We present an unusual case of a retained resectoscope beak detected 10 months following transurethral resection of a bladder tumour. We describe this rare complication after transurethral surgery and present a safe method for removing a resectoscope beak from the urethra. This case prompted several improvements in our local surgical checklists to prevent such an event from recurring. It is important to check the integrity of surgical equipment in addition to counting equipment in and out during theatre; without checking, as exemplified by the resectoscope in this case, we risk missing the point.
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HaynesABWeiserTGBerryWR. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med2009; 360(5): 491–499.
