A rendezvous technique using laparoscopy and cystoscopy to remove transmigrated intrauterine contraceptive device from abdomen and urinary bladder

Abstract

Intrauterine contraceptive devices (IUCDs) are the most commonly used reversible contraceptive methods. Uterine perforation followed by transmigration is a rare but potentially life-threatening complication associated with the use of IUCDs. Perforation of the bladder by an IUCD is extremely rare. We present the case of a 36-year-old woman with a 3-year history of IUCD placement presenting with symptoms of lower urinary tract infection. X-ray of the pelvis and hysteroscopy revealed an inverted T-shaped metallic shadow resembling an IUCD in the pelvis and an empty uterine cavity, respectively. Using a cystoscope, the IUCD was visualized embedded in the urinary bladder and its retrieval was attempted unsuccessfully with the cystoscope. Hence a rendezvous technique, in which laparoscopy, assisted with cystoscopy was performed. The vertical limb and half of the horizontal limb of the copper-T were retrieved from the outer wall of the urinary bladder laparoscopically, and the intravesical part of the horizontal limb along with the calculus was retrieved per urethra.

INTRODUCTION

Intrauterine contraceptive devices (IUCDs) are one of the most widely used reversible modes of contraception in India.[¹] Although it is relatively safe, complications such as IUCD expulsion, menorrhagia, cramps, ectopic pregnancy and uterine perforation have been reported.[¹²³] Uterine perforation is an uncommon complication of IUCDs and its incidence ranges from 0 to 1.6/1000 insertions.[³] Perforation and intravesical migration are extremely rare.[¹²³⁴⁵] In this report, we present a case of unusual uterine perforation by a copper-T that migrated to the peritoneal cavity and embedded into the bladder with subsequent calculus formation.

CASE REPORT

A 36-year-oldwoman presented to the gynaecologist with complaints of dysuria, lower abdominal discomfort and irregular menstruation for the past 7 months. The patient had three prior normal deliveries and her last childbirth was 9 years back. On clinical examination, there were no strands seen per vaginally. Her laboratory tests were normal with the exception of urinalysis, which showed pyuria. Plain X-ray of the abdomen showed an inverted T-shaped metallic shadow resembling an intact IUCD located in the pelvis [Figure 1a]. There was no additional imaging performed. The patient's past history revealed that she had undergone an IUCD placement by a trained gynaecologist about 3 years previously, but there had been no follow-up regarding the IUCD. She had undergone dilatationand curettage 7 months back for irregular menstruation, and the IUCD was assumed to have fallen out of the uterus.

Figure 1: (a) Plain X-Ray of the abdomen showing an inverted T-shaped metallic shadow resembling an IUCD located in the pelvis. (b) Cystoscopy view showing half of the horizontal limb of the Copper-T in the bladder with encrustation and stone formation.

As the X-ray was showing an intact IUCD in the pelvis, and since there were no strands seen per vaginally, thus the decision was made to retrieve it via hysteroscope. Hysteroscopy showed an empty uterine cavity. Due to non-visualisation of the IUCD in the uterus, and since the patient was having lower urinary tract symptoms, a cystoscopic examination was done in the same setting.

Cystoscopy revealed the encrusted half of the horizontal limb of copper-T in the urinary bladder which was embedded in the bladder wall [Figure 1b]. Initial attempts to retrieve the stone cystoscopically were unsuccessful. A diagnostic laparoscopy was performed to search for the rest of the IUCD. A 10-mm umbilical camera port with two 5-mm working ports on either side was placed. The uterus and bilateral adnexa were found to be normal. However, adhesions were found between the posterior wall of the bladder and the anterior wall of the uterus around the right cornu with surrounding omental adhesions [Figure 2a]. Adhesiolysis was performed and the copper-T, whose vertical limb and half of the horizontal limb were adherent to the bladder wall, was removed [Figure 2b]. The intravesical part of the horizontal limb of copper-T with the stone was extracted per urethra via cystoscope. The perforated site of the bladder was repaired with a 2-0 polyglactin suture.

Figure 2: (a) Adhesions between the posterior wall of bladder and anterior wall of uterus around the right cornu and omental adhesions around it. Red arrow showing the tip of half of the horizontal limb. (b) Vertical limb with the tail and half of the horizontal limb of the copper-T removed laparoscopically.

Her post-operative period was uneventful and was discharged on the 2^nd day with a Foley's catheter for 3 weeks.

The patient was called for follow-up after 3 weeks for Foley's catheter removal and again at 2 months. There was an improvement in her presenting complaints and no fresh symptoms. No abnormality was detected on clinical evaluation, and no follow-up imaging was performed.

DISCUSSION

Migration of the IUCD from its normal position in the uterine fundus is a frequently encountered complication, varying from uterine expulsion to displacement into the endometrial canal to uterine perforation.[⁶] Uterine perforation is an uncommon complication. 80% of uterine perforations are into the peritoneal cavity where it lies freely.[¹³] However, it might penetrate various organs such as omentum, rectum, sigmoid colon, appendix, urinary bladder, small bowel, iliac veins or even adnexa.[²] IUCD migration into adjacent organs has led to bowel obstruction and perforation, peritonitis, appendicitis, vesical calculus formation, menouria, obstructive nephropathy, fistula formation and intraperitoneal adhesions leading to infertility.[³⁴⁵]

Uterine perforation is the most serious complication of IUCDs and may occur either at the time of insertion or by gradual pressure necrosis of the uterine wall by the IUCD with eventual extrauterine migration.[³⁴]

A plain X-ray of the abdomen may be used for initial detection. Ultrasonography, computed tomography scan and magnetic resonance imaging can help to localise the devices more accurately.[²⁴] Cystoscopy is another means of visualising the intravesical IUD and may assist with removal.[⁵]

Cases of silent urological involvement in IUCD perforation have been reported.[³] In the present case, the development of urinary symptoms 4 years after IUCD insertion may be secondary to either the entrance of the copper-T into the bladder or the development of a calculus around the copper-T in the bladder.

Due to the rarity of bladder perforation by an IUCD, there may be a dilemma in the diagnosis. Furthermore, most of these cases have delayed presentation and are difficult to diagnose.[¹] Patients might present with mild-to-severe lower urinary tract symptoms.[¹⁵] In our case, the patient presented with repeated episodes of cystitis after 3 years of IUCD insertion, which were treated with antispasmodics and antibiotics.

The International Planned Parenthood Federation has recommended that all perforated IUCDs be immediately removed given the rare but potentially catastrophic consequences.[³] An IUCD perforating the bladder may be removed by suprapubic cystostomy or by cystoscopy.[³] In the present case, one of the horizontal limbs of the copper-T with encrusted vesical calculi was successfully removed by cystoscopy, and the rest of the IUCD was removed laparoscopically from the peritoneal cavity.

In conclusion, the possibility of intravesical perforation by IUCD should be considered although rare in a patient of migrated IUCD. After establishing the diagnosis by clinical and radiological methods, concomitant laparoscopy and cystoscopy can be a safe tool for localisation as well as removal of the migrated IUCD from the abdomen and urinary bladder.

Declaration of patient consent

The authors certify that they have obtained allappropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in thejournal. The patients understand that their names and initial s will not be published and due efforts will bemade to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.