UROGENITAL IMAGING & CONTRAST MEDIA

Iran J Radiol. 2015 April; 12(2): e11303. DOI: 10.5812/iranjradiol.11303

Published online 2015 April 15. Case Report

Hanging Bladder calculi Secondary to Misplaced Surgical Suture

1,* 2
Ali Mahdavi ; Hasan Mostafavi
1Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran
2Department of Radiology, Iran University of Medical Sciences, Tehran, IR Iran

*Corresponding author: Ali Mahdavi, Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran. Tel: +98-9121508905, E-mail: [email protected]

Received: March 25, 2013; Revised: May 21, 2013; Accepted: June 3, 2013

Bladder calculi, a rare condition in the pediatric population, occur most commonly as a result of either migration from the kidney or
urinary stasis in the bladder. We report the case of a 3-year-old boy with recurrent urinary tract infections (UTI) secondary to bladder calculi
formation on the sutures from a previous herniorrhaphy.A 3-year-old boy with previous history of herniorrhaphy presented with recurrent
episodes of urinary tract infection, resistant to antibiotic therapy. Physical examination was unremarkable. Ultrasonography (US) showed
an echogenic fixed intra-luminal lesion in the bladder. Cystoscopic evaluation was performed and confirmed presence of calculi forming
around several permanent silk sutures fixed to the bladder wall. The patient undergone cystotomy and the calculi were resected. The stone
analysis revealed 80% uric acid calculi. The final diagnosis was of bladder calculi due to remnant suture from past herniorrhaphy.

Keywords:Urinary Bladder Calculi; Urinary Tract Infections; Sutures; Herniorrhaphy

1. Introduction
Bladder calculi, a rare condition in the pediatric popula- function. The physical examination was unremarkable.
tion, occur most commonly as a result of either migra- Dimercaptosuccinic acid (DMSA) scan showed no evi-
tion from the kidney or urinary stasis in the bladder. dence of renal parenchymal scarring. The patient had a
Previous pelvic or inguinal surgery with non-resorbable positive urine culture for P. aeruginosa. The serum blood
sutures, especially in the proximity of the bladder, may urea nitrogen (BUN) and creatinine levels were normal.
complicate with lithiasis, a starting point for recurrent The intravenous urography (IVU) only revealed duplica-
UTI. Here, we report a 3-year-old boy with previous his- tion of the right pyelocaliceal system. In the ultrasound
tory of herniorrhaphy presented with recurrent episodes (US) examination, multiple confluent linear echogenici-
of urinary tract infection, resistant to antibiotic therapy. ties (10-20mm) with posterior acoustic shadows, locat-
Physical examination was unremarkable. Ultrasonogra- ed inside the bladder and fixed to the antero-superior
phy (US) showed an echogenic fixed intra-luminal lesion wall during changes in patient position, were observed
in the bladder. Cystoscopic evaluation was performed (Figure 1 A). On color doppler US, a small vascular flow
and confirmed presence of calculi forming around sev- was observed in the posterior acoustic shadow, making
eral permanent silk sutures fixed to the bladder wall. it difficult to make the distinction between bladder tu-

2. Case Presentation
mor or stone aggregate with ring down artifact (Figure
1 B). Based on ultrasound results, cystoscopy was per-
A 3-year-old boy was referred to our hospital for evalu- formed to uncover the underlying cause, and the pres-
ation of recurrent urinary tract infection (UTI) since ence of multiple fixed calculi on the bladder dome was
about two and half years prior to admission. The patient confirmed. Transurethral resection of the calculi was
had undergone herniorrhaphy procedure when he was not possible and the patient underwent open cystos-
5 months old and he experienced the first episode of tomy, which revealed multiple bladder calculi forming
UTI just 1 month after the surgery. After that, he devel- around several permanent silk sutures fixed to the blad-
oped four additional episodes of UTI, requiring hospi- der wall (from the previous herniorrhaphy). These su-
talization and antibiotic therapy. Three months before tures had been aberrantly included in the bladder wall
admission in our center, he suffered from persistent UTI during the remote right herniorrhaphy, as a starting
with Pseudomonas aeruginosa (P. aeruginosa), resistant point for bladder stone formation (Figure 2). The blad-
to antibiotic therapy. Upon admission, the patient was der calculi were resected and analysis revealed 80% uric
a well-developed 3-year-old boy, with normal develop- acid composition. After surgery, the UTI resolved and
mental milestones, without urinary symptoms. He had the patient discharged from hospital with good condi-
several periods of fever and chills, without voiding dys- tion and negative urine culture.

