A report of an iatrogenic bladder rupture in a normal healthy child during voiding cystourethrography

Iatrogenic Rupture of the Urinary Bladder in an Infant During Retrograde Cystourethrography

ABSTRACT

Iatrogenic bladder rupture in children during a retrograde cystourethrography is very uncommon. We present a case of iatrogenic intraperitoneal bladder rupture in a 9-month child during the retrograde cystourethrography performed by a radiologist. The child presented in a paediatric emergency after 6 h with an acute abdomen indicating urinary peritonitis. An urgent laparotomy was performed and the perforation was repaired in two layers. The follow-up was unremarkable. This report emphasises the importance of respecting the criteria of the proper retrograde cystourethrography imaging procedure.

Pediatric cystogram: Are we considering age-adjusted bladder capacity?

INTRODUCTION

There are a small number of reports in the literature describing bladder rupture during cystograms in children. We hypothesized that children undergoing cystograms may have their bladder overfilled during the test. We aimed to evaluate the current practice when performing cystograms in our institution, contrasting actual volume used to fill the bladder to the age-adjusted bladder capacity.

METHODS

We performed a retrospective review of all voiding cystourethrograms(VCUG) and radionuclide cystograms (RNC) performed at the Children's Hospital of Eastern Ontario from 2006-2013. Formulas used to estimate age-adjusted bladder capacity: 1) infants <1 year: Capacity (mL) = (2.5 × age [months]) + 38 (Holmdahl et al, 1996); and 2) older children >1 year: Capacity (mL) = (2 + age [years]) × 30 (Koff et al, 1983).

RESULTS

A total of 2411 cystograms were done (1387 VCUG; 1024 RNC) in 817 infants and 1594 children older than one year - 1113 boys and 1298 girls. Generally, bladders tended to be overfilled with 32% more volume in mL than the expected age-adjusted bladder capacity - VCUG 151 (122) mL vs 120 (97) mL (p< 0.001) and RNC 191 (97) mL vs. 151(74) mL (p<0.001). Most importantly, infants had a striking overfilling rate of 64% and 38 % more volume than their expected age-adjusted bladder capacity for VCUG and RNC, respectively (p<0.001).

CONCLUSION

Bladders are filled above the estimated age-adjusted capacity in mL at the following rates: 32% in the whole group and 64% in infants undergoing VCUG. It raises concern of possible bladder rupture in this age group. Furthermore, this may lead to overgrading and overdiagnosing of vesicoureteric reflux, as well as overestimation of post-void residual. Attention should be paid to filling to age-adjusted bladder capacity and allowing the child adequate time to void during performance of the cystogram.

Bladder rupture after voiding cystourethrography: A case report and literature review on pitfalls and bladder volume estimation

Voiding cystourethrography (VCUG) is a common diagnostic study in pediatric urology. Although generally considered a safe procedure, VCUG can incur some complications. Bladder rupture following VCUG is a very rare complication and mostly happens in the setting of unused bladders, previous surgeries, or underlying disease. The rupture is almost always intraperitoneal needing prompt surgical treatment. We present a unique case of extraperitoneal bladder rupture after VCUG in an 8-month-old boy. The rupture remained unnoticed and the patient recovered spontaneously without medical or surgical intervention. To the best of our knowledge, this is the first such case report in the English literature. The information provided may guide clinicians on the proper use of bladder volume formulas in children and also help them in getting a proper VCUG study.

Are we accurately predicting bladder capacity in infants?

INTRODUCTION

Estimating bladder capacity is an important component in the evaluation of many urological disorders. For estimates to be of clinical value, precise reference ranges are needed. While accepted reference ranges have been established in adults and older children, none have been validated in infants. We endeavour to determine the normal bladder capacity of children less than 1 year of age.

METHODS

We retrospectively reviewed the charts of children aged 0 to 12 months with cutaneous stigmata of spinal dysraphism who were referred to the urology clinic to rule out tethered cord between October 2004 and July 2011. Patients with normal urologic assessment, who did not have surgery during the time they were followed, were included in the study cohort. Urodynamic studies were performed using the Laborie Medical Technologies UDS-600. Bladder filling occurred via a catheter at a rate of 10% of the expected total bladder capacity/minute. Bladder capacity was defined as the volume of filling when the child voided around the catheter. We collected data, including age at urodynamics, bladder capacity, detrusor pressure at capacity, bladder compliance and length of follow-up.

RESULT

In total, 46% (84/183) of patients had a normal urologic assessment and met the inclusion criteria. The median age was 9.0 months (interquartile range [IQR] 6.8-11.0). The average bladder capacity was 48.9 mL (standard deviation [SD] 32.8) and the mean detrusor pressure at capacity was 8.5 cmH2O (SD 10.0). Mean compliance was 14.1 mL/cmH2O (SD 13.6). The average length of follow-up was 40.7 months (SD 26.2) and during this interval no patients were found to have urologic or neurologic abnormalities and none underwent tethered cord release.

CONCLUSION

Bladder capacity in infants with a median age of 9.0 months was found to be 48.9 mL. This is less than half of the volume predicted by a commonly employed formula. A novel method of estimating bladder capacity in infants is required.

Urinary bladder rupture during voiding cystourethrography

Voiding cystourethrography (VCUG) is a commonly performed diagnostic procedure for the evaluation of vesicoureteral reflux with urinary tract infection or congenital renal diseases in children. The procedure is relatively simple and cost-effective, and complications are very rare. The iatrogenic complication of VCUG range from discomfort, urinary tract infection to bacteremia, as well as bladder rupture. Bladder rupture is a rare complication of VCUG, and only a few cases were reported. Bladder rupture among healthy children during VCUG is an especially uncommon event. Bladder rupture associated with VCUG is usually more common in chronically unused bladders like chronic renal failure. Presented is a case of bladder rupture that occurred during a VCUG in a healthy 9-month-old infant, due to instilled action of dye by high pressure. This injury completely healed after 7 days of operation, and it was confirmed with a postoperative cystography. The patient's bladder volume, underlying disease, velocity of the contrast media instilled, catheter size, and styles of instillation are important factors to prevent bladder rupture during VCUG. Management of bladder rupture should be individualized, but the majority of infants are treated with the operation. In conclusion, bladder rupture is a rare complication, however, delicate attention is needed in order to prevent more dire situations.