Holmium laser-assisted endoscopic extraction of a fishhook from the male urethra at SciVerse ScienceDirect Urological Science 23 (2012) 64e66 Contents lists available Urological Science journal homepage: www.urol-sci.com Case report Holmium laser-assisted endoscopic extraction of a fishhook from the male urethra Hui-Ming Chung a,*, Sheng-Hsuan Chen b a Department of Urology, Mennonite Christian Hospital, Hualien, Taiwan b Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan Open access under CC BY-NC-ND license. a r t i c l e i n f o Article history: Received 6 October 2010 Received in revised form 23 December 2010 Accepted 18 April 2011 Available online 9 May 2012 Keywords: endoscopy fishhook holmium laser male urethra * Corresponding author. Department of Urology, M 44 Min-Chuan Road, Hualien 970, Taiwan. E-mail address: hchung@jhsph.edu (H.-M. Chung) 1879-5226 Copyright � 2012, Taiwan Urological Asso doi:10.1016/j.urols.2012.03.003 a b s t r a c t A man 37 years of age presented with frequency and dysuria. Rigid cystoscopy revealed the presence of a fishhook in the anterior urethra. Initial attempts to remove the fishhook in one piece by forceps or a basket were unsuccessful. The fishhook was cut into two pieces using a holmium laser via a 9-Fr ureteroscope and removed by forceps. The anterior urethra experienced a minor tear during the procedure. He voided well without significant urethral stricture 6 months postoperatively. An open urethrotomy is usually indicated for unsuccessful endoscopic removal of foreign bodies from the male urethra, which often leads to recurrent urethral stricture. The novel use of a holmium laser to facilitate the endoscopic removal of a fishhook from the male urethra may reduce the risk of postoperative urethral stricture. Copyright � 2012, Taiwan Urological Association. Published by Elsevier Taiwan LLC. 1. Introduction Various kinds of foreign bodies lodged in the male urethra have been reported, and the management of such cases can be chal- lenging for urologists. First-line treatment is endoscopic extraction of the foreign body. However, the restricted space of the male urethra makes it very difficult for endoscopic instruments, such as forceps or baskets, to effectively remove a foreign body. Open surgery is indicated when endoscopic extraction is unsuccessful, which often leads to significant urethral stricture or a fistula postoperatively. We herein report the successful use of a holmium laser to facilitate endoscopic extraction of a fishhook lodged in a male urethra. 2. Case report A man 37 years of age presented to the emergency department of our institution (Mennonite Christian Hospital, Hualien, Taiwan). He had experienced dysuria and frequency for several days. On physical examination, there was a palpable mass within the ante- rior part of the urethra. Initial renal ultrasonography showed hydronephrosis of the right kidney, but the plain abdominal film failed to reveal any ureteral stones. An abdominal computed tomographic (CT) scan showed calcified material in the anterior urethra (Fig.1) and a radiolucent stone in the right distal ureter. The ennonite Christian Hospital, . ciation. Published by Elsevier Taiw patient was not married, and his socioeconomic status was of a lower class. He had a history of mental retardation but no medical diseases. Laboratory data showed that complete blood counts and blood biochemistry tests were within normal limits. Urinalysis revealed hematuria and pyuria. The patient was subjected to an endoscopic procedure under general anesthesia in the operating room. With a 22-Fr cystoscope, a fishhook was found in the urethra (Fig. 2). Initial attempts were made to remove the fishhook in one piece by forceps or a basket; however, they were unsuccessful because the hook was snagged in the urethra. The fishhook was then cut into two pieces using a holmium laser (with a pulse energy of 0.8 J and a pulse rate of 8 Hz) via a 9-Fr ureteroscope, and the fragments were removed with forceps using a 22-Fr cystoscope (Fig. 3). The anterior urethra experienced a minor tear during the procedure. A urethral catheter was put in place to prevent post- operative urethral stricture. After the surgery, we attempted to determine how and when the fishhook became lodged in the urethra. However, neither the patient nor his caregivers could provide any meaningful information on this issue. The patient was discharged after the urethral catheter was removed on post- operative day 8. The patient was doing well with a normal uroflow rate at the 6-month postoperative follow-up. 3. Discussion Although rare, various kinds of foreign bodies in the male urethra have been described in the literature, including ballpoint pens, wires, Allen keys, and pins.1e4 The clinical presentation may vary from asymptomatic to swelling of the external genitalia, an LLC. Open access under CC BY-NC-ND license. mailto:hchung@jhsph.edu www.sciencedirect.com/science/journal/18795226 http://www.urol-sci.com http://dx.doi.org/10.1016/j.urols.2012.03.003 http://dx.doi.org/10.1016/j.urols.2012.03.003 http://dx.doi.org/10.1016/j.urols.2012.03.003 http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ Fig. 1. Computed tomography scan showing calcified material in the male urethra. Fig. 3. Realigned fragments of the fishhook. H.