Spontaneous perforation of an augmented bladder

Spontaneous bladder perforation in paraplegia as a late complication of augmentation enterocystoplasty: case report

The management of spinal cord injured (SCI) patients with small capacity, noncompliant bladders has focused on the preservation of renal function and social continence. When conservative management is unsuccessful, surgical intervention may prove beneficial. Augmentation enterocystoplasty is a reliable method of achieving increased bladder capacity while decreasing intravesical filling pressure. Spontaneous bladder rupture is a rare complication of augmentation enterocystoplasty. Because the urine is often colonized with bacteria, bladder rupture may result in chemical and bacterial peritonitis, which is associated with a 25% mortality rate. SCI patients may not present with the classic signs of an acute abdomen. Early diagnosis is critical so that aggressive management may be instituted. The case of late spontaneous perforation of an augmentation enterocystoplasty in a 33-year-old man with T7 complete paraplegia is presented, and the literature discussing the etiology, diagnosis, management, and prevention of augmented bladder perforation is reviewed.

Clinical outcome and quality of life following enterocystoplasty for idiopathic detrusor instability and neurogenic bladder dysfunction

OBJECTIVE

To study the long-term outcome of patients undergoing enterocystoplasty.

PATIENTS AND METHODS

The study comprised 48 patients (17 men and 31 women; mean age 46 years) who underwent enterocystoplasty for idiopathic detrusor instability (DI, 35 patients) or neurogenic bladder dysfunction (13 patients). Symptoms were scored from 0 to 14 and the overall outcome and generic quality of life were assessed using a Visick grading system (groups A to E) and the Nottingham Health Profile (NHP). These assessments were carried out before, 3 months after operation and at the final follow-up (38 +/- 18 months, range 13-78). Urodynamic studies were performed before and after operation.

RESULTS

No patient died after operation and there was minimal early morbidity. Late complications (> 30 days) included incisional hernia (3), anastomotic perforation (1), calculus formation (1) and urethral stricture (1). Clean intermittent self-catheterization (CISC) was performed by 36 (75%) patients. Early symptomatic outcome was good in 40 (83%) patients, moderate in seven (15%) and unsatisfactory in one (2%) patient. The mean symptom scores before and 3 months after surgery were 10 (range 2-14) and 3 (range 2-14), respectively (P < 0.001). There was a significant increase in total bladder capacity (307 +/- 140 to 588 +/- 217 mL; P < 0.001) and bladder compliance (37 +/- 50 to 169 +/- 162 mL/cm H2O; P < 0.001). DI persisted in 15 (31%) patients. NHP scores revealed significant improvements in all domains. Final assessment showed a less satisfactory situation, with recurrent urinary tract infection (UTI) in 17 (37%) patients, a need for long-term antibiotic therapy in seven (15%) and a change in bowel habit in 15 (33%) (13 DI, two with neurogenic bladder dysfunction). CISC was performed by 39 (85%) patients. The long-term outcome was good or moderate in 12 patients (92%) with neurogenic bladder dysfunction and good or moderate in only 19 patients (58%) with DI.

CONCLUSION

Clam enterocystoplasty remains an effective management option in some patients with DI, but most patients with neurogenic bladder dysfunction do well. The procedure is, however, associated with long-term complications such as disturbance of bowel habit and recurrent UTIs, which impair the outcome in the long-term in patients with DI despite general improvements in irritative bladder symptoms.