Copyright 2015, Tehran University of Medical Sciences and Iranian Society of Radiology. This is an open-access article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the mate-
rial just in noncommercial usages, provided the original work is properly cited.
 Mahdavi A et al.

Figure 1. A 3-year-old boy with recurrent UTI and history of herniorrhaphy. A,B, Ultrasound exam revealed echogenic foci within bladder suspicious of
calculi

Figure 2. Urinary calculi formed around surgical sutures remnant within bladder wall

3. Discussion
Bladder stone is rare in the pediatric population. Blad- flammation, and these are known as "hanging" bladder
der calculi occur most commonly as a result of either stones (1). Foreign bodies, such as surgical sutures, may
migration from the kidney or urinary stasis in the blad- act as a leading point for developing bladder calculi.
der. Urinary stasis is usually related to bladder outlet These stones are typically non-mobile and present as
obstruction, cystocele, neurogenic bladder, or a foreign hanging fixed echogenicitie son US. On the other hand,
body in the bladder (1). Urinary tract stones and urinary herniorrhaphy is one of the most commonly performed
tract infection are strongly associated. Infection is impli- operations worldwide. Iatrogenic bladder injury is a rare
cated as the cause of stones in about 15% of stone form- complication of this surgery. Incorrect deep suturing or
ers, and the development of infection can complicate surgical mesh used in inguinal herniorrhaphy may in-
the management of preexistent calculi. Left untreated, volve the bladder wall and lumen, and intraluminal por-
both situations can result in loss of kidney function, tion can act as a nidus for stone formation (3, 4). Based
and may become, although rarely, life threatening con- on literature reviews, other surgical operations, such as
ditions (2). On US, a mobile, echogenic focus with distal extrophy repair (5), stress urinary incontinence surgery
acoustic shadowing will be seen in the bladder. If the (6), prostatectomy (7), caesarian section (8) etc., may
stone is large, edema of the ureteral orifices and thicken- also cause bladder stone formation due to application of
ing of the bladder wall may be seen. Occasionally, stones non-absorbable sutures, like silk sutures. Even though,
can adhere to the bladder wall because of adjacent in- most of these complications occur in adult population,

2 Iran J Radiol. 2015;12(2):e11303

 Mahdavi A et al.

the review of our patients medical history revealed the tumor, because of the focal doppler signal in the lesion.
etiology. As far as we know, it is the first pediatric case Nevertheless, one must be aware of the possibility of
of iatrogenic bladder calculi forming around the surgi- hanging stones or foreign bodies, especially in patients
cal sutures remnants. Here, we reported a 3-year-old boy with a positive history for previous surgery in the pelvi
who suffered from recurrent UTI with unknown origin, cor inguinal regions. Suture remnants in the bladder
beginning just after herniorrhaphy surgery. The underly- have an important role in recurrent cystolithiasis in ani-
ing etiology was underdiagnosed for about two and half mal studies (9). This case confirms the lithogenic nature
years. Finally, in our department, aberrantly positioned of non-absorbable sutures in contact with urine, in the
surgical sutures remnant into the bladder wall were dis- pediatric population. These stones are extremely prone
covered after cystostomy, as a nidus for stone formation to cause urinary infections and surgery is the mainstay of
and the cause of recurrent UTI. The differential diagnosis treatment for such infections. Stone removal is the goal
for multiple linear fixed echogenicities in the bladder, and a range of minimally invasive treatments are avail-
with posterior acoustic shadow, includes multiple blad- able (2). However, to avoid serious complications, sur-
der calculi, calcified bladder tumor, foreign bodies, blad- geons must be careful and to use absorbable sutures in
der wall inflammation and infection. Each of these can deep structures and also to take more attention to avoid
cause a mass like lesion in the bladder. Foreign bodies in bladder injury during nearby operations.
the bladder wall are extremely rare, and a careful review
of the patients medical history is necessary when foreign Acknowledgements
bodies are suspected. The patient underwent open surgi-
Special thanks to Dr. Hassan Otoukesh for his support
cal excision of the suture remnants and surrounding cal-
during this case report.
culi. After that, antibiotic therapy withheld and patients
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