-M. Chung, S.-H. Chen / Urological Science 23 (2012) 64e66 65 dysuria, urethral discharge, and urinary tract infection. The most commonly reported reasons for self-inflicted foreign bodies in the male urethra are of an erotic or sexual nature, especially sexual gratification or masturbation, a mental illness, or drug intoxica- tion.3 The patient in this case had a history of mental retardation, but it was not clear whether the fishhook was inserted by himself or by someone else. The composition, size, and origin of foreign bodies in the male urethra differ greatly, but the treatment is similar with endoscopic extraction the first-line treatment. Sometimes, a foreign body can be pushed back into the urinary bladder and grasped by forceps or a retrieval basket.2 In this patient, it was impossible because the fishhook was snagged in the urethra. An open urethrotomy is Fig. 2. Cystoscopy revealed that a fish indicated in cases where endoscopic procedures are unsuccessful, which often leads to urethral stricture or a fistula.5 We tried a novel approach using a holmium laser to facilitate removal of the fish- hook. Because this method is less traumatic, we hoped to avoid an open urethrotomy and possible urethral stricture. Although it is possible that a high-energy laser can cause thermal injury to the urethra, the risk can be minimized with meticulous manipulation of the endoscopic procedure. In this case, the patient had a smooth recovery with no urethral stricture or fistula during the 6-month postoperative follow-up period. Holmium lasers are used primarily for lithotripsy, but they are also used to cut soft tissues or tumors; however, the mechanisms differ. The holmium laser is highly absorbed by water. Because tissues are composed mainly of water, the majority of the holmium laser energy is absorbed superficially, which results in superficial cutting or ablation. By contrast, the holmium laser can cut through hook was snagged in the urethra. H.-M. Chung, S.-H. Chen / Urological Science 23 (2012) 64e6666 metal and cause stone evaporation primarily through a photo- thermal mechanism.6 Recently, some authors demonstrated the effectiveness and safety of using a holmium laser to cut large or complex foreign bodies in vitro and within the human urinary bladder.6,7 However, the restricted space in the urethra makes it more challenging for endoscopic extraction. It is recommended that treatment be commenced with low-pulse energy (e.g., 0.6 J) with a pulse rate of 6 Hz and that the pulse frequency be increased as needed to facilitate treatment.8 To the best of our knowledge, this is one of the earliest reported cases using a holmium laser to facilitate endoscopic removal of a foreign body from the male urethra. Other than a holmium laser, there are currently no other endoscopic tools that can cut a fish- hook in a male urethra, as we did in this case. We recommend that holmium lasers be considered in endoscopic extraction of foreign bodies from the male urethra. Conflicts of interest statement The authors declare that they have no financial or non-financial conflicts of interest related to the subject matter or materials dis- cussed in the manuscript. Source of funding Mennonite Christian Hospital, Hualien, Taiwan. References 1. Forde JC, Casey RG, Grainger R. An unusual penpal: case report and literature review of posterior urethral injuries secondary to foreign body insertion. Can J Urol 2009;16:4757e9. 2. Mitterberger M, Peschel R, Frauscher F, Pinggera GM. Allen key completely in male urethra: a case report. Cases J 2009;2:7408. 3. Stravodimos KG, Koritsiadis G, Koutalellis G. Electrical wire as a foreign body in a male urethra: a case report. J Med Case Reports 2009;3:49. 4. Gokce G, Topsakal K, Ayan S, Kilicarslan H, Gokce SF, Gultekin EY. Case report: nonobstructive giant urethral stone with two safety pins. Int Urol Nephrol 2004;36:65e6. 5. Frenkl TL, Rackley RR, Vasavada SP, Goldman HB. Management of iatrogenic foreign bodies of the bladder and urethra following pelvic floor surgery. Neu- rourol Urodyn 2008;27:491e5. 6. Wyatt J, Hammontree LN. Use of Holmium:YAG laser to facilitate removal of intravesical foreign bodies. J Endourol 2006;20:672e4. 7. Bedke J, Kruck S, Schilling D, Matter A, Horstmann M, Sievert KD, et al. Laser fragmentation of foreign bodies in the urinary tract: an in vitro study and clinical application. World J Urol 2010;28:177e80. 8. Spore SS, Teichman JM, Corbin NS, Champion PC, Williamson EA, Glickman RD. Holmium:YAG lithotripsy: optimal power settings. J Endourol 1999;13:559e66. Holmium laser-assisted endoscopic extraction of a fishhook from the male urethra 1. Introduction 2. Case report 3. Discussion Conflicts of interest statement Source of funding References