Bladder Tattooing in the Urological Armamentarium: An Experimental Study

ABSTRACT

Objective: To evaluate the feasibility of tattooing of the bladder urothelium using different stains.

Methods: The study was performed on 20 healthy male and female dogs, which were divided into 4 groups according to the injected material. The first group (4 animals) was injected with hydrated iron (II) sulphate. The second group (4 animals) was injected with methylene blue added to hydrated iron (II) sulphate. The third group (8 animals) was injected with India ink, and the fourth group (4 animals) was injected with methylene blue. The procedure was performed under general anesthesia. The doses as well as the injection technique were standardized. Re-exploration with sacrifice of the dogs was performed after 40 days. The bladder was examined grossly for dye retention. Bladder, spleen, and liver specimens were sent for histopathological examination.

Results: Tattooing was performed successfully without any immediate reaction. Postoperative complications occurred in a single case in the form of vesicocutaneous fistula. At re-exploration, the dye was retained in both the first and second groups, and there was no difference in color intensity. Methylene blue increased the local inflammatory changes. The third and the fourth groups failed to retain the dye. Local reaction at the site of injection, as well as in the bladder, was present in all cases, being most severe in the third group. In cases of the first, second, and third groups the inflammatory reaction involved the liver with hepatic degeneration up to cirrhotic changes. Histopathological examination showed the presence of ferrous particles in the submucosa as well in the detrusor muscles. The presence of ferrous particles was also detected in the spleen.

Conclusion: In our study, tattooing the bladder urothelium was successful. Despite the side effects of the used materials, tattooing remains feasible; however, the type of material, dose titration, and long follow-up are needed to detect the most suitable material.


Tarek Abdallah Swellam, Ahmed S Zayed, Muhammed Ali, Ahmed Refaat, Muhammed Magdy El-Mahdi, Muhammed M Wishahy

Submitted January 23, 2012 - Accepted for Publication March 12, 2013


KEYWORDS: Bladder tattooing, urothelial marking, Indian ink, ferrous sulphate

CORRESPONDENCE: Tarek Abdallah Swellam, MD, PhD, Theodor Bilharz Research Institute, Giza, Imbaba, Egypt ()

CITATION: UroToday Int J. 2013 April;6(2):art 26. http://dx.doi.org/10.3834/uij.1944-5784.2013.04.13

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INTRODUCTION

Dermal pigmentation is a mark made by inserting pigment into the skin for decorative or other reasons. It is known in Egypt as “Al Washim” and used since ancient times for decoration of the face and arms in the villages of upper Egypt and the delta. Dermal pigmentation is also called tattooing. It is commonly believed that the original root word “tattoo” comes from the Tongan or Tahitian words “mark” or “strike twice” [1].

The body responds to pigment incursions in predictable and specific ways with an initial sloughing of the overlying epidermis, variable dermal inflammation, and gradual assimilation of the pigment into the macrophages. Eventually much of the pigment is carried to the regional draining lymph nodes, with a residue staining within macrophages localized to dermal perivascular regions [2]. A wide range of dyes and pigments can be used in dermal pigmentation, from inorganic and organic materials (e.g., titanium dioxide and iron oxides to carbon black, azo dyes, and acridine; quinoline, phthalocyanine, and naphthol derivatives; and dyes made from ash and other mixtures) [1].

India ink has been previously used in tattooing colonic tumors aiding in future identification of resection sites during colonoscopy [3,4,5]. Also, it is used in the esophagus of patients with Barrett’s esophagus for marking the proximal squamocolumner junction [6]. Various India ink preparations were used whether unsterilized, autoclaved, or gas sterilized, as well as from undiluted to 1:100 (with 0.9% saline) [5].

