Hem-O-Lok clip: a neglected cause of severe bladder neck contracture and consequent urinary incontinence after robot-assisted laparoscopic radical prostatectomy

Abstract

BackgroundHem-o-lok clips are widely used during robot-assisted and laparoscopic radical prostatectomy to control the lateral pedicles. There are a few reports of hem-o-lok clip migration into the bladder or vesico-urethral anastomosis and only four cases of hem-o-lok clip migration resulting into bladder neck contracture. Herein, we describe the first case, to our knowledge, of hem-o-lok clip migration leading to severe bladder neck contracture and subsequent stress urinary incontinence.Case presentationA 62-year-old Caucasian man underwent robot-assisted laparoscopic radical prostatectomy for a T1c Gleason 8 prostate cancer. One month after surgery the patient was fully continent; however, three months later, he presented with acute urinary retention requiring suprapubic drainage. Urethroscopy showed a hem-o-lok clip strongly attached to the area between the vesico-urethral anastomosis and the urethral sphincter and a severe bladder neck contracture behind it. Following cold-knife urethral incision and clip removal, the bladder neck contracture was widely resected. At 3-month follow-up, the patient voided spontaneously with a peak flow rate of 9.5 ml/sec and absence of post-void residual urine, but leaked 240 ml urine at the 24-hour pad test. To date, at 1-year follow-up, his voiding situation remains unchanged.ConclusionsThe present report provides further evidence for the risk of hem-o-lok clip migration causing bladder neck contracture, and is the first to demonstrate the potential of such complication to result into stress urinary incontinence.

Management Strategies for Post-Prostatectomy Bladder Neck Contractures

“…In 20 % (3/15) of the patients experiencing BNC, a migrated foreign body was noted at the level of the vesicourethral anastomosis [2]. This is consistent with multiple recent case reports describing hem-otomotic stricture [10][11][12][13].…”

An update on best practice in the diagnosis and management of post-prostatectomy anastomotic strictures

“…Anastomotic urine leak, intravesical foreign body, increased operative time and increased estimated blood loss have been cited by multiple studies as risk factors for VUAS. 6,7,13,19,27,28,[33][34][35][36][37][38][39] Given that most of these factors are caused by or increase the risk of poor anastomotic mucosal apposition, it is intuitive to assume this as an important risk factor for VUAS formation. 29 To address this concern, Srougi et al described a technique in which the bladder neck mucosa was everted to improve apposition and reduce VUAS, but an improvement in rates of VUAS with this technique was not noted.…”

Incidental detection of asymptomatic migration of Hem‐o‐lok clip into the bladder after laparoscopic radical prostatectomy

“…To our knowledge, 13 cases have been reported in 8 articles about HOLC migration into the bladder after radical prostatectomy (Table ). In 2008, Banks et al were the first to report a case of HOLC migration into the bladder after LRP, in which a calculus formation was found in the region of the bladder neck, presenting with persistent bladder spasms.…”