Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Laparoscopy management for spontaneous bladder rupture: a case report

Laparoscopy management for spontaneous bladder rupture: a case report We present a case of a 79-year-old man with lower abdominal pain and negative Blumberg sign. An indwelling bladder catheter was inserted for urinary retention due to a tight phimosis 2 months earlier. A contrast-enhanced computed tomography scan revealed a huge gastrectasia and small bowel distention due to a suspected adherent bridle. The clinical signs and the laboratory tests were highly suspicious for bowel obstruction and emergency surgery was indicated. Exploratory laparoscopy showed a bladder hole tamponade by an ileum loop. The perforation was sutured laparoscopically and the patient was discharged on the 14th postoperative day. In our case, emergency laparoscopic exploration was useful for the diagnosis and the treatment of spontaneous bladder rupture. We hope this case report can be useful to give these patients better outcomes. Notably we would like to emphasize that the presence of a urinary catheter can be a risk factor for intraperitoneal bladder rupture. tomography (CT) scans. A multidetector CT cystography is INTRODUCTION the gold standard for suspected bladder rupture evaluation Spontaneous bladder rupture is a rare and life-threatening event. [3]. Once the diagnosis is established, the management of The most common risk factors are chronic inflammation such spontaneous bladder rupture can be either non-operatively or as infections or irradiation, urinary retention due to outflow surgical. Surgery is indicated for intraperitoneal ruptures [4]. The obstruction or neurogenic bladder, and malignancies [1, 2]. In objective of this case report is to highlight the role of emergency these conditions, the development of bladder diverticula is eas- laparoscopic exploration. ier. Bladder diverticula are bulging sacs from weakness points on the bladder wall with a higher risk of perforation. The most frequent sites of diverticulum perforation described in the liter- CASE REPORT ature are intraperitoneal: bladder dome or posterior wall [1]. Patients with intraperitoneal bladder rupture present with A 79-year-old man was referred to our Emergency Department symptoms and signs of acute abdomen and the perforation (ED) for abdominal pain since morning without other symptoms. is often initially misdiagnosed even with the aid of computed His medical history consisted of Parkinson’s disease and recent Received: October 27, 2020. Revised: December 3, 2020. Accepted: December 10, 2020 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2021. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article/2021/01/rjaa570/6102031 by DeepDyve user on 26 January 2021 2 S. Celotti et al. Table 1. Preoperative laboratory tests in our ED Blood test Hemogasanalisis Leukocytes (×10 /l) 16.05 pCO2 (mmHg) 25.8 Hemoglobin (g/dl) 12.1 pO2 (mmHg) 71.4 Platelets (×10 /l) 188 BE (mmol/l) -5.6 C-Proteine Reactive (mg/dl) >7 HCO3- (mmol/l) 17 Creatinine (mg/dl) 1.3 Lactate (mmol/l) 1.10 PT-ratio (INR) 1.26 Sodium (mmol/l) 145.8 PTT-ratio 1.10 Potassium (mmol/l) 3.29 NG unintentionally, when a few hours later the tube was inserted again and 450 ml of fecal fluid were aspirated. The clinical signs and the worsened laboratory tests were highly suspicious for bowel obstruction and emergency surgery was indicated. A supra-umbilical Hasson’s port was inserted and exploratory laparoscopy showed turbid effusion in Morrison’s pouch, spleno- renal pouch and pouch of Douglas. Two more trocars of 10 mm were inserted. Running the small bowel, a loop appeared densely adherent to the bladder and releasing the bowel from adhe- sions a bladder hole was found out (Fig. 3). The rupture of a bladder diverticulum was tamponade by an ileal loop and was critically inflaming the peritoneal cavity. An accurate laparo- scopic adhesiolysis was performed. The ileal loops appeared vital and no bowel resection was necessary. The bladder hole was sutured with a knotless barbed suture. Dilute methylene blue was injected into the urinary catheter to check the watertight closure. No blue spreading was seen and a drain was inserted into pelvis. The surgery was performed by a skilled general surgeon and the consultant urologist wasn’t necessary. The postoperative course was characterized by Enterobac- ter aerogenes and Pseudomonas aeruginosa positive urine culture results. The drain was removed on the fifth postoperative day Figure 1: Plain abdomen radiography shows distended stomach and dilatated and the patient was discharged on the 14th postoperative day loops of bowel without free gas in the peritoneal cavity. in good general conditions with the indwelling bladder catheter. The patient went to a rehabilitation center for 3 months and then he returned to his residential home for elderly. The follow-up was only by phone. He had an episode of urinary tract infection onset of Alzheimer’s disease. Bilateral hydronephrosis secondary 4 months later due to the indwelling catheter. The Klebsiella of a tight phimosis occurred 2 months earlier. An indwelling pneumoniae urinary infection was treated with antibiotics with- bladder catheter was inserted for urinary retention and routinely out sequelae. Considering his conditions without symptoms, a changed. The patient had not prior surgical history. postoperative cystography wasn’t performed. His vital signs were blood pressure 115/60 