Conservative management of an intraperitoneal rupture of an augmentation cystoplasty and continent urinary diversion in an adult

Cystoscopically Guided Repair of a Posterior Perforation of Augmented Bladder

Background: Augmentation cystoplasty for the management of neurogenic bladder is one of the mainstays of pediatric urology. This procedure has multiple well-known complications. The most dangerous of these complications is bladder perforation, which has a mortality rate of 23% to 25% in large part caused by delayed presentation and sepsis. This case report discusses a novel method for identifying the perforation using endourologic techniques to allow for easier repair.

Case Presentation: A 24-year-old woman with a history of spina bifida s/p augmentation cystoplasty with appendicovesicostomy and rectus fascia bladder neck sling 5 years ago presented to the emergency department with a 2-day history of decreased oral intake, nausea, vomiting, fevers, diffuse abdominal pain, and distention. She was found on CT cystogram to have a contrast extravasation from the posterior-dependent portion of the bladder and a large retrovesical fluid collection. On exploratory laparotomy, a leak from the posterior portion of the bladder was confirmed. Owing to the conditions in the abdomen and the patient's obese body habitus, the perforation was very difficult to view. A 17F rigid cystoscope was utilized and the perforation was identified on the posterior inferior portion of the bladder at the anastomotic line. A wire was passed through the perforation into the abdomen where it was seen and an 18F council catheter was then placed in an antegrade manner from the abdomen. Placement of the catheter and inflation of the balloon did not cause any additional apparent damage to the bladder mucosa. With the catheter on traction, the dependent bladder could be pulled back into the operative field, allowing complete observation of the defect for water-tight two-layer closure.

Conclusion: Bladder perforation after augmentation cystoplasty is a potentially life-threatening complication that can be difficult to repair. This article serves to present a novel way to identify and facilitate repair of the defect intraoperatively using endourologic principles for a posterior defect.

Complications and salvage options after laser lithotripsy for a vesical calculus in a tetraplegic patient: a case report

Background

Laser lithotripsy of vesical calculi in tetraplegic subjects with long-term urinary catheters is fraught with complications because of bladder wall oedema, infection, fragile urothelium, bladder spasms, and autonomic dysreflexia. Severe haematuria should be anticipated; failure to institute measures to minimise bleeding and prevent clot retention can be catastrophic. We present an illustrative case.

Case presentation

A tetraplegic patient underwent laser lithotripsy of vesical stone under general anaesthesia. During lithotripsy, severe bladder spasms and consequent rise in blood pressure occurred. Bleeding continued post-operatively resulting in clot retention. CT revealed clots within distended but intact bladder. Clots were sucked out and continuous bladder irrigation was commenced. Bleeding persisted; patient developed repeated clot retention. Cystoscopy was performed to remove clots. Patient developed abdominal distension. Bladder rupture was suspected; bed-side ultrasound scan revealed diffuse small bowel dilatation with mild peritoneal effusion; under-filled bladder containing small clot. Patient developed massive abdominal distension and ileus. Two days later, CT with oral positive contrast revealed intra-peritoneal haematoma at the dome of bladder with perforation at the site of haematoma. Free fluid was noted within the peritoneal cavity. This patient was managed by gastric drainage and intravenous fluids. Patient's condition improved gradually with urethral catheter drainage. Follow-up CT revealed resolution of bladder rupture, perivesical haematoma, and intra-peritoneal free fluid.

Conclusion

If bleeding occurs, bladder irrigation should be commenced immediately after surgery to prevent clot retention. When bladder rupture is suspected, CT of abdomen should be done instead of ultrasound scan, which may not reveal bladder perforation. It is debatable whether laparotomy and repair of bladder rupture is preferable to nonoperative management in tetraplegics. Anti-muscarinic drugs should be prescribed prior to lithotripsy to control bladder spasms; aspirin and ibuprofen should be omitted. If significant bleeding occurs during lithotripsy, procedure should be stopped and rescheduled. Percutaneous cystolithotripsy using a wide channel could be quicker to clear stones, as larger fragments could be retrieved; lesser stimulant for triggering autonomic dysreflexia, as it avoids urethral manipulation. But in patients with small, contracted bladder, and protuberant abdomen, percutaneous access to urinary bladder may be difficult and can result in injury to bowels.

Management of delayed bladder augmentation perforation

BACKGROUND

A 17-year-old male, with a history of bladder augmentation enterocystoplasty 7 years earlier, presented with nausea, emesis and acute abdomen.

INVESTIGATIONS

Physical examination, blood and urine culture, and abdominal and pelvic CT cystography.

