Removal of intramural trapped intrauterine device by cystoscopic incision of bladder wall

Abstract

A healthy 37 - year - old woman referred to our clinic with one - year history of recurrent urinary tract infection, dysuria and frequency. Her past medical history informed us that an IUD (Copper TCu380A) had been inserted 11 years ago. Eleven months after the IUD insertion she had become pregnant, unexpectedly. At that time, she had undergone gynecological examination and abdominal ultrasound study. However, the IUD had not been found, and the gynecologist had made the diagnosis of spontaneous fall out of the IUD. She had experienced normal pregnancy and caesarian section with no complications. On physical examination, pelvic examination was normal and no other abnormalities were noted. Urinalysis revealed microhematuria and pyuria. Urine culture was positive for Escherichia coli. Ultrasound study revealed a calculus of about 10 mm in the bladder with a hyperdense lesion. A plain abdominal radiograph was requested which showed a metallic foreign body in the pelvis. We failed to remove the IUD by cystoscopic forceps because it had strongly invaded into the uterine and bladder wall. Despite previous papers suggesting open or laparoscopic surgeries in this situation ( 1 , 2 ), we performed a modified cystoscopic extraction technique. We made a superficial cut in the bladder mucosa and muscle with J - hook monopolar electrocautery and extracted it completely with gentle traction. This technique can decrease the indication of open or laparoscopic surgery for extraction of intravesical IUDs. In the other side of the coin, this technique may increase the risk of uterovesical fistula. Therefore, the depth of incision is important and the surgeon should cut the bladder wall superficially with caution. Although present study is a case report which is normally classified as with low level of evidence, it seems that our modified cystoscopic extraction technique is a safe and useful method for extraction of partially intravesical IUDs.

Gross Hematuria Caused by Intravesical Migration of a Forgotten Intrauterine Device: A Case Report and Literature Review

“…However, unless the extraction is performed by experienced hands, the risk of urine leak and uterovesical fistula can be significant. 1,3,8,17 In our patient, a trial of cystoscopic removal was unsuccessful due to tight local adhesion, and hence an open trans-vesical removal was performed.…”

“…In such cases, a contrast-enhanced CT scan is recommended to define the device orientation and possible local attachment. 1 , 16 , 17 …”

“…Neglected cases might end up in severe morbidity and complex lower urinary tract reconstruction procedures. 12 , 17 The management of an intravesical IUD can be variable depending on many factors. Cystoscopy-guided removal is often employed in a complete intravesical migration of IUD.…”

“…A thorough contraceptive history should not be overlooked in any patient with recurrent UTI and hematuria. 12 , 17 …”

“…In such cases, a contrast-enhanced CT scan is recommended to define the device orientation and possible local attachment. 1,16,17 Table 1 Types of IUD-Related Uterine Perforations Based on the Extent of Device Migration. 16…”