Intravesical Hemostatic Clip Migration After Robotic Prostatectomy: Case Series and Review of the Literature George A. Turini III, MD, Joseph M. Brito III, MD, Andrew R. Leone, MD, Dragan Golijanin, MD, E. Bradley Miller, MD, Gyan Pareek, MD, and Joseph F. Renzulli II, MD Abstract Introduction: The Weck Hem-o-lokÔ Ligating clip is a routinely used hemostatic tool in robotic and laparo- scopic 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. Materials and 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. Discussion: 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. Introduction T he Hem-o-lokÔ Ligating clip (Weck Surgical In- struments; Teleflex Medical, Durham, NC) is a routinely used hemostatic tool in open, robotic, and laparoscopic sur- geries. It is estimated that more than 100 million ligation clips have been used worldwide. 1 It has been routine practice in our institution to use these clips for hemostatic control of the vascular pedicles during robotic-assisted laparoscopic radical prostatectomy (RALRP). The clips are made of sterile plastic and are therefore nonabsorbable. Migration of these clips has been reported intermittently throughout the literature dating back to *2008, primarily in single or dual patient case re- ports. 2–6 Blumenthal and Sutherland reported on what ap- pears to be the largest case series thus far in the literature identifying two of their patients with bladder neck contrac- tures secondary to migrated clips found in the urinary tract and 1 patient who was found to have migrated clips after being diagnosed with an anastomotic leak. 7 Other instances of migrated Weck clips include migration into the bladder with resultant stone formation around the clip and migration into the rectum. 8,9 In this review, we present our own case series of patients who have experienced intravesical Weck clip migration following robotic-assisted laparoscopic radical prostatec- tomy. Through an open discussion of our experience with this complication, we hope to stimulate further study into patient and operative characteristics, which may predict clip movement and suggest modified usage of this product in RALRP. Minimally Invasive Urologic Institute, The Miriam Hospital, Alpert Medical School of Brown University, Providence, Rhode Island. JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 26, Number 9, 2016 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2015.0506 710