Methylene blue is a thiazine dye. It occurs as dark green crystals or as a crystalline powder, having a bronze-like luster and a slight odor. Methylene blue is soluble in water and sparingly soluble in alcohol, and forms deep blue solutions. Methylene blue has a pH of 3 to 4.5 [7]. As a marking agent it has been used in the diagnosis of sentinel nodes [8,9,10], the marking of tumors during thoracoscopy via computed tomography (CT) guided injection [11], as well as laparoscopic colonic tumor identification [12,13].

Hydrated iron (II) sulfate can be found in various states of hydration and many of these forms exist in nature [14]: FeSO4.H2O, FeSO4.4H2O, FeSO4.5H2O, and FeSO4.7H2O. Hydrated iron (II) sulfate is used in many fields [14].

METHODS

This study was performed in the animal laboratory in the Theodor Bilharz Research Institute (TBRI). Approval of the ethical committee was obtained for this research project.

This study was performed on 20 healthy dogs; 8 females and 12 males, respectively. Under general anesthesia, a midline transperitoneal incision was performed. The bladder was identified and held between 2 stay sutures. A stay suture was taken in the mucosa by means of 4-0 vicryl sutures, and the tattoo material was injected submucosally via an insulin syringe injecting 0.2 ml of the tattoo material. The suture was tied during extraction of the syringe to prevent leakage of the injected material.

The dogs were divided into 4 groups based on the marking material used. The first group (4 animals) was injected with hydrated iron (II) sulfate (Chemie Lab), and FeSO4.7H2O dissolved as 43.5 grams/100 ml of distilled water. The second group (4 animals) was injected with hydrated iron (II) sulfate with the addition of diluted methylene blue, 1:1 (volume/volume). The third group (8 animals) was injected with undiluted India ink. The fourth group (4 animals) was injected with Methylene blue.

The bladder was closed by 4-0 vicryl, and the abdominal incision was closed en masse by using continuous 0 prolene sutures. Re-exploration and sacrifice of the dogs was performed after 40 days. The bladder was examined grossly for dye retention. Cystectomy, liver, and spleen specimens were sent for histopathology.

RESULTS

Tattooing was performed in 20 dogs. Four different materials were used in 4 groups. Tattooing was performed successfully in all cases without any immediate reaction to any of the injected materials. There was variable tissue staining caused by the injected material. There was minimal staining in the first group (pale yellow) and deep staining in all other groups (blue to black). Postoperative complications occurred in a single animal in the third group in the form of vesicocutaneous fistulae. Retention of the dye was observed in the first and second groups with no difference in color intensity. The third and fourth groups failed to retain the dye. Local site reaction was present in all 4 groups, being more severe in the third group. The additive effect of methylene blue to hydrated iron (II) sulfate increased the local reaction complications with no benefit in color retention.

Diffuse inflammatory reaction was present in all animals. Inflammatory reactions were limited to the bladder in the methylene blue group in the form of gross mucosal ulceration. Microscopically, there was marked urothelial sloughing with fibrosis and atrophy of the underlying muscle layer. In the groups with India ink and hydrated iron (II) sulfate there was additional involvement of the liver and spleen. Hepatic changes ranged from hepatic periportal degeneration with homogenizing degeneration around the blood vessels to bile duct hyperplasia with periportal fibrosis or cirrhotic changes. Hepatic affection was found in 16 animals (80%). Twelve animals (60%) showed microscopic splenic congestion with homogeneity around the large blood vessels. Pathological examination showed the yellow particles of hydrated iron (II) sulfate located both in the submucosa and the detrusor muscles.

DISCUSSION

Our objective in the current study was to investigate the possible use of urothelial tissue marking, and we examined 3 known substances that were used before in marking the colonic mucosa when doing polypectomy or tumor resection. We believe that it will be valuable in urologic practice for the follow-up of superficial bladder tumors after complete transurethral resection. Also, it may help in an easier identification of the ureteric orifice after sometimes-troublesome ureteroneocystostomy. Identification failure might lead to the abortion of some interventions or changing the treatment modality.

