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Postinfrapubectomy extruded Bone wax as cause of recurrent urethral polyp formation after progressive perineal urethroplasty: a rare scenario
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  1. Shrawan Kumar Singh,
  2. Kapil Chaudhary,
  3. Shantanu Tyagi and
  4. Jeni Elizabeth Mathew
  1. Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
  1. Correspondence to Dr Shantanu Tyagi; metyagishantanu{at}gmail.com

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Description

A 36-year-old man, with a history of pelvic fracture with urethral distraction defect (PFUDD) and failed progressive perineal urethroplasty (PPU), presented with per urethral discharge and splaying of the urinary stream. On endo assessment, near-complete obliteration of urethral lumen with mucosal polyps was noted at the anastomotic site (figure 1A). The patient underwent Holmium:Yttrium Aluminum Garnet laser-assisted ablation of the polyp and underlying fibrous scar. While ablating the base of the polyp, a piece of bone wax was noted protruding into the urethral lumen (figure 1B,C). On further ablation, complete extrusion of bone wax in the urethral lumen occurred when perineal pressure was applied (figure 1D–F). Following the procedure, the patient was kept on 18 Fr Foleys catheter for 7 days and is currently asymptomatic at 6 months follow-up.

Figure 1

(A) Mucosal polyp noted at the site of anastomosis. (B) Wax protrusion from polyp into the urethral lumen. (C) Laser ablation of the polyp. (D) Complete extrusion of wax into the urethral lumen. (E) Empty cavity after wax extrusion. (F) Patent urethral lumen after complete polyp resection.

Horsley described bone wax first in 1886.1 It is used by surgeons to control bleeding by mechanically occluding the blood channels in cancellous bone. The surgeon should be wary of its adverse effects such as interference with bone healing and osteogenesis. Bone wax-induced foreign-body granulomatous reaction has been described in the past at various surgical sites. Bone wax granulomas have been reported in lumbar disc surgical site,2 at the cerebellopontine angle,3 mastoid,4 sternotomy site, in the subarachnoid space near medulla oblongata, and in femoral neck osteoplasty site.1 A patient with PFUDD has been reported to have haematuria due to post-traumatic vascular lesions detected with ultrasonography. The urethral polyp may mask the underlying pathology such as a post-traumatic vascular lesion. Therefore, the performance of ultrasound rules out that any post-traumatic arteriovenous fistula or pseudoaneurysm is safe and very important before the transurethral approach to urethral polyps.5

To the best of our knowledge, our case is the first such reported case of postinfrapubectomy bone wax-induced recurrent urethral polyp, resulting in splaying of urine stream after redoing PPU.

Learning points

During infrapubectomy for urethral reconstruction

  • In view of the propensity for foreign body reaction, one should be cautious and ensure complete washout of the excess bone wax.

  • Maintain a high index of suspicion for retained bone wax, in patients presenting with above-mentioned symptoms and clinical findings after urethroplasty.

References

Footnotes

  • Contributors SKS: planning, conduct and concept. KC: literature review and drafting. ST: planning, conduct and reporting. JEM: literature review and drafting.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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