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. Invented by Milo Ellik at the University of Iowa in the 1930s, the design has remained essentially unchanged because the compression-decompression / gravity-trap mechanism is hard to improve on.^[1]

Design

• Two stacked transparent chambers (glass or polycarbonate) joined by a one-way internal pathway.
• Compressible bulb between them.
• 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:

1. Compress the bulb → fluid is driven into the bladder, agitating chips, clots, and fragments into suspension.
2. Release the bulb → ~ 80–100 mmHg of negative pressure aspirates the suspended material back through the sheath.
3. The one-way pathway directs returning debris into the lower chamber, where it settles by gravity.
4. 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:

• Simple prostatectomy / BPH surgery — chip evacuation at the end of TURP, HoLEP / ThuLEP enucleation, plasmakinetic enucleation, and any LUTS-surgery chip-producing modality. The retrieved tissue is sent for pathologic survey for incidental cancer per AUA / EAU LUTS guidelines.^[2]
• Post-procedure gross-hematuria clot evacuation following any transurethral or open bladder procedure, post-radiation cystitis, post-AUS / IPP revision, or post-cystotomy — the dominant non-OR daytime use in the inpatient setting.
• 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 — 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 / organized clot retention — the Ellik's ~ 80–100 mmHg ceiling is often insufficient. Direct connection of the cystoscope sheath to centralized wall suction (~ 250 mmHg) has been described as a salvage technique, successfully evacuating clots in patients who failed traditional Ellik evacuation.^[3]
• Adjuncts for refractory clot retention:
  • Chymotrypsin / sodium-bicarbonate intravesical irrigation — non-surgical enzymatic dissolution.^[4]
  • Hydrogen-peroxide bladder irrigation — simple, effective in case-series data for clot evacuation when mechanical methods fail.^[5]
• 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 the historical injury class — modern plastic variants have largely eliminated this; 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	~ 80–100 mmHg	Routine chip / small-clot / fragment retrieval	Fails on organized clot burden
Direct sheath-to-wall-suction (~ 250 mmHg)	~ 250 mmHg	Salvage for tenacious clot when Ellik fails[3]	Higher mucosal-injury risk if applied to bladder wall
Toomey syringe (60 mL) hand evacuation	Variable	Bedside / non-OR clot evacuation through a Foley	Slow; no closed loop
Enzymatic dissolution (chymotrypsin / NaHCO₃)	N/A	Non-surgical alternative for refractory clot retention[4]	Hours to days to act
H₂O₂ irrigation	N/A	Simple bedside / OR adjunct for clot dissolution[5]	Case-series evidence only

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 (1905–1992) was a urologist at the University of Iowa who introduced the evacuator in the 1930s to address the chip-retrieval bottleneck at the end of open and transurethral prostatectomy. The instrument's elegant two-chamber gravity-trap design has survived nearly a century of redesign attempts and remains on the standard back table for every transurethral case in modern urology.^[1]

---

References

1. Ellik M. "A modification of the evacuator." J Urol. 1937;38(3):327–8.

2. Xu N, Chen SH, Xue XY, et al. "Older age and larger prostate volume are associated with stress urinary incontinence after plasmakinetic enucleation of the prostate." Biomed Res Int. 2017;2017:6923290. doi:10.1155/2017/6923290

3. 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

4. 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

5. 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