The urethra is approximately 20 cm in men and 4 cm in women. In men, it is broadly classified into the anterior (penile and bulbar) and posterior urethra (membranous and prostatic part). There are natural urethral curvatures at the bulbo-membranous junction and peno-bulbar junction. The bulbar urethra curves anterior beginning at the peno-bulbar junction and is sometimes challenging to negotiate on cystoscopy. The uniqueness of our case is that this long rigid foreign body has negotiated these normal curvatures and bends of the urethra and has traversed the whole length of it to lodge in the urinary bladder without causing any significant damage.
Various treatment approaches have been reported for the treatment of bladder foreign bodies, for example, endoscopic, laparoscopic, percutaneous, radiological, open surgery or combination approach and various techniques using retrieval baskets, laser haven been described6. However, still, endoscopic extraction is the preferred approach among urologists. The method of choice for extraction depends on the size and mobility of the object inside the bladder1. In addition, the availability of instrumentations and urologist experience plays an important role. A wide range of grasping armamentarium may be required including stone basket, grasping forceps, stone punch, snares and other modified instruments. Satisfactory success rate for cystoscopic extraction of bladder foreign bodies was reported in literature ranging between 60% and 94%6,7,8.
Most large foreign bodies in the bladder are treated by surgical exploration in the past either due to their long size with increased liability to perforate or the formation of a large bladder stone over a neglected foreign body that requires open cystolithotomy. However, endoscopy was successfully used in the extraction of the ball-point pen and avoided the need for an open procedure. The challenges that we faced during endoscopic extraction are: 1) the sharp end of the pen appeared to be penetrating the bladder wall but during cystoscopy, the pen was mobile freely inside the bladder with no evidence of penetrating injury 2) the wide diameter of the pen which made it very difficult to hold by the routine grasper instruments 3) The plastic nature of the pen made it slippery to hold with a bi-prongs grasper and required multiple attempts to hold the tip firmly with a tri-prongs grasper. 4) the long length of the pen posed a constant risk of injury to the bladder and urethra during the entire procedure and only with careful maneuvering we could successfully extract the pen in toto. 5) Check cystoscopy was normal except for few small insignificant mucosal tears in the urethra and per-urethral catheterization was done. The post-operative period was uneventful and the catheter was removed on the third postoperative day and the patient was discharged. On follow-up, the patient is voiding well without any difficulty. Ultrasound and uroflowmetry findings are normal.