Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 2  |  Page : 241-243  

Breakage of cystoscope sheath and detachment of metallic tip, a rare cystoscope dysfunction: A report of two occasions, one with retained metallic foreign body in urinary bladder


1 Department of Paediatric Surgery, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
2 Department of Surgery, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India

Date of Web Publication13-Mar-2015

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.153176

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  Abstract 

We present two cases of breakage of pediatric cystoscopy sheath, one leading to retention of the broken piece in the patient's bladder and the other occurring just before commencement of the procedure. The first child required a suprapubic retrieval of the foreign body leading to increased morbidity and hospital stay. This is a rare occurrence, which has not been previously reported in pediatric surgical literature. We present these two cases with an aim to increase awareness among pediatric urologists regarding such an occurrence.

Keywords: Cystoscope sheath breakage, detachment of tip, foreign body in urinary bladder


How to cite this article:
Handu AT, Patankar SS. Breakage of cystoscope sheath and detachment of metallic tip, a rare cystoscope dysfunction: A report of two occasions, one with retained metallic foreign body in urinary bladder. Med J DY Patil Univ 2015;8:241-3

How to cite this URL:
Handu AT, Patankar SS. Breakage of cystoscope sheath and detachment of metallic tip, a rare cystoscope dysfunction: A report of two occasions, one with retained metallic foreign body in urinary bladder. Med J DY Patil Univ [serial online] 2015 [cited 2020 Dec 1];8:241-3. Available from: https://www.mjdrdypu.org/text.asp?2015/8/2/241/153176


  Introduction Top


Cystoscopy is a commonly performed procedure in children. We are able to perform numerous diagnostic and therapeutic cystoscopy procedures even in neonates with availability of miniature cystoscopes and sheaths. At the same time, these instruments are prone to damage, wear and tear because of handling, disinfection procedures and instrumentation. [1],[2],[3] We here describe a very rare incidence where the metallic tip of cystoscope sheath got detached as foreign body in bladder. This occurrence is a potential catastrophic instrument dysfunction, which may require a complex, morbid corrective surgery.


  Case Reports Top


Case 1

Cystoscopy and valve ablation was done in an 18-month-old male child with posterior urethral valves (PUV) and bilateral vesicoureteric reflux. A 9.5 Fr Karl Storz cystoscope sheath with 30° Karl Storz telescope was used. Bladder wall, trigone and ureteric orifices were inspected and the cystoscope was gradually withdrawn into the prostatic urethra. Valve leaflets were seen arising from lower end of verumontanum. Valve leaflets were ablated at 4 and 7 O'clock position with help of Bugbee electrode introduced through the instrument channel. After confirming satisfactory ablation, the cystoscope was removed. We then noticed that the distal metallic tip of cystoscope sheath had got detached from the rest of the body and was missing. The distal 25 mm of the telescope was exposed [Figure 1]. A diagnostic cystourethroscopy was immediately done with a 7.5 Fr ureteroscope. The penile urethra was found to be normal. There was evidence of bleeding and clot formation in the bulbar and distal prostatic urethra. On flushing the loose clot, no serious injury, false passage or active bleeding was seen in the urethra. The detached metallic tip of the cystoscope sheath was found in bladder. The parents were made aware of the unexpected incident and consent for suprapubic cystostomy and removal of foreign body was taken. The metallic piece was removed by performing a suprapubic cystotomy and the bladder was closed in two layers. The metallic tip matched with the proximal part of the sheath [Figure 2]. The baby was kept catheterized for 5 days and discharged on the 6 th postoperative day. The patient is following with us and we have planned a check cystourethroscopy after 6 weeks.
Figure 1: Cystoscope sheath with detached metallic tip, the distal part of telescope is exposed

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Figure 2: Metallic tip matched with cystoscope sheath after removal

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Case 2

Cystoscopy and valve ablation was planned in a 6-month-old baby suspected to have PUV. Lithotomy position was given under general anesthesia. 9.5 Fr cystoscope sheath and 30° Karl Storz telescope had been kept in 2% glutaraldehyde solution for about 30 min before the procedure. While the scope and sheath were being assembled, we noted that the metallic tip of cystoscope sheath measuring about 25 mm had got detached from main body. The procedure was deferred and the parents were informed about the events.


