Ellik Evacuator
The Ellik bladder evacuator is a double-chambered manual irrigation-and-aspiration bulb attached to the resectoscope or cystoscope sheath, used to flush and retrieve bladder contents (chips, clots, and small fragments) at the conclusion of any transurethral procedure. Milo Ellik described it in 1937 while a urology resident at the University of Iowa, and the compression-release, gravity-trap design has changed little since.[1][5]
Design
- Two stacked transparent chambers (glass or plastic) joined by a narrowed waist; retrieved solids settle in the lower chamber by gravity.
- Compressible bulb attached to the upper chamber.
- Nozzle with a tapered fitting that mates to standard resectoscope / cystoscope sheaths.
- Upper chamber acts as the irrigation reservoir; lower chamber acts as the gravity-settling trap for retrieved solids.
- Reusable (glass / autoclavable) or single-use plastic variants.
Mechanism
Manual squeeze-and-release cycle:
- Compress the bulb; fluid is driven into the bladder, agitating chips, clots, and fragments into suspension.
- Release the bulb; the resulting suction aspirates the suspended material back through the sheath. Pressure depends on the operator and device; use gentle cycles and monitor bladder distension, especially after a recent resection or repair.
- Returning debris enters the upper chamber and may settle into the lower chamber by gravity; unsettled fragments can recirculate into the bladder.[7]
- Clear supernatant in the upper chamber is reused on the next cycle.
This allows continuous closed-circuit evacuation without disconnecting the sheath.
Reconstructive / Functional Urology Uses
The Ellik is on the back table of essentially every transurethral case relevant to WARWIKI:
- BPH surgery: chip and residual-fragment evacuation after TURP, plasmakinetic enucleation when chips are produced, or HoLEP / ThuLEP when small pieces remain. In the cited HoLEP technique, mechanical morcellation retrieves enucleated lobes; an Ellik removes residual small pieces or clots.[8] Send retrieved tissue to pathology according to the operation and local protocol.
- Post-procedure gross-hematuria clot evacuation after selected transurethral or open bladder procedures, radiation cystitis, prosthetic revision, or cystotomy when transurethral access is appropriate. Before passing a sheath in a patient with an AMS 800 AUS, deflate the cuff and deactivate the device; assess sheath size against the urethra and cuff.[6]
- Bladder-stone / fragment retrieval after intravesical lithotripsy at the time of bladder-stone evacuation for outlet-obstruction sequelae, neurogenic-bladder stones, or stones on long-indwelling foreign material (catheter, sling, mesh, AUS cuff erosion).
- Foreign-body retrieval of small fragments after intentional or unintentional foreign-body cystoscopy.
- TURBT chip evacuation is the bladder-cancer use case; out of WARWIKI's primary scope but mentioned because the instrument is identical and the reconstructive trainee will encounter it on combined trays.
Technique Pearls
- Connect with the sheath nozzle in the bladder, not in the urethra. Premature disconnection during withdrawal sprays chips into the urethra and prostatic fossa.
- Steady rhythm beats hard squeezes. A slow 1-second compress, 1-second release is more effective than rapid hard pumps, which generate cavitation bubbles and rebreak chips.
- Empty the lower chamber before it fills to the level of the internal pathway; overfilling reintroduces sediment into the irrigation stream.
- Send the entire lower-chamber contents to pathology in saline; piecemeal sampling under-represents both volume and incidental cancer detection.
- Pre-warm the irrigant (saline / sterile water as appropriate to the procedure) to reduce intraoperative hypothermia in the long resection case.
Limitations and Failure Modes
- Tenacious or organized clot retention. The Ellik's hand-generated suction is often insufficient. In a 15-adult series of patients who had failed Ellik evacuation, attaching a 25 Fr cystoscope or 26 Fr resectoscope sheath directly to central wall suction (up to 250 mmHg) cleared the clot in an average of 88 minutes. Apart from punctate mucosal hemorrhagic spots there were no complications; the series is small and uncontrolled.[2]
- Adjuncts for refractory clot retention:
- Chymotrypsin / sodium-bicarbonate intravesical irrigation is a non-surgical enzymatic dissolution. In 22 men with severe clot retention (40,000 U chymotrypsin in 50 mL of 5% sodium bicarbonate through a 20–24 Fr Foley for 30 minutes, repeated 2–4 times), 19 were treated successfully.[3]
- Hydrogen-peroxide bladder irrigation has been described in a single-center retrospective series of 31 patients, in which clots were cleared in 27 and 4 needed surgery.[4] Both chemical methods rest on small nonrandomized reports.
