|Year : 2014 | Volume
| Issue : 3 | Page : 176-179
Intravesical migration of gossypiboma following vaginal hysterectomy: An unusual cause of acute urinary retention
Mohammad A Mohammad1, Anyanwu L Chukwuemeka1, Sani A Aji1, Jamilu Tukur2, Garba I Diggol2, Musa Ibrahim3
1 Department of Surgery, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Obstetrics and Gynecology, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
3 Department of Surgery, Children Surgical Unit, Murtala Mohammed Specialist Hospital, Kano, Nigeria
|Date of Web Publication||8-Dec-2014|
Dr. Mohammad A Mohammad
Department of Surgery, Aminu Kano Teaching Hospital, Bayero University, Kano, PMB 3452 Kano
Source of Support: None, Conflict of Interest: None
A gossypiboma also known as textiloma or cottonoid are terms used to describe a foreign object, such as a mass of cotton matrix or a sponge that is left behind in a body cavity during an operation. It is an uncommon surgical complication. The manifestations and complications of gossypiboma are so variable that diagnosis may be difficult and patient morbidity is significant. The incidence of retained surgical instruments is estimated at 1 in 100-3,000 of all surgical interventions and 1 in 1,000-1,500 for all intra-abdominal operations. We report a case of extrusion of forgotten gauze following vaginal hysterectomy in a 49-year-old woman. The gauze migrated into the bladder presenting with acute urinary retention. She had vesicostomy retrieval of the gossypiboma and repair of the defect on posterior wall of the bladder. She did well postoperatively with no complication. Any woman that had pelvic surgery and is presenting with recurrent pelvic pain, urinary tract infection (UTI) and lower urinary tract irritative, or obstructive symptoms gossypiboma should be suspected and investigated.
Keywords: Gossypiboma, urinary retention, transurethral, extrusion
|How to cite this article:|
Mohammad MA, Chukwuemeka AL, Aji SA, Tukur J, Diggol GI, Ibrahim M. Intravesical migration of gossypiboma following vaginal hysterectomy: An unusual cause of acute urinary retention. Arch Int Surg 2014;4:176-9
|How to cite this URL:|
Mohammad MA, Chukwuemeka AL, Aji SA, Tukur J, Diggol GI, Ibrahim M. Intravesical migration of gossypiboma following vaginal hysterectomy: An unusual cause of acute urinary retention. Arch Int Surg [serial online] 2014 [cited 2022 Jul 5];4:176-9. Available from: https://www.archintsurg.org/text.asp?2014/4/3/176/146435
| Introduction|| |
A gossypiboma, textiloma,  or cottonoid are terms used to describe a foreign object, such as a mass of cotton matrix or a sponge that is left behind in a body cavity during an operation. It is an uncommon surgical complication. The manifestations and complications of gossypibomas are variable that diagnosis may be difficult and patient morbidity is significant.  The incidence of retained surgical instruments is estimated at 1 in 100-3,000 of all surgical interventions and 1 in 1,000-1,500 for all intrabdominal operations. ,, Many cases of gossypiboma after surgical procedures have been reported, but migration of surgical gauze into the urinary bladder is rare. To our knowledge only one case of spontaneous transurethral extrusion of the retained gauze was reported,  which did not present with acute urinary retention. We report a case of an extrusion of forgotten gauze following vaginal hysterectomy, presenting with acute urinary retention in a 49-year-old woman.
| Case Report|| |
The patient was a 49-year old woman who had vaginal hysterectomy in a peripheral hospital, 5 years prior to presentation for a third degree uterovaginal prolapse. She presented with painful inability to pass urine of 10-h duration and was in severe distress. She previously had several episodes of dysuria, pyuria, and hematuria and has been treated for urinary tract infection (UTI) on account of urine cultures yielding Escherichia More Details coli and Staphylococcus aureus. A day prior to presentation, she noticed progressive reduction of her urinary stream until she was unable to pass urine, with associated suprapubic pain and swelling. Just before the onset of the retention she noticed a spongy substance protruding through her external urethra meatus, she made failed attempts to pull it out which worsens the symptoms of acute urinary retention.
Examination revealed a middle-aged woman in painful distress, who was restless. She was afebrile, not pale, not dehydrated, and no facial or pedal edema. Abdominal examination revealed no surgical scars. She had a tender suprapubic swelling measuring about 7 cm from the pubic symphisis, with no loin pain or renal angle tenderness and examination of the perineum revealed a piece of gauze emerging from the external urethral meatus. Vaginal examination revealed no evidence of urine leakage from the introitus and closed vaginal vault [Figure 1] and [Figure 2]. Attempt at catheterization using Foley's catheter was not successful and a metal catheter was thus used to relieve her acute urinary retention.
