# A Novel Use for the Rigid Cystoscope: The Removal of  Sacral Tacks after a Coloanal Anastamosis Dehiscence

Authors: W. Mahmalji; H. Mackenzie; A. Chopada; A. Raza
Journal: Advances in Urology
 (2009)

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## Abstract

A 69-year-old female presented as an emergency with atrial fibrillation, which was treated with warfarin. She subsequently developed fresh rectal bleeding and after further investigations a Dukes B adenocarcinoma of the rectum was found. She subsequently underwent a low anterior resection, coloanal anastamosis and a defunctioning ileostomy. Three sterile surgical metallic tacks (pins) were inserted into the sacrum to stop brisk bleeding from the presacral venous plexus. Following discharge, she was readmitted with septic shock and a CT scan revealed a presacral fluid collection in the area surrounding the sacral tacks (pins) and an anastamotic dehiscence. The patient was not fit for further pelvic surgery to remove the tacks, so an alternative minimally invasive cystoscopic procedure was performed. The sacral tacks (pins) were removed by the urologist using a rigid cystoscope and cold cup biopsy forceps. To our knowledge, this is the first reported case in the literature.


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## Body

## 1. Case Report

A 69-year-old Caucasian female presented as an emergency in November
2006 with atrial fibrillation, which was treated with warfarin. Within one
month, she developed fresh rectal bleeding. Her international normalised ratio  (INR) was 2.4. Her past medical history
included, type 2 diabetes, left renal calculi, and an anterior myocardial
infarction in 2001 (followed by a coronary angio-bypass graft). Subsequent
inpatient investigations revealed a Dukes B adenocarcinoma of the rectum 5 cm
from the anal verge. She underwent a low anterior resection, coloanal
anastamosis and a defunctioning ileostomy.
The procedure was complicated by presacral venous plexus haemorrhage. Attempts
to control the bleeding with packing and suturing were unsuccessful; three
sterile surgical metallic tacks (pins) were inserted into the sacrum to
compress the veins and stop the bleeding (Figure1). This successfully
controlled the haemorrhage and no transfusion was required.Figure 1
Computerised tomography (CT) scout film showing the placement of
the surgical tacks in the sacrum.After discharge
she was referred back to the surgical team with hypotension and a temperature of37.8°C. Her systolic blood
pressure was consistently below 90 mmHg, and she was tachycardic with a pulse
rate of 96 bpm. Examination revealed a purulent, foul smelling discharge oozing
from the drain site wound. The patient was oliguric. Initial blood tests showed
the following: white cell count, 22.1×109/L(3–10×109/L);
CRP, 16 mg/L (0–5 mg/L); sodium,
131 mmol/L (135–145 mmoL/L); Potassium,
8.8 mmoL/L (3.5–5.1 mmoL/L); urea
of 38.3 mmol/L (1.7–8.3 mmoL/L); creatinine
of 986 umoL/L (49–92 umoL/L). Arterial
blood gas sampling on room air revealed the following: pH, 7.197 (7.35–7.45); PCO2, 2.82 kPam; PaO2, 16.1 kPa; base excess −18.2 (−2 to 2); cHCO3 8.0.She was admitted
to the Intensive Care Unit (ICU) for haemofiltration for acute renal failure
and management of her septic shock. Intravenous cefuroxime and metronidazole antibiotics
were started. A CT of her abdomen and pelvis revealed a large 9.0 cm by 3.5 cm presacral
collection with flecks of gas. Her abdominal drain wound swab cultured methicillin-resistant
staphylococcus aureus (MRSA); linozolid was added to her antibiotic regimen.Her discharge from
ICU was followed by a transfer to the Coronary Care Unit (CCU) for palpitations
and increasing shortness of breath. An echocardiogram showed moderate to severe
left ventricular function and mitral regurgitation.She continued to
be treated conservatively for her pelvic collection and sepsis in CCU. Within
one month she became hypotensive and was readmitted to ICU for inotropic
support. Her worsening sepsis was
treated with tazocin, ciprofloxacin, and metronidazole, and the presacral
collection was drained under CT guidance. A rigid sigmoidoscopy showed pus
around the anastamosis, and a gastrografin enema revealed an anastamotic
leak. A colostomy was considered but
cancelled due to her poor cardiac function and breathlessness on minimal
exertion. Other contraindications to invasive surgery and a general anaesthetic
included a weight loss of 3.5 stone (24.5 Kg), ongoing sepsis and recurrent urinary
tract infections (UTI's). A CT Urogram (CT-IVU) was organised to investigate
her renal tract and recurrent urinary tract infections, this revealed left-sided
hydronephrosis and 3 cm by 1 cm presacral thick-walled collection around the
region of the surgical tacks (pins) in the sacrum. Attempts were made to
optimise her nutritional status and improve her sepsis prior to surgical
removal of the tacks, as it was felt they may be the underlying cause of her
sepsis.After a month she
was still unfit for major invasive surgery or a general anaesthetic. A decision
was made to remove the tacks through the rectum by passing a rigid cystoscope through
the anastamotic defect and removing these from the sacrum. She underwent an
examination under spinal anaesthesia. The sacral tacks (pins) were removed by
the urologist using a Storz 22 French standard rigid cystoscope with a30° lens. Normal
saline was used as irrigation fluid although the view was still slightly
restricted by the inflammatory tissue and some bleeding as the tacks (pins)
were removed. The tacks (pins) were identified by their gold colour. The tacks (pins)
were removed using a standard cold cup biopsy forceps. The edge of the circular
tack (pin) was difficult to pick up with the biopsy forceps and the pin had to
be levered of the sacrum by applying counter pressure on the sacrum (Figure 2).
All 3 tacks were successfully removed although the patient did feel some
discomfort during the procedure due to pressure on the sacrum during pin
removal. There was moderate oozing from the sacrum after the tacks were removed
and further haemostasis was achieved using a single strip of surgicell which
was left in the cavity.Figure 2
This is an illustration of the cold cut biopsy forceps passing
through the anastamotic defect, and removing the tacks in the sacrum.The patient made an
excellent recovery postprocedure, with improving infective and inflammatory
markers confirming resolution of the inflammatory response. The patient had a
follow-up CT scan of her abdomen on 24/10/2007 and although the presacral collection
improvement was minimal from a previous CT scan 4 months earlier (Figure3),
clinically the patient was much improved.(a) CT precystoscopic tack removal. Note the thick
walled presacral collection. (b) CT post cystoscopic tack removal. Although the improvement
in pre-sacral soft tissue thickening and fluid collection is minimal, the
patient was clinically much improved.
(a)(b)


## 2. Discussion

The use of the
rigid cystoscope in the anus and rectum has been described previously for closure
of genitourinary fistulae [1] and the resection of rectal villous
adenomas or adenocarcinomas [2, 3]. However this case is unique and is
the first reported case in the literature. The use of a rigid cystoscope to
remove the sacral tacks was possible using the cold cup biopsy forceps but
could have been made easier in retrospect if a Collins knife or perhaps a steel
wire basket had been used. This would have allowed the edge of the drawing pin
(tack) to be lifted of the sacrum more readily as the tack was well embedded
into the sacral bone. This case demonstrates how close cross surgical specialty
referral and team work can help solve an unusual problem in a patient not fit
for a general anaesthetic.



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