Combined double-endoscopic treatment of intrauterine device ectopic bladder complicated with bladder calculi: a case report

doi:10.21203/rs.3.rs-4173233/v1

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Case Report

Combined double-endoscopic treatment of intrauterine device ectopic bladder complicated with bladder calculi: a case report

https://doi.org/10.21203/rs.3.rs-4173233/v1

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An intrauterine device (IUD) is a first-line contraceptive regimen recommended by the World Health Organization (WHO) and is widely used worldwide. Ectopic IUD to the bladder associated with bladder stones is rare, and there is no standard treatment. We report here a case of a female patient who presented with hematuria, initially diagnosed with bladder stones, and found intraoperatively that the intrauterine device had migrated to the bladder. We reviewed the literature to analyze possible causes and propose a new feasible minimally invasive surgical protocol.

Intrauterine device

Bladder calculi

Hematuria

Cystoscopy

Laparoscopy

Compared with men, the urethra of women is short and thick, and the incidence rate of obstructive bladder stones is lower. The repeated formation of female bladder stones requires not only the exclusion of urethral stricture, neurogenic bladder, and other diseases but also the vigilance against rare cases of foreign bodies in the bladder, such as ectopic birth control devices. IUD contraception is a low-cost, long-term, and effective contraceptive method, which is particularly popular among Chinese women. However, stone formation from ectopic IUD to the bladder is rare. Here we report the diagnosis and treatment of a case of stones from ectopic IUD to bladder by double mirror combined treatment, and review the literature to analyze the possible causes and feasible solutions.

A 48-year-old woman presented with hematuria for one month, and urinary ultrasound showed no obvious abnormalities in both kidneys or ureters. The right wall of the bladder was hyperechoic, and bladder stones were considered, but the possibility of bladder tumor or bladder blood clot was not excluded; so we performed a cystoscopy on her, and a yellow stone was observed under cystoscopy, and no other abnormalities were found. So we considered the diagnosis of bladder stones.

After evaluating that the patient could tolerate the operation, we arranged transurethral cystoscopic holmium laser lithotripsy for her.

When we used the holmium laser to break up half of the bladder stones, we found something wrong. There was a metal-like thing connecting the stone to the bladder(Figure1). At this point, we highly suspected that the IUD had migrated to the bladder and penetrated the bladder to form a stone. But because there is only one corner in the bladder, at the moment we are not clear where the body of the IUD is. So we asked the obstetrician and gynecologist to consult the hysteroscope, found an IUD inside, and removed it intact. At this time we consider an ectopic IUD in the pelvic cavity, so we in the cystoscope light guide, through the laparoscope found an ectopic IUD(Fig. 2). The other side is embedded in the muscular layer of the bladder and has not yet penetrated the bladder. In the literature reported previously, most of them were partial bladder resection under laparoscopy or open surgery, and the suture was performed after removing the IUD; We tried a new method after fully separating the IUD, straightening the ring laparoscopically and then removing it from the bladder through a cystoscope, thus avoiding suturing the bladder and achieving minimal trauma(Fig. 3). During the operation, we performed a bladder water injection test, indwelling F20 three-lumen catheter, and removed the catheter after the operation(Fig. 4). The patient recovered well without any complications(Fig. 5).

As the first-line contraceptive scheme recommended by the WHO, the intrauterine device is widely used worldwide due to its convenience, safety, low cost, long duration, and reversibility, and is the main contraceptive method for Chinese women [1, 2]. The intrauterine device may bring abdominal pain, dysmenorrhea, pelvic infection, and other adverse reactions, but the occurrence of complications such as ectopic IUD is less [3]. According to the literature, IUDs are common ectopic places with omentum (26.7%), Douglas 'pouch (21.5%), colonic cavity (10.4%), etc. Migration to the urinary system is rare [4], and ectopic IUD to the bladder complicated with bladder stones is even rarer [5]. Ectopic IUD lack characteristic performance, even without any symptoms, so sometimes can not be detected in time. Therefore, after the placement of the intrauterine device, should be done at least once a year for a gynecological examination, to understand if the position of the device is normal [6]. Diagnosis requires CT, cystoscopy or hysteroscopy, and other joint examinations. This patient visited the hospital due to hematuria, and we first thought of the possibility of a tumor. Ultrasound showed a high echo of the right wall of the bladder, considering bladder stones, which did not exclude the possibility of a bladder tumor or bladder blood clot. We then performed a cystoscopy but failed to find an ectopic IUD due to stone shielding. Unfortunately, we did not do further CT or X-rays.

There are a variety of treatments for ectopic IUDs to the bladder, and there is no absolute standard. Atakan et al. [7] reported on a patient who underwent an open suprapubic cystotomy to remove an ectopic IUD. Shin et al. [8] performed laparoscopic removal of the IUD from the ectopic bladder. Xiong et al. [9] showed that both laparoscopic and open surgery can successfully remove ectopic IUD and bladder stones, while laparoscopy brings less trauma and shorter hospital stay. However, partial cystectomy was performed regardless of the surgical approach, followed by suturing. We performed a new procedure that avoided suturing the bladder. We use a holmium laser through a cystoscope after breaking stones, under the guidance of a cystoscope light source, quickly find the position of the ectopic IUD through the laparoscope, and after full separation, we take the IUD out of the bladder through the cystoscope. There is no doubt that preoperative examination including CT, cystoscopy, hysteroscopy, etc. to fully evaluate the position of ectopic IUD is conducive to our development of a surgical plan [10].

In conclusion, we need to consider the rare complication of the ectopic bladder with IUD in women with hematuria and bladder stones; CT, cystoscopy and hysteroscopy can be used to make a clear diagnosis and guide the surgical strategy, and the combined treatment of double endoscopy can achieve the minimum trauma.

Consent for publication

Informed written consent was obtained from the patient for publication of this case report and any accompanying images.

Competing interests

No authors have disclosed any conflicts of interest.

Authors' contributions

Wenyang Pang: Conception and design of study, Acquisition of data, Drafting of manuscript; Zhongbo Du: clinical and interpretation; Shulin Cheng: review-editing & Supervision; All authors have read and approved the final version of the manuscript.

Funding

Not applicable.

Availability of data and materials:

All data generated or analysed during this study are included in this published article.

Ethics approval and consent to participate

Not applicable.

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No competing interests reported.

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Combined double-endoscopic treatment of intrauterine device ectopic bladder complicated with bladder calculi: a case report

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