Cystoscopy revealed a bunch of gauze penetrating the posterior wall of the urinary bladder, part of which was floating freely within the bladder; an attempt to extract the gauze with forceps failed. She was prepared for and had vesicostomy and extraction of the gauze from the posterior wall and the rent communicated with the vaginal vault [Figure 3]. The defect was repaired separately with polygalactine 110 and the cystostomy closed in layers. Foley's catheter was inserted for continuous bladder drainage for 14 days. She did well and was followed-up for 2 years with no episode of UTI or lower urinary tract symptoms or features suggestive of urinary fistulae.
| Discussion|| |
Several cases of retention of surgical gauze after surgical procedures have been reported; however, many remain unreported for fear of litigation.  Forgotten gauze has been known to migrate to several hollow intra-abdominal organs such as intestine, stomach, and thoracic cavity. ,,,,,,,,, Migration of surgical gauze into the urinary bladder is rare.  To our knowledge, only one of the many reported cases of gossypiboma have mentioned spontaneous transurethral extrusion of the retained gauze and none have presented with acute urinary retention in a female patient.  Manipulations of variety of foreign bodies to the urethra have been reported in the literature.  Different foreign bodies have been forgotten, transported, or left accidentally in the adult vagina over a period of time. Such objects included tampons, sex toys, bottle caps, and sometimes dangerous substances like batteries and illicit drugs.  The true incidence of this condition may not be accurately known as this event may not be reported for fear of litigation and adverse publicity.  Reported age range for patients with this condition was 6-92 years.
In an experimental animal, a study to evaluate the process of migration of gossypiboma; four stages ware described. These are foreign-body reaction, secondary infection, mass formation, and remodeling. Pathologically, two types of foreign-body reaction can occur. The first is an aseptic fibrinous response that creates adhesions and encapsulation. The second response is exudative in nature and leads to abscess formation with or without secondary bacterial invasion.  The intestine is the most commonly affected site due to the relatively large outer surface of the small intestine and because its thin wall offers the least resistance. The stomach is an unusual site for transmural migration because of its relatively small outer surface area, higher location in the abdomen, and thick wall. Migration of surgical gauze into the urinary bladder is rare probably because of the thick wall of the detrusor muscle. A long period of chronic inflammation is therefore required to penetrate the thick wall  as in the case being reported, where the gauze was left in situ for 5 years. In this case, the chronic inflammation was caused by the presence of the gauze. The gauze in the vaginal vault which was in contact with the posterior wall of the bladder eventually eroded into the urinary bladder and served as a foreign body leading to repeated episodes of UTI. Finally, when a significant length of the gauze was in the bladder, it was extruded into the urethra while voiding, which then resulted in acute urinary retention. Plain radiography and computerized axial tomography (CAT) scan can diagnose most cases of gossypiboma. However, MRI is useful in differentiating a foreign body from an abscess. ,,,, Malignant transformation has been reported following long standing irritation from gossypiboma resulting in hematoma, granulomatous inflammation, abscess formation cystic masses, and/or neoplasm. ,
The treatment modality for gossypiboma depends on the location, size, complications, and facilities available; ranging from laparoscopic retrieval to open surgery. ,, Uncomplicated gossypiboma can be retrieved laparoscopically. However, migration to hollow organs requires exploration, removal of the foreign body, followed by resection, and/or repair of the perforated organs, toileting, and sometimes drainage of the cavity. Our patient presented with acute urinary retention. There was minimal time for extensive evaluation and the diagnosis was obvious on perinea examination. Our patient was treated with open vesicostomy, repair of the posterior wall, and followed-up without any complication.
| Conclusion|| |
One important point needs to be stressed as fallout of this case report is that; surgeons need to be extra careful during surgery to avoid leaving any foreign body within the patient. The measures that need to be employed include gauze and instrument count, before closing the patient and use of gauze mounted on a swab stick or with the edges held with an artery forceps. Surgeons need to keep in mind the possibility of gossypiboma during every surgical procedure to avoid the unnecessary suffering by patients as reported in this case report. We suggest that recurrent pelvic pain and UTI in patients with a history of transabdominal or vaginal hysterectomy should be carefully reviewed, examined, and investigated for gossypiboma.
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[Figure 1], [Figure 2], [Figure 3]