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On Mar 24, 2016 12:52 AM guyfergy wrote:

On Nov 11, 2013 10:42 AM DEB57 wrote:

To all Post robotic surgery patients

Another serious complication that can develop - robotic prostatectomy patients should be aware - is from the clips that are used in most of these operations. Along with many of my other post surgical complications, this recent one was never foreshadowed as a possibility before my surgery.

I've recently had yet another invasive medical procedure, the third since my prostatectomy on 1 September 2010, to rectify this latest complication. This latest side effect is called surgical clip migration.

Surgical clips are used extensively in robotic and laproscopic surgery procedures. They are applied to, and clamped over vessels and arteries to seal them so the surgeon can cut the downstream side of the vessel or artery. They are quick to apply and offer an efficient option when performing robotic or laproscopic surgery. Complications can arise if they are applied incorrectly, in a position within the body that encourages migration. This outcome is well documented and occurs more frequently than you might think.

One of these surgical clips made its way through the wall of my bladder near the anastomosis, it was finally detected when it was about 40% into the bladder with 60% still firmly embedded in my bladder wall, and it is thought there may be another clip on a similar mission at the rear of my bladder. A bulge in the bladder wall is clearly visible on scans although the suspected clip has not yet penetrated the mucosa.

Hem-o-lok surgical clips are made of polymer, come in various sizes and are radiolucent: they cannot be seen using Xray CT scan imaging, nor can they be detected by MRI imaging as they do not contain hydrogen. This unique property of a surgical device used in the body with known causes in complications amazes me.

I have been informed that I had 24 Hem-o-lok surgical clips used in my robotic prostatectomy, and I was billed for them. I have since consulted another urologist who told me he uses an average of six to eight clips per robotic prostatectomy. The Hem-o-lok surgical clip detail that was used in my surgery is part No 544240 (large) and is white in colour as can be seen by the photo image of the clip removed from my bladder on 11 October 2013.

My post-surgical symptoms after my prostatectomy in 2010 were dominated initially by those caused by hip ligament and pudendal nerve damage. The diagnosis attributed this damage to the Trendelenburg position my body was placed in during robotic surgery.

Along with the resulting peroneal pain, I had urge and stress incontinence, nocturnal enuresis and a restricted urinary flow. The pain in my lower abdomen was extensive and, at that time, it was thought the pudendal nerve was the main cause of the pain, and that bladder nerve damage was triggering the incontinence issues. I had CT scans, MRI scan and an Ultrasound scan of my bladder and all of them showed it to be normal.

Ditropan was prescribed at the 12 month mark (after my prostatectomy) by the surgeon and for a very short time my symptoms seemed to be settling, but at about 18 months post surgery my symptoms began to get much worse, even with Ditropan being taken regularly.

The original urge to urinate that I'd experienced virtually since my initial surgery, was replaced by an ever increasing pain that I can best describe as a dull ache when my bladder was empty, converting to a sharp stabbing pain when my bladder was near full. If I tried to tolerate this sharp pain for long, the urinary sphincter would open involuntarily.

I seemed to be a medical mystery: I was described as a 'one in four year patient' and I had no medically identifiable issues to fix. I thought all my debilitating symptoms must have been a result of my body simply not being able to cope with major surgery.

In May 2013, 32 months post surgery, these symptoms were causing me to lose around three hours sleep each night. Typically, twice each night I would be woken by the pain associated with my filling bladder, and then unable to return to sleep for around an hour because of a different pain which resulted from emptying my bladder.

I researched the internet looking for causes of bladder pain and came upon the article from the Korean Journal of Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ "" target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ " target="_blank" rel="nofollow">Urologyhttp://www.kjurology.org/DOIx.php?id=10.4111/ kju.2010.51.10.683.

Part of its 'conclusions' fairly much sums up the problems associated with surgical clips;

“CONCLUSIONS

It appears that surgical clips are prone to migration and may cause, or significantly contribute to, BNC or the formation of bladder stones after radical prostatectomy. These findings raise questions regarding the use of foreign bodies in close proximity to the vesicourethral anastomosis during radical prostatectomy. At the very least, they indicate that care must be taken with the surgical clips used for inducing hemostasis near the apex of the prostate in radical prostatectomy. In addition, because the incidence of BNC after RALP is low, when unexplained voiding difficulty occurs after RALP, one should suspect that a Hem-o-lok clip has migrated, especially because Hem-o-lok clips cannot be detected on X-rays.”

I was amazed that I had similar symptoms to those described in this article and quickly raised the question with my GP and a urologist. A new Ultrasound was done on my bladder in early July 2013 and identified a post surgical aetiology (medical description) near the left ureteric jet close to the sphincter. At last I seemed to have an answer.

Dr Peter Swindle in Brisbane, carried out a flexible cystoscopy to identify the object and later a rigid cystoscopy to remove what turned out to be the clip. My relief the next day was obvious. Although I was very sore from the cystoscope and afraid to urinate whilst standing due to a nasty sting, the bladder pains were finally gone.

After three years of relying on pain as a signal that it is time to urinate and empty my bladder, now that the pain is gone I have no recognisable 'full bladder' signal at all. Instead I have to remember to regularly empty my bladder to avoid ending up in a very damp and embarrassing mishap. Hopefully as my body repairs and readjusts, the painless signals of my past will return.

Now, I can look forward finally, and I'm hoping that this resolution of chronic bladder pain will accelerate my very slow recovery in sexual function, which was recently scored at 14 compared to a normal pre-prostatectomy score of 25.

If anyone has strange symptoms like mine that seem to defy answers and wants more information, I'll be happy for them to contact me.

DEB57

Can you tell me where you got help about the clip, maybe a doctors name? I have some sort of lump inside me on the pelvic floor that when pressed causes extreme pain. My radical prostatectomy was back on 2012 and I have been in pain ever since. After more than 3 years I found someone who thinks it's pudendal neralgia and they are talking about installling a nerostimulator inside me. I have been suspicious that there is a clip that migrated and they did an MRI and said there isn't a clip. Now I read that they can't see the clip in an MRI. Can you help me out witha doctor or hospital that you got help from.

Two weeks ago I had four hem-o-lok clips removed using cystoscopy (don't know whether a rigid device was required however).  They were placed during a robotic assisted laparoscopic radical prostatectomy I had in December of 2015.  Had severe pain, only when I moved, for 16 months.  DRE's by five MD's did not find the clip embedded in the anastomosis much less the three embedded in my bladder.  All MDs said the pain would go away and that I should exercise.  Any exercise hurt.  I had a fantastic PT that discovered one clip while trying to massage what was thought to be fibrous/scar tissue or adhesions of some degree.  Get a cystoscopy done.  Tell the doctor to look for more than one clip.  My relief was immediate, like a switch was turned off.  No more pain at all!  Still working on continence issues, but that seems to be getting better.  If the first MD won't do a cystoscopy, keep going until you find one that will.  You don't even need general anaesthesia.  Carefully consider the value of an MRI in this case.  All the radiologist could say prior to my cystoscope was that the MRI showed "post surgical" changes.  I know what you are experiencing. Best of luck to you.

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