達文西手臂攝護腺根除術後血管夾遷移造成之膀胱結石

吳冠儒¹、許烱明¹

¹台灣基督長老教會馬偕醫療財團法人馬偕紀念醫院泌尿科

Bladder stone with core component of Hem-o-Lok Clips after Robotic-assisted Radical Prostatectomy: A Case Report and Literature Review

Kuan-Ju Wu¹、Jong-Ming Hsu¹

¹Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan

Introduction –

  The Hem-o-lok clip (manufactured by Weck, a subsidiary of Teleflex, based in Morrisville, NC, USA) is a nonabsorbable polymer clip widely employed in laparoscopic surgeries to ligate the neurovascular bundle. According to previous articles and case reports, Hem-o-lok migration caused complications and the most common was intravesical migration. The estimated incidence of intravesical clip migration falls in the range of approximately 0.57% to 1%.

  We would like to share our experience with a 73-year-old male who had previously undergone a robotic-assisted radical prostatectomy (RARP) and was subsequently diagnosed with a bladder stone, the core of which was composed of Hem-o-Lok clips.

Case Presentation –

  A 73-year-old male presented at our outpatient clinic in early 2019, reporting lower urinary tract symptoms that included nocturia four to five times a night, increased frequency, and a weak urinary stream. As a result, a series of diagnostic examinations were initiated. Transrectal prostate ultrasound revealed a total prostate volume of 42.2 cm³, and digital rectal examination indicated bilaterally hard consistency. Subsequently, a transrectal ultrasound-guided prostate biopsy was performed, yielding a diagnosis of prostate adenocarcinoma with a Gleason score of 5+5. The initial prostate-specific antigen (PSA) level was 30.29 ng/mL. Comprehensive evaluation, including bone scan and prostate CT scan, revealed no specific abnormalities. No regional lymph node or distant metastases were detected.

  After discussing the available treatment options with the patient, he elected to undergo robotic-assisted radical prostatectomy (RARP). The procedure, which included bilateral pelvic lymph node dissection, was successfully performed. The final pathology report confirmed prostate adenocarcinoma with a Gleason score of 5+3=8, involving 60% of the prostate. The regional lymph nodes were found to be positive, and the apical margin of the prostate showed signs of invasive carcinoma. The patient's recovery after the surgery was uneventful, and he was discharged on the ninth postoperative day.

  Subsequently, the patient received regular follow-up care at our outpatient clinic and opted for androgen deprivation therapy (ADT) to manage the adverse effects of the therapy. Over time, his PSA levels gradually decreased, allowing for the discontinuation of ADT after a year. However, due to concerns about his condition, a follow-up PSA test was conducted a year after stopping ADT, which revealed a recurrence. As a result, ADT was resumed.

  During this period, the patient also reported lower urinary tract symptoms, including frequency, urgency, incomplete emptying, and hesitancy. In response to these symptoms, we conducted a cystoscopy and a whole abdomen CT scan for further evaluation. The findings indicated a mild urethral stricture and the presence of a large bladder stone, measuring approximately 4 cm. Consequently, endoscopic cystolithotripsy was arranged, and to our surprise, a Hem-o-Lok clip was discovered at the core of the stone. The bladder stone was fragmented using a lithoclast and completely removed. Following this procedure, the patient experienced relief from lower urinary tract symptoms, and treatment for PSA recurrence related to prostate adenocarcinoma continued.

Discussion –

  Radical prostatectomy is deemed a suitable therapeutic option for any patient diagnosed with clinically localized prostate cancer that is amenable to complete surgical excision. Since the minimally invasive operation was valued in recent periods, Robotic-assisted radical prostatectomy (RARP) was a crucial technique for prostate adenocarcinoma treatment. In the context of minimally invasive intra-abdominal surgery, the paramount objectives are the proficient management of hemorrhage and the secure fixation of tissue. Within this spectrum, there exist both absorbable and nonabsorbable devices. Therefore, vigilant postoperative surveillance is imperative to address the potential migration of clips to unforeseen sites, especially with nonabsorbable variants. Among these devices, Hem-o-lok clips (HOLC) are prominently employed and have demonstrated their safety and reliability in the context of vascular control during laparoscopic procedures. Within the realm of RARP, Hem-o-lok clips (HOLC) are employed for ligating the vasa deferentia, seminal vesicle arteries, and prostatic pedicles. This application serves to mitigate excessive electrocautery and reduce the risk of injury to the neurovascular bundles. Most of the documented complications associated with Hem-o-lok clips (HOLC) pertain to clip migration and bladder neck contracture. While the exact mechanism behind intravesical clip migration remains uncertain, it undeniably contributes to increased medical resource utilization. A prior study documented a 1.4% occurrence of clip migration among patients in their cohort following RARP. These individuals exhibited prolonged hospital stays and necessitated a greater quantity of blood transfusions when contrasted with patients who did not experience clip migration. The hypothesis of the clip's migration was that inflammation had developed around the urinary bladder or vesicourethral anastomosis, involving the surgical clip, which subsequently led to erosion of the bladder wall and eventual migration into the bladder. The reason for Hem-o-lok clip (HOLC) migration in our case might be attributed to a mechanism similar to the one described above.

  The symptoms associated with the bladder stone resulting from HOLC migration manifested over varying durations, with some cases presenting within less than 1-2 years post-surgery. It is plausible that the migrated hemostatic clip contributed to the gradual formation of the bladder stone. In a prior case report, a 54-year-old patient who underwent robot-assisted laparoscopic radical prostatectomy in June 2014 presented with lower urinary tract symptoms and hematuria three months later. In this case, a stone with a Hem-o-lock clip as the nidus was successfully removed, resulting in the patient's prompt and favorable recovery.