Marwane Andaloussi Benatiyaa, Azeddine El Kiassia, Ghizlane Raisb, c

aDepartment that Urology, Hassan 2 Hospital, Agadir, MoroccobMedical Oncology Department, regional Center of Oncology, Agadir, MoroccocCorresponding Author: Ghizlane Rais, medical Oncology Department, local Center of Oncology, Agadir, Morocco

Manuscript it is registered June 15, 2018, accepted June 27, 2018Short title: Ureteral Clip Migrationdoi: https://doi.org/10.14740/jmc3114w


Abstract▴Top

Inadvertent ureteric injury is a peril of laparoscopic hysterectomy and also may reason usually ureteric fistulae or obstruction. Ureteral clip migration adhering to laparoscopic hysterectomy together iatrogen ureteric injury has never to be described. Below we report an unusual case of a 45-year-old female that presented with appropriate flank pain. She has actually an background of laparoscopic hysterectomy 1 year ago. Abdominopelvic computed tomography (CT) scan confirmed the diagnosis of best renal colic complying with migration that a metalic clip. The patient was treated by the ureteroscopic ablation the the clip with the use of dual J stent and also had effective outcomes.

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Keywords: Surgical clip migration; Ureter; Laparoscopic hysterectomy


Introduction▴Top

The bulk of ureteral injuries space iatrogenic in nature. Together injuries are often known to occur most frequently during urology, gynecology and general surgical procedure <1, 2>. However, ureteral obstruction as result of surgical clip migration into the ureter is one extremelly rarely phenomenon <1, 2>. Us report below an interesting situation of spontaneous migration of metal clip right into the ureter in a woman patient that underwent laparoscopic hysterectomy 1 year previously for polymyomatous uterus. To the best of our knowledge, this is the very first case decribed in a patient after laparoscopic hysterectomy. The objective of presenting this situation report is not only to report one uncommon case of operation clip migration, but additionally to advanced awareness amongst clinicians the this rarely entity have the right to occurs after laparoscopic hysterectomy.

Case Report▴Top

A 45-year-old lady presented with repetitive episodes of appropriate flank pain because 3 weeks. She past background was significant for laparoscopic hysterectomy because that polymyomatous uterus 1 year ago. Plain radiography of the abdomen revealed a 5-mm opacity projected end the pelvic portion of the ideal ureter (Fig. 1). The renal ultrasonography confirmed moderate right ureterohydranephrosis there is no detectable lithiasis. Abdominopelvic computed tomography scan revealed a 0.5-cm opacity (arrow) top top the right reduced ureter (Fig. 2).

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Figure 1. Plain X-ray the the abdomen revealed metallic operation clips (arrow) ~ above the right reduced abdomen.
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Figure 2. Abdominopelvic computed tomography scan revealed a 0.5-cm opacity (arrow) ~ above the right proximal ureter.

Ureteroscopy with the patience under basic anesthesia confirmed metalic foreign body at the lower right ureter (Fig. 3) through incomplete stenosis that was dilated by a balloon. The medium-sized surgical clip was identified and removed making use of a dormia basket maker and a double J stent was inserted for 2 months. At 3-month follow-up, the patient to be asymptomatic through absolutely regular renal function test and lack of ureterohydonephrosis in abdomen ultrasonography.

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Figure 3. (a) Ureteroscopy confirmed a metallic parallelepiped international body in ~ the lower right ureter. (b) The international body was eliminated by use of a ureteroscopic stone basket maker and was figured out as a metallic unresorbable clip.
Discussion▴Top

Surgical clips have been used for countless years in a selection of surgical procedures and also they have proven competency and efficacy. The number of the operation clips provided is variable and unpredictable which depends on the procedure. However, nevertheless of their type, hike of the surgical clips away from the surgical site is a well-known phenomenon that occurs fairly regularly.

While hike of clips right into the typical bile duct has actually been formerly reported in numerous laparoscopic cholecystectomies <3, 4>, migrations of operation materials right into the urinary tract prefer pelvicalyceal system, ureter and bladder room a rare condition. It has been reported complying with various urological actions either in the ureter ~ laparoscopic partial nephrectomy <5-7> or into the bladder after surgical treatment laparoscopic radical prostatectomy <5, 8>. Moreover, a case of intrarectal migration after ~ prostatectomy <7> and also a case of migrate in the colon after partial nephrectomy <9> have additionally been reported.

This instance is an extremely interesting due to the fact that to the best of ours knowledge, this is the an initial described case of migrate of surgical clip into the ureter after ~ laparoscopic hysterectomy.

It was suggested that moved clips are much more often associated with laparoscopic measures <5, 6>. This means that us would expect to see much more of moved clips through the large preferred use of laparoscopy

The specific sequence of occasions leading come clip hike is poorly understood, but is believed to be partly impacted by technical components such as correct placement and use of minimal number of clips <5>. A proposed device of clip migration after cholecystectomy involved the compression of the clipped cystic duct through the liver. The cystic duct and clips then come to be inverted into the lumen the the usual bile duct. Over time, this structure becomes necrotic, and also the clips autumn away right into the common bile duct. The number of clips used during the initial surgical procedure is also an important factor <3, 4>. In our patient, the non-absorbable surgical clip more than likely eroded right into the ureter which has obstructed ultimately probably due to chronic inflammation reactions, and also caused ureterohydronephrosis.

The mean time the clip hike is usually 2 years, however it can vary from 11 days to 20 years, if the median number of migrated clip is 1 (range: 1 - 6) <5>. In this patient, clip migration to be diagnosed 1 year after laparoscopic hysterectmy which concord v the literature.

The selection of treatment is based upon the location, kind and expand of ureteral injury led to by migrated clip <10>.There is a report the the hike of absorbable Lapra-Ty suture clips in the collecting device after laparoscopic partial nephrectomy <10>, and also Massoud <11> additionally reported the migration of a steel surgical clip right into the ureter after open up partial nephrectomy, every one of which to be passed spontaneously. The majority of patients through delayed diagnosed ureteral injuries must be managed by an initial endourological approach.

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To enhance the monitoring of ureteric injury, there must be a high index of suspicion, especially after laparoscopic operations. Most reported situations were treated through endourological therapy which yields acceptable results.