In the literature, tattooing of the colon was successfully performed to mark sites of colonic resection helping identify previously resected areas during follow-up as well as during open and laparoscopic surgery. Many dyes have been used such as India ink, methylene blue, and indocyanine green. India ink alone achieved persistence of the dye whereas both methylene blue and indocyanine green failed to persist [15,16].

In the current study, 3 different materials were used, namely hydrated iron (II) sulfate, undiluted India ink, and methylene blue. The injection technique was standardized. We want to emphasize the importance of suturing the injection site upon withdrawal of the needle. This successfully controlled the dye leakage. Park et al., who studied the safety and efficacy of colonoscopic tattooing, reported a similar recommendation [17].

Upon injection, the pale yellow color of hydrated iron (II) sulfate was observed in the first group. A combination of methylene blue to hydrated iron (II) sulfate was used to benefit from its deep blue color as a marking agent in the second group. India ink demonstrated a black color in the third group, and there was a deep blue color of methylene blue in the fourth group. No complications occurred during injection or in the early postoperative period.

On re-exploration, the first and second group retained the pale yellow color of hydrated iron (II) sulfate with no difference in color intensity. The third and fourth group failed to retain the dye. The results of failure to retain India ink in the bladder submucosa are contradictory to other studies, which proved dye retention in colonic mucosa [3,18,19,20,21]. However, in the present study, dye retention failure can be explained by using undiluted India ink, which was responsible for the severe inflammatory reaction and ulceration.

Dye retention failure in the fourth group matches other studies [12,16] that reported methylene blue dye retention failure 7 days after colonic injection. Local reactions at the injected sites were observed in all 4 groups, with the most severe occurring in the third group, causing severe ulceration and vesicocutaneous fistulae in 1 case. These results are in line with other studies reporting colonic mucosal reactions in undiluted India ink as well as colonic perforation resulting from India ink injection [5,18,22,23,24].

Local inflammatory reactions to India ink and methylene blue were also reported [12]. Reactions to India ink included necrosis, edema, and neutrophilic infiltration in the submucosa and muscularis propria. Vessels were inflamed but without fibrinoid necrosis. Early reactions to methylene blue included ischemic ulceration, necrosis, and eosinophilic infiltration in the submucosa as well as fibrinoid necrosis of vessel walls. Later reactions due to methylene blue-induced injury showed obliterative intimal fibrosis. Such changes were absent in the colons injected with India ink.

In the present study, hydrated iron (II) sulfate in the first and second groups showed retention of the dye in both groups without changing color intensity; however, there was more severe tissue reaction at the injection site in the second group. This can be explained by the additive effect caused by a combination of both substances.

The pale yellow color of hydrated iron (II) sulfate particles was demonstrated histopathologically in both the submucosa and the detrusor muscles. The bladder mucosa showed severe inflammatory reaction in all 4 groups, both grossly and by histopathological examination. The reaction to the different materials was systemic and not localized to the bladder mucosa. Draining pelvic lymph nodes showed inflammatory reactions as well. The liver showed hepatic cell degeneration and portal tract fibrosis, which extended between the hepatic cells in 2 animals. The spleen showed the presence of deep orange/yellow to green substances in the macrophages in the first and second groups. This dye substance migration was also reported with Fu et al. [19] after the use of India ink during preoperative tattooing of the colon.

We noticed that there was some contradiction in our results and those done on the colonic mucosa. While the question may be raised about the histologic difference between the colonic mucosa and the urothelium, we believe that our pilot study is not enough to conclude study. Instead, we are proceeding toward a bigger study where we are planning to use different dilutions of the coloring substances and to examine for the long-term effect of using such a procedure.

CONCLUSION

In our study, the feasibility of tattooing the bladder urothelium was successful. Despite the side effects of the used materials, tattooing remains feasible; however, the type of material, dose titration, and long follow-up are needed to determine the most suitable material.

FIGURES

Figure 1

Figure 2

Figure 3

Table 1

REFERENCES

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