceptable pressure capacity should always be under ureteric pressure to avoid back pressure and kidney damage. Large capacity at low pressure is referred to as good compliance. Desirable preparations for augmentation, which is the use of the shortest length of the intestine, reduce the chance of diarrhea and vitamin deficiency and retain the intestines which may be required for augmentation.AimClinical and urodynamic evaluation of the recent postoperative condition of the patient who underwent ileocystoplasty, confirmed by the theory of detubularization (spherical) configuration.Case presentationPatient with complaints of frequent urination and small amount of urine. Ultrasound examination showed low volume bladder capacity and bilateral hydronephrosis and hydroureter. From cystography and VCUG examination, low capacity bladder, grade 1 VUR on the right side, grade 4 VUR on the left side accompanied by bilateral hydronephrosis and hydroureter. The patient has a history of right nephrectomy in 2014 for pyonephrosis due to kidney stones. The patient was then subjected to bladder augmentation using a segment of the ileum (ileocystoplasty) in 2015. In the postoperative evaluation, clinical symptoms, radiological and uroflowmetric examinations were evaluated.ConclusionThe detubularization form offers greater volume and lower pressure in the reservoir to augment the bladder.     

Early postoperative colonic ventriculoperitoneal shunt migration with trans-anal protrusion: A unique case report

Introduction and importanceColonic ventriculoperitoneal shunt (VPS) migration with trans-anal protrusion remains uncommon. Patients may be asymptomatic, and diagnosis may only be made on visualization of the prolapsed catheter from the anus. This unique case of early post-operative trans-anal shunt protrusion highlight the possibility of this rare complication specially when shunt revision accompanies bowel surgery.Case presentationThe authors present a case of early postoperative colonic shunt migration in a thirteen-year-old female with who underwent Malone Antegrade Continence Enema (MACE) with concomitant revision of the distal part of the peritoneal catheter. She presented two weeks post operatively with shunt catheter protruding from the anus. This was noticed by her carer and she was asymptomatic on her presentation.Clinical discussionDelayed post-operative shunt related bowel perforation and trans-anal shunt protrusion is an uncommon complication after ventriculoperitoneal shunting. Most cases present months after surgery and majority are asymptomatic on presentation. The exact pathophysiology is not established, and mechanisms have been proposed. Early post -operative trans-anal shunt protrusion is rare and suggests inadvertent occult bowel injury especially when shunt placement or revision accompanies extensive bowel surgery.ConclusionThe authors recommended shunt imaging within the first two to three weeks after shunt revision in patient who undergo concomitant bowel surgery with risk of inadvertent bowel injury to identify early colonic migration and avoid its potentially fatal sequelae.     

Laparoscopic removal of a perforated intrauterine device from the perirectal fat.

BACKGROUND: The intrauterine device (IUD) was a very common form of birth control in the United States. The most serious potential complication of IUD use is uterine perforation. Uterine perforation is common among women with "lost" IUDs and can cause severe morbidity and mortality and should be carefully managed. The recommended treatment is removal of the perforating IUD. This can usually be managed laparoscopically unless bowel perforation or other severe sepsis is present. METHODS: An intra-abdominal IUD was removed laparoscopically from the perirectal fat of a 49-year-old woman who had been diagnosed over 20 years earlier with an "expelled" IUD. CONCLUSIONS: It is important that the possibility of uterine perforation be considered in anyone who has had a diagnosis of an expelled IUD without actual confirmation that the IUD is no longer present in the body. In any woman who presents with pelvic pain and a history of a "lost" IUD, the surgeon should have a high index of suspicion and obtain radiological studies. It may be advisable to question women about possible IUD use when they present with pelvic pain of unknown origin.     

Giant bladder stone with squamous cell carcinoma of bladder: Case report and the literature review

Introduction and importanceConcurrent bladder neoplasm and giant bladder stone are rare in contemporary urological practice. Squamous cell carcinoma (SCC) is rare histologic diagnosis of bladder cancer.Case presentationA 45 y.o. male, with lower abdominal pain when urinating, that comes and goes in the last 35 years. He had gross hematuria a year ago. The patient comes from a rural region, which undiagnosed for years. Physical examination showed a suprapubic abdominal solid mass, sized 20 × 10 cm, without tenderness. On plain radiography, showed radiopaque lesion which fully occupies the bladder. The ultrasound showed bilateral hydronephrosis. The patient underwent vesicolithotomy, and a giant bladder stone (size of 14 × 9 cm) was found, with incidental finding of suspicious malignant mass. The patient refuses radical cystectomy. Due to mass characteristics that are manageable for complete excision and the need for histopathological studies, bladder preservative therapy was applied with complete tumor excision and biopsy. The mass pathological diagnosis is grade 2 squamous cell carcinoma with lamina muscularis invasion, staged pT3bN0M0. The patient underwent cisplatin-based chemotherapy, with regular evaluation. The possibility of future radical cystectomy remains open.Clinical discussionBy diameter, the stones found in our patient is perhaps one of the largest that ever reported being associated with bladder SCC. The bladder stones causing chronic mucosal injury, lead to the development of SCC. In limited situation, bladder preservation therapy may be considered for muscle-invasive bladder cancer.ConclusionDespite its rarity, SCC along with the chronic bladder stone is possible, and needs more attention.     