mmHg, rhythmic pulse rate of 99 beats per minute, oxygen saturation 94% on room air and body temperature of 37.1 C. His urine output was 80 ml/h by a well-functioning catheter. DISCUSSION The physical examination showed a painful distended abdomen especially in the lower quadrants with a weak Spontaneous bladder perforation is a rare event and represents peristalsis and negative Blumberg sign. Laboratory analysis a challenging diagnosis even with the aid of CT imaging. The showed elevated white blood cells count and C-reactive protein risks of the rapture may be attributed to chronic inflammation (Table 1). such as infections or irradiation, to urinary retention due to Plain abdomen radiography was performed at the ED and outflow obstruction or neurogenic bladder, and to malignancies showed distended stomach and small bowel with air-fluid levels [1, 2]. Patients present acute abdominal pain and abdominal (Fig. 1). No free gas in the peritoneal cavity was seen. A contrast- distension due to free fluid in peritoneal space. Most of the enhanced CT scan revealed a huge gastrectasia with liquids, time, the diagnosis is intraoperatively as in our case. The mis- small bowel distention due to a suspected adherent bridle. Some diagnosis or delayed diagnosis of spontaneous bladder perfora- loops of the ileum showed emphysematous walls (Fig. 2). A min- tion can be life-threatening [5, 6]. Traumatic bladder ruptures imal perihepatic liquid effusion was observed due to suffering are more common extraperitoneal and strictly connected with bowel. pelvic fractures, whereas the most frequent site of spontaneous A conservative approach was performed with antibiotic ther- ruptures is intraperitoneal. The guidelines of bladder perforation apy, nasogastric (NG) and rectal tube insertion. Immediately management suggest a conservative approach with the insertion 2000 ml of enterobiliary fluid came out from the NG tube and the of bladder catheter for extraperitoneal ruptures and surgery for symptoms improved. During the night, the patient removed the intraperitoneal ones [7]. Exploratory laparoscopy can be safely Downloaded from https://academic.oup.com/jscr/article/2021/01/rjaa570/6102031 by DeepDyve user on 26 January 2021 Laparoscopy management for spontaneous bladder rupture 3 Figure 2: Axial CT scans of abdomen show gastrectasia with the NG tube just inserted (A) and a suspected image of bowel emphysematous walls (B). Figure 3: Intraoperative findings of the bladder diverticulum, before (A)and after(B) suture. performed also in emergency surgery and may offer a safe proce- INFORMED CONSENT dure with a high rate of correct identification in acute disease in Informed consent was obtained for all the patients enrolled in many abdominal emergencies [8, 9]. Laparoscopy improves post- clinical research studies. operative outcomes reducing the number of non-therapeutic laparotomies and days of recovery. CT cystography is recom- mended for a correct evaluation of each case when rupture is REFERENCES suspected [3]. In our case, the suspected preoperatively diagnosis 1. Ahmed J, Mallick IH, Ahmad SM. Rupture of urinary bladder: was a bowel obstruction and exploratory laparoscopy turned out a case report and review of literature. Cases J 2009;3:15–7. to be the therapeutic solution [4, 6, 10]. In the present patient, 2. Mitchell T, Al-hayek S, Patel B, Court F, Gilbert H. Acute the tight phimosis with urinary retention and the indwelling abdomen caused by bladder rupture attributable to neuro- catheter could be the greatest risk factors. We would like to genic bladder dysfunction following a stroke: a case report. J emphasize that the presence of a urinary catheter does not Med Case Reports 2011;5:254. preclude ruptures [2] and can hide urinary symptoms. Moreover, 3. Chan DPN, Abujudeh HH, Cushing GL, Novelline RA. CT in our patient, we suspect that the bladder perforation probably cystography with multiplanar reformation for suspected occurred long before the gastro-intestinal symptoms. bladder rupture: experience in 234 cases. Am J Roentgenol 2006;187:1296–302. 4. Parker H, Hoonpongsimanont W, Vace F, Lotfipour S. Spon- taneous bladder rupture in assosiation with alcoholic binge: CONCLUSION a case report and review of the literature. J Emerg Med In conclusion, emergency laparoscopic exploration is useful for 2009;37:386–9. the diagnosis and the treatment of spontaneous rupture of 5. Limon O, Unluer EE, Cakalagaoglu Unay F, Oyar O, Asli S. Case bladder diverticula. Urinary catheterization can be a risk factor report—an unusual cause of death: spontaneous urinary of intraperitoneal bladder rupture. We hope that this case report bladder perforation. Am J Emerg Med 2012;30:2081.e3–5. can be useful to give these patients better outcomes. 6. Sung C, Chang C, Chen S, Tseng W. Spontaneous rupture of urinary bladder diverticulum with pseudo-acute renal failure. Intern Emerg Med 2018;13:619–22. 7. Yeung LL, McDonald AA, Como JJ, Robinson B, Knight CONFLICT OF INTEREST STATEMENT J, Person MA, et al. Management of blunt force bladder None declared. injuries: a practice management guideline from the eastern Downloaded from https://academic.oup.com/jscr/article/2021/01/rjaa570/6102031 by DeepDyve user on 26 January 2021 4 S. Celotti et al. Association for the Surgery of trauma. J Trauma Acute Care 9. Nielsen LBJ, Tengberg LT, Bay-Nielsen M. Laparoscopy in Surg 2019;86:326–36. major abdominal emergency surgery seems to be a safe 8. Byrne J, Saleh F