- Lost-chip risk. Chips can sequester in bladder diverticula, behind the trigone, or in the prostatic fossa; perform a deliberate sweep of all walls under direct vision before terminating the case.
- Glass-bulb breakage is a risk with glass Ellik evacuators; plastic variants avoid this material-specific failure mode.[9] If a glass Ellik is in use, inspect for fracture lines before each compression cycle.
Ellik vs Alternatives for Bladder Content Evacuation
| Method | Suction range | Best fit | Limitation |
|---|---|---|---|
| Ellik evacuator | Low, hand-generated | Routine chip / small-clot / fragment retrieval | Fails on organized clot burden |
| Direct sheath-to-wall-suction | Up to 250 mmHg (reported) | Salvage for tenacious clot when Ellik fails[2] | Higher mucosal-injury risk if applied to bladder wall |
| Toomey syringe (60 mL) hand evacuation[10] | Variable | Bedside / non-OR clot evacuation through a Foley | Slow; no closed loop |
| Chymotrypsin / NaHCO₃ plus manual evacuation | N/A | Small reported series for refractory clot retention[3] | Requires 30-minute instillations followed by saline irrigation and syringe suction; repeated 2–4 times in the cited series |
| Diluted H₂O₂ manual washout | N/A | Catheter-based clot washout after failed standard irrigation in a small series[4] | The reported protocol used a 1:5 mixture of 3% H₂O₂ and saline through a large-hole 20 Fr Foley; evidence is retrospective |
See also: Toomey Syringe, Resectoscope, Rigid Cystoscope, Three-Way Catheter (the continuous-bladder-irrigation companion for post-operative clot prevention).
Historical Context — Milo Ellik
Milo Ellik (1905–1979) was born in Chicago, graduated from the University of Iowa (MD 1932) and trained in urology there under Nathan Alcock. He published the evacuator in 1937 as an improvement on an earlier evacuator design, and later practiced in Long Beach, California. The two-chamber gravity-trap design remains in use on transurethral trays.[1][5]
References
1. Ellik M. "A modification of the evacuator." J Urol. 1937;38(3):327–8. doi:10.1016/s0022-5347(17)71960-x
2. Goel A, Sengottayan VK, Dwivedi AK. "Mechanical suction: an effective and safe method to remove large and tenacious clots from the urinary bladder." Urology. 2011;77(2):494–6. doi:10.1016/j.urology.2010.09.035
3. Bo J, Yangyang Y, Jiayuan L, et al. "Evaluation of bladder clots using a nonsurgical treatment." Urology. 2014;83(2):498–9. doi:10.1016/j.urology.2013.09.022
4. Xu M, Jin L, Shan Y, Zhu J, Xue B. "A simple and effective method for bladder blood clot evacuation using hydrogen peroxide." J Int Med Res. 2020;48(5):300060520924546. doi:10.1177/0300060520924546
5. Didusch Museum of Urologic History. "Milo Ellik, MD (1905–1979)." urologichistory.museum
6. Boston Scientific. AMS 800 Artificial Urinary Sphincter: Indications, Safety, and Warnings. IFU 51266569-01.
7. Blake JW III. Urological evacuator. US Patent 5,338,294. August 16, 1994. Background description of the standard Ellik evacuator.
8. Kuo RL, Paterson RF, Kim SC, Siqueira TM Jr, Elhilali MM, Lingeman JE. "Holmium laser enucleation of the prostate (HoLEP): a technical update." World J Surg Oncol. 2003;1:6. doi:10.1186/1477-7819-1-6
9. British Association of Urological Surgeons. "Ellik Evacuator." BAUS Museum.
10. Romsons. "Toomey Syringe (GS-6015): Product Specifications." Manufacturer product page.