TECHNIQUE FOR REMOVAL OF SYMPTOMATIC BONE ANCHORS PLACED DURING STRESS INCONTINENCE SURGERY JOHN T. STOFFEL, SEUNG-JUNE OH, AND EDWARD J. MCGUIRE ABSTRACT Introduction. To present an uncomplicated, reliable technique for bone anchor removal in patients with anchor-related infections or chronic pain. Technical Considerations. We removed 17 anchors from 9 patients between 1999 and 2004. The surgical technique used fluoroscopy for localization of the anchors and an orthopedic broken screw removal instrument for resection of the anchor and surrounding bone. Nine patients with bone anchors had been symptomatic with chronic pain and/or wound drainage for a mean of 23.7 months before surgery. After removal, 10 anchors grew positive bacterial cultures. The most common organism was coagulase-negative Staphylococcus. During a mean follow-up period of 6.8 months after hardware removal, 8 of the 9 patients had symptomatic improvement. Conclusions. Fluoroscopic localization and en bloc resection with a broken screw removal instrument is an effective method of removing symptomatic bone anchors. UROLOGY 65: 583–586, 2005. © 2005 Elsevier Inc. B one anchors are commonly used as a method of suture fixation in stress urinary incontinence surgery because they offer a stable, immobile fixation point. 1–5 In this technique, the anchor is directly at- tached to the pubic symphysis with a hand-held drill or pressure device through either a suprapubic or transvaginal incision. Overall, the number of osseous complications attributed to bone anchor use is very low. 6 However, bone anchors need to be removed if they become infected or cause intractable suprapubic pain. 7–11 At our institution, 17 bone anchors from 9 patients were removed because of these symptoms between 1999 and 2004. We present our technique for intraoperative localization and removal of symp- tomatic bone anchors. MATERIAL AND METHODS Patients were identified from review of the operative records of a single surgeon (E.M.) between 1999 and 2004. The preoperative and postoperative data were obtained from a retrospective chart review after institutional review board ap- proval. All patients in this study were originally referred from outside physicians to our institution for evaluation of chronic pelvic pain after stress incontinence surgery. We did not use or place bone anchors during stress incontinence surgery at the investigating institution (University of Michigan) during the study period. PREOPERATIVE EVALUATION Patients presenting with chronic pubic symphysis or pelvic pain after a bone anchor pubovaginal suspension procedure were first examined for evidence of foreign body erosion or abscess. If the pelvic and cystoscopic examinations were neg- ative, patients underwent fluoroscopic urodynamics (FUDS) testing. After the patient was positioned on the fluoroscopy table and a scout film taken, the patient was asked to point with a surgical clamp to the specific suprapubic/pelvic region causing the greatest discomfort. The FUDS was then com- pleted with radiologic imaging in the anteroposterior and lat- eral planes. The films were reviewed to determine whether the region covered by the tip of the clamp correlated with the location of a bone anchor. Patients were also simultaneously evaluated with FUDS for urethral obstruction and uninhibited bladder contractions as a source of the chronic pain. For pa- tients unable to localize the pain, radionucleotide bone scans were also obtained to identify pubic symphysis inflammation. All patients with symptoms localized to the region of a bone anchor by either FUDS or bone scan were then treated with cyclooxygenase-2 inhibitors for 6 weeks. Those patients with- out qualitative changes in symptoms after conservative treat- From the Department of Urology, Lahey Clinic, Burlington, Massachusetts; and Department of Urology, University of Mich- igan, Ann Arbor, Michigan Reprint requests: John T. Stoffel, M.D., Department of Urology, Lahey Clinic, 41 Mall Road, Burlington, MA 01805. E-mail: stoffelj7@yahoo.com Submitted: May 25, 2004, accepted (with revisions): October 7, 2004 SURGICAL TECHNIQUES IN UROLOGY © 2005 ELSEVIER INC. 0090-4295/05/$30.00 ALL RIGHTS RESERVED doi:10.1016/j.urology.2004.10.013 583