  Discussion Top


We can perform numerous diagnostic and therapeutic cystoscopy procedures due to availability of pediatric and neonatal cystoscopes. These small equipments demand extra care and expertise, while storage, disinfection and performing procedures. The thin telescopes are prone to damage because of bending, stacking with other instruments or inadvertently putting a heavy object on it. [1],[2],[3] This may lead to loss of vision due to damage to optics. The cystoscope sheath is a sturdy outer covering, which protects the telescope, allows water flow for irrigation and passage of various instruments. Breakage or detachment of a part of pediatric cystoscope sheath is unique instrument dysfunction and has not been reported in literature. The probable reason for such breakage is "metal fatigue." [4] It is described as development of a tiny fracture or crack developing at weld line or junction of two metallic components. With stress of repeated use and sterilization, the crack widens until the two parts come apart.

Cystoscope sheaths in both the above mentioned incidences had been in use for about 4 years. They were used about 2 or 3 times a week for procedures like diagnostic cystoscopy, valve ablation, stent insertion or stent removal. Each time before use, the cystoscope and sheath were immersed in 2.4% activated gluteraldehyde solution (CIDEX® ) for at least 20 min and thereafter flushed thoroughly with normal saline. This is a standard method of disinfection recommended and allowed by manufacturers. [5] On close inspection of the cystoscope sheath, it was found that the sheath was made up of two parts. The proximal part consisted of the main body having channel for cystoscope, locking mechanism for telescope, instrumentation channel and two irrigation ports. The distal part was about 25 mm in length, having two lumens for the telescope and instrument. This part was attached to the main body of the sheath by a joint. In both cases, the metal tip had got detached at this particular joint placed in the distal portion of the sheath [Figure 3]. The protruding edges of the proximal portion after detachment of distal tip were extremely sharp and potentially traumatic.

Although cystoscope sheath breakage leading to foreign body in urinary tract is an extremely rare event, steps to localize and remove it should be taken promptly. Methods for localization and retrieval of such foreign body are individualized in each case. Intra-operative X-ray or screening with C- arm unit can be of great help. Cystoscopy with another cystoscope can also be a diagnostic and therapeutic tool. There are reports where such metallic foreign bodies are retrieved carefully after manipulating into a larger sheath. [4] However, the size of the urethra in children would not allow such maneuvers. The sharp edges of the retained metallic part could cause severe trauma if per-urethral removal is tried. Hence, we localized the detached tip in the bladder with cystoscopy and removed with suprapubic cystostomy.
Figure 3: Both the cystoscope sheaths with detached tips

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The metallic tip of the sheath in the first case probably got detached in the bladder while we were inspecting bladder and ureteric orifices. The urethral injury was inflicted by the sharp edge of the proximal part of the sheath, while doing valve ablation. It was evident by noting some bleeding in the prostatic urethral region. Had the tip got detached in the urethra, retrieving it would have been very difficult and would have required a very complex and morbid urethral surgery. Fortunately in the second case, the tip got detached before commencement of the procedure and further catastrophic event was avoided.

The unexpected complication in both these babies had led to increased morbidity, parental anxiety and increased expenses due to prolonged hospital stay. The first baby had required an additional surgical procedure. This baby would require a follow-up micturating cysto-urethrogram and a check cystoscopy to rule out any urethral injury. The cystoscopy would be planned later in the second child once the new cystoscope sheath is procured. We have communicated with the manufacturer of the sheath regarding these events and suggested to modify the design. We have inquired whether it is technically possible to exclude the joint in distal portion of the sheath and manufacture it as a single structure. This would prevent such an occurrence in the future. It is recommended that before performing any cystoscopy, the surgeon should check the cystoscope for any loose joints to prevent such an occurrence during the procedure.

 
  References Top

1.
Urology overview: Part II, cystoscope processing and handling procedures. Available from: https://www.distance.purdue.edu/training/cssp/cis/pdf/CIS239.pdf. [Last accessed on 2014 May 16].  Back to cited text no. 1
    
2.
Quick Reference Handling and Cleaning Guide for Karl Storz Rigid Endoscopes. Available from: http://www.austvetendoscopy.com.au/files/Karl Storz Cleaning Guide.pdf. [Last accessed on 2014 May 16].  Back to cited text no. 2
    
3.
Peter LD, Tan PK. Cystourethroscopic instrumentation and equipment. In: Peter LD, editor. Atlas of Urogynecological Endoscopy. Informa UK Ltd; 2007. p. 18-9.  Back to cited text no. 3
    
4.
Fernandez A, Pautler SE. Metal fatigue causing cystoscope rupture during bladder neck incision. JSLS 2011;15:421-3.  Back to cited text no. 4
    
5.
General reprocessing instructions for KARL STORZ products (USA). Available from: http://www.urologicservices.com/documentation/karl-storz-general-reprocessing-instructions.pdf. [Last accessed on 2014 May 16].  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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