The Surgical Blade as an Uncommon Foreign Body Retained In the Urinary Bladder: A Case Report and Review of Literature

Our patient presented with an incidental finding of a retained foreign body (surgical blade) in the urinary bladder following open suprapubic cystostomy. Iatrogenic surgical causes of retained intravesical foreign bodies, as seen in our patient, are common complications encountered in surgical practice [1]. They may follow simple surgical procedures such as urethral catheterization using Foley catheter or open suprapubic cystostomy to more complex procedures such as transvesical prostatectomy and endoscopic procedures on the bladder. Bansal et al found parts of Foley catheters in four patients who previously had transurethral resection of the prostate, one patient who had transurethral resection of a bladder tumour and two patients who had open prostatectomy, with all iatrogenic causes accounting for 40.8% in their study [1]. Forgotten double J-stents, which later got calcified over time and presented as bladder stones have also been reported. Amu et al in Enugu Nigeria reported a case of a bladder stone with an embedded scalpel blade in an 84-year-old man who had open radical prostatectomy for early prostate cancer 10 years prior to presentation [15]. Other reported sources of intravesical FBs include self-insertion for sexual gratification or in psychiatric conditions, and sexual abuse [1,7,11-16].

We had cause to believe that the surgical blade was inadvertently left in the bladder of our patient during the emergency suprapubic cystostomy he had to relieve his acute urinary retention after a failed urethral catheterization. It is possible that several sizes of surgical blades were tried in the course of the procedure and one probably found its way into the bladder unnoticed. Sadly, for the blade to detach from the scalpel without being noticed by the surgeon, or the assistant or perioperative nurse amounted to gross negligence and poor adherence to such simple surgical principle as instrument count after open surgery [23]. It has been suggested that FBs were more likely to be inadvertently forgotten during emergency surgical procedures than in elective cases, and even more so when a life-threatening complication like an uncontrolled bleeding develop during surgery and there is need to hasten the surgery [17,23,24].

Patients with retained intravesical FB often present with severe lower abdominal/pelvic pain, haematuria, urinary frequency, dysuria, bladder irritation and symptoms that mimic urinary tract infection (UTI). Bansal et al reported that 67.3% of their patients presented with haematuria, 59.1% with urinary frequency and dysuria, 10.2% with pelvic pain and 6.1% with urinary retention [1]. Our patient presented with a history of severe suprapubic pain and haematuria, in addition to the background symptoms of BPH which he had and which necessitated the suprapubic cystostomy. These symptoms are consistent with those recorded by previous researchers and are thought to be due to the constant irritation of the bladder mucosa by the retained sharp blade [2,3,8,16]. Diagnosis was made in our patient through imaging evaluation with ultrasonography and plain X-rays of the pelvis. In iatrogenic cases and in situations where it is difficult to obtain a suggestive history from the patient, diagnosis is often made as an incidental finding, as was the case in our patient. X-ray imaging may reveal opaque FBs while other FBs may be detected through ultrasound scan, CT scan or MRI [16-20]. Apart from causing irritative bladder symptoms and bleeding, the size 23-surgical blade can become a focus for stone formation over time as reported by other researchers [14,20]. Elbashir et al in Khartoum Sudan reported a case of stone formation with a sewing needle in the bladder as a nidus [25]. Similarly, Makkawi et al also in Sudan reported a case of a giant urinary bladder stone formed around a pin in a young girl [26]. Our patient had the retained surgical blade removed during an elective transvesical prostatectomy for his BPH. The foreign body could also have been removed through the already existing suprapubic cystostomy or endoscopically by cystourethroscopy.

We could not identify or relate with the “culprit” surgeon because our patient was not willing to provide further details about the surgeon. Instead, he considered the successful outcome of the prostatectomy more important than the detected retained surgical blade.