title: Intravesical Hemostatic Clip Migration After Robotic Prostatectomy: Case Series and Review of the Literature.
abstract: BACKGROUND
  The Weck Hem-o-lok™ Ligating clip is a routinely used hemostatic tool in robotic and laparoscopic surgery. It has been the practice in our institution to use such clips for hemostasis of the vascular bundles during robotic prostatectomy. Migration of such clips has been reported in the literature as single case reports. In this study, we present a case series of intravesical Weck clip extrusions presenting as bladder calculi. Such events have led to a change in our practice, and more research is needed to assess the impact of this change.
  
  
  METHODS
  A retrospective chart review was conducted over the period 2006-2011. Patients included in the study required cystoscopic intervention for removal of encrusted or impacted Weck clips. Primary data points included type of intervention required, time to presentation, and number of presentations. Postoperative anastomotic leak, duration of postoperative hospital stay, and initial operative time were also investigated.
  
  
  RESULTS
  Out of 570 total men undergoing robotic-assisted laparoscopic radical prostatectomy (RALRP), eight required return to the operating room for clip extraction (1.4%). Extraction methods included laser lithotripsy, blunt litholapaxy, and grasper extraction. Men experiencing clip migration were hospitalized for a longer period of time (7.6 days vs. 2.1 days, P < .01) and they required more blood transfusions (1.4 units vs. 0.05 units, P < .01) than men who did not experience clip migration. The most common site for clip intrusion was the bladder neck. Average time to presentation was 1.75 years.
  
  
  CONCLUSIONS
  Weck clip migration is a recognized complication of robotic-assisted radical prostatectomy. Men with recurrent urinary tract infection, bothersome voiding symptoms, or hematuria following RALRP should be considered for cystoscopic evaluation. Increased length of hospital stays and the need for a larger volume blood transfusion following prostatectomy were significant predictors of clip migration. More research is needed to determine if implemented changes to our surgical technique have mitigated these risks.
authors.affiliation: Minimally Invasive Urologic Institute, The Miriam Hospital, Alpert Medical School of Brown University , Providence, Rhode Island.
authors.forename: George A
authors.initials: GA
authors.lastname: Turini
authors.affiliation: Minimally Invasive Urologic Institute, The Miriam Hospital, Alpert Medical School of Brown University , Providence, Rhode Island.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Brito
authors.affiliation: Minimally Invasive Urologic Institute, The Miriam Hospital, Alpert Medical School of Brown University , Providence, Rhode Island.
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Leone
authors.affiliation: Minimally Invasive Urologic Institute, The Miriam Hospital, Alpert Medical School of Brown University , Providence, Rhode Island.
authors.forename: Dragan
authors.initials: D
authors.lastname: Golijanin
authors.affiliation: Minimally Invasive Urologic Institute, The Miriam Hospital, Alpert Medical School of Brown University , Providence, Rhode Island.
authors.forename: E Bradley
authors.initials: EB
authors.lastname: Miller
authors.affiliation: Minimally Invasive Urologic Institute, The Miriam Hospital, Alpert Medical School of Brown University , Providence, Rhode Island.
authors.forename: Gyan
authors.initials: G
authors.lastname: Pareek
authors.affiliation: Minimally Invasive Urologic Institute, The Miriam Hospital, Alpert Medical School of Brown University , Providence, Rhode Island.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Renzulli
mesh_terms: D005547:Foreign Bodies / Q000209:etiology* / Q000601:surgery; D006417:Hematuria / Q000209:etiology; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011468:Prostatectomy / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D011471:Prostatic Neoplasms / Q000601:surgery; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000009:adverse effects* / Q000295:instrumentation; D013525:Surgical Instruments / Q000009:adverse effects*; D001743:Urinary Bladder; D014552:Urinary Tract Infections / Q000209:etiology