Three colonic cancers,two sites of complete occlusion,one patient: A case report

BACKGROUNDSynchronous colonic cancer incidence is uncommon, and awareness about this rare condition is improved recently. However, in the presence of acute colonic obstruction, investigation and management of synchronous colonic cancer can be difficult and challenging. CASE SUMMARYA patient presented with acute colonic obstruction with impending rupture and complete examination of this patient revealed the presence of three colonic cancers, of which two were completely occluding.CONCLUSIONThe presence of multiple colonic cancers must be ruled out in order to plan the best management. We present the case with a review of literature and discuss the management of the case.     

Laparoscopic management of a small bowel obstruction secondary to Elipse intragastric balloon migration: A case report

IntroductionThe Elipse™ intragastric balloon (IGB) for weight loss is a swallowable capsule that is filled with 550 mL of fluid and resides in the stomach for four months before being excreted from the gastrointestinal tract. Although initial data showed that use of this device is safe and free from serious complications, we report for the first time the successful management of an Elipse™ IGB-related adverse event.Presentation of caseA 41-year-old woman presented to our emergency department following two days of abdominal pain, vomiting, and constipation. Her medical history included four caesarean sections and insertion of the Elipse™ IGB 16 weeks prior to presentation. The patient was vitally stable at presentation and abdominal examination revealed a mildly distended abdomen. Plain X-ray revealed a small bowel obstruction (SBO), and a double contrast computed tomography scan showed a dilated small bowel with mild free fluid proximal to a transition zone at the distal jejunum. Laparoscopic enterotomy was performed just proximal to the obstruction site, and the balloon was visualized and extracted after it had been incised and emptied. The enterotomy incision was closed with an intracorporeal continuous absorbable suture. The patient’s recovery was uneventful and she was discharged on postoperative day 4.DiscussionWe discuss the possible etiologies of SBO following Elipse™ IGB insertion, and present a brief literature review regarding surgical and nonsurgical management options for such cases.ConclusionAlthough initial data showed the Elipse™ IGB to be safe, complications can occur and be managed successfully.     

A rare case report of vulvar necrotizing fasciitis in a healthy patient

IntroductionNecrotizing fasciitis (NF), a necrotizing infection of the soft tissue, is a medical emergency usually occurring in the lower extremities and abdominal regions and often difficult to diagnose promptly.Presentation of caseThis case report looks at one atypical presentation of NF with the unusual location of the vulva and no known associated comorbidities or risk factors.DiscussionDiagnosing this patient was particularly difficult due to the inconsistent clinical, laboratory and imaging findings. The CT scans and WBC count were indicative of NF, but the LRINEC score was not high enough to make the diagnosis of NF. As a result, we relied on the hemodynamic instability and clinical findings of the physical exam to be strong indicators of NF, and acted on that indication.ConclusionActing quickly on the hemodynamic findings and suspicion as opposed to waiting for a confirmed diagnosis resulted in a good prognosis since immediate surgical debridement is imperative to surviving this acute condition. Despite major advancements in the imaging modalities and the introduction of a laboratory score, our case suggests that the diagnosis still heavily relies on clinical findings, such as hemodynamic instability. Furthermore, our case suggests that NF should be included in the differential regardless of atypical location and lack of common clinical associations.     

Septic gonococcal arthritis in a pediatric patient: Rare case report

IntroductionSeptic arthritis is an orthopedic emergency that requires rapid diagnosis and treatment due to the rapid destruction to cartilage. The responsible organism and etiology differs depending on patient age, especially in children. Gonococcal Arthritis in toddlers is a rare occurrence with few documented cases in the literature. An orthopedic surgeon is likely not to come across this either in training or through their careers. Consequently, its presentation and subsequent treatment algorithms leave several gray areas.Presentation of caseIn this case report, we present a rare and not so straightforward presentation of a toddler with septic gonococcal arthritis along with a summary of treatment considerations described in the current literature and the course of treatment for this patient.Our patient is a toddler who originally presented to the emergency department with shoulder and knee pain for several days after an unwitnessed fall. He was subsequently discharged and presented again the next day with a knee effusion and elevated inflammatory markers. An MRI showed a large joint effusion without any underlying abscess or osteomyelitis to explain his elevated inflammatory markers. A knee aspiration was subsequently preformed which eventually grew out Neisseria Gonorrhea on hospital day 3 after the patient had been on antibiotics. He was taken back for an arthroscopic irrigation and debridement for definitive treatment.Clinical discussion/conclusionDisseminated gonococcal infection in toddlers is a rare occurrence without much information in the literature and should not be dismissed as a differential. We recommend a high index of suspicion with thorough work up. We also recommend surgical management of a septic joint due to DGI diagnosed via arthrocentesis (gross purulence, symptoms not improving on medical therapy, positive aspiration cultures, elevated synovial cell counts, and medically unstable patients) given the sequelae of medical management alone. The importance of interdisciplinary team collaboration that include pediatrician, infectious disease specialist, social worker, and government child safety associations is pivotal.