DIAGNOSIS

Acute abdomen from perforation of bladder augmentation.

MANAGEMENT

Support and stabilization, bladder decompression, and broad-spectrum intravenous antibiotics, followed by immediate exploratory laparotomy with repair of enterocystoplasty and peritoneal lavage.

Nonoperative treatment of isolated posttraumatic intraperitoneal bladder rupture in children-is it justified?

PURPOSE

Open surgical repair has been the standard treatment for intraperitoneal bladder rupture. We sought to explore the possibility of nonoperative treatment of isolated intraperitoneal bladder rupture in children.

MATERIALS AND METHODS

Eight children (4 girls and 4 boys) with a mean age of 6.3 +/- 4.6 years (range 1 to 13) presented with isolated posttraumatic intraperitoneal bladder rupture between 1993 and 2003. Retrograde cystogram was performed in all cases. Diagnosis was confirmed by aspiration and chemical analysis of the free intraperitoneal fluid in patients with an equivocal cystogram. Four patients who presented early in the series (group 1) were treated with the classic open repair, whereas the last 4 patients (group 2) were treated nonoperatively with adequate bladder drainage and percutaneous intraperitoneal tube drain. The mechanisms of injury, clinical presentation, management, complication, hospital stay and duration of catheterization were reviewed in both groups.

RESULTS

Six patients had a history of a direct blow to the full bladder, while 2 presented following a motor vehicle accident. All patients presented with vomiting and abdominal distention, and 5 had mild gross hematuria without associated clots or hemodynamic instability. One patient in group 1 had early urinary leakage and wound sepsis, and was treated conservatively. All patients in group 2 demonstrated significant improvement in general condition within a few hours of the bladder and peritoneal drainage. Intraperitoneal tube drains were removed at 1 to 4 days. There were no post-intervention complications in group 2 and surgical treatment was never required. Mean indwelling catheter duration was 9.3 +/- 7.9 and 11.8 +/- 2.6 days (p = 0.24), and mean hospital stay was 10.5 +/- 8.4 and 7.3 +/- 3.9 days (p = 0.56) in groups 1 and 2, respectively.

CONCLUSIONS

Nonoperative treatment is a justified initial approach for isolated intraperitoneal bladder rupture in children. Indications for surgical intervention include improper bladder drainage, unduly prolonged urinary drainage through the peritoneal drain and/or lack of clinical improvement.

The continent bladder: indications and techniques for the continent catheterizable segment

PURPOSE OF REVIEW

Continent catheterizable segments are a substantial part of the urologist's armamentarium for providing bladder drainage. It is used for a myriad of indications, and there are multiple techniques currently used for its formation. Despite refinements in these techniques significant complications still occur, and there is continued advancement and ongoing investigation. This review examines the current status of the continent catheterizable segment with regard to indications for its use, techniques in its formation, discussion of complications, and ongoing and future directions in research.

RECENT FINDINGS

The continent catheterizable segment is indicated when it is not feasible to use the urethra for evacuation (e.g. bladder exstrophy, neurogenic bladder, radiation injury, and marked urethral dysfunction) or to facilitate catheterization. Compliance with catheterization and irrigation regimens is essential in patient selection. Multiple methods exist for its formation, either with or without the need for bladder augmentation. Although Mitrofanoff techniques with multiple applications predominate, "hemi" augments with efferent limbs also play a significant role. Stoma placement should be performed to best facilitate catheterization. Complications relating to catheterizable segments mainly pertain to continence, stenosis, and ability to catheterize, with more significant morbidity relating to the bladder augmentation. Ongoing research to develop more physiologic tissue substitutes and less invasive techniques may hopefully be superseded by prevention of the underlying lower urinary tract pathology.

SUMMARY

Catheterizable segments allow the patient to control bladder evacuation, and continue to be refined by ongoing investigations in terms of indication and technique, with attendent decreasing morbidity.

Rupture and perforation of urinary reservoirs made from bowel

A review of the literature involving the rupture or perforation of urinary reservoirs made from the bowel indicates that this complication is perhaps not as rare as commonly perceived. It is a severe complication for which a high index of suspicion needs to be maintained. Physicians attending to patients with such urinary reconstructions should be aware that the diagnosis is often difficult to confirm without resorting to exploratory laparotomy and in particular that a negative cystogram can be misleading. A practical suggestion to help alert these physicians to the possibility of a ruptured urinary reconstruction is that such patients should carry a medical card stating the type of reservoir they have along with their special circumstances. From the reported experiences, it is, however, clear that in carefully selected cases and with vigilant monitoring, some patients may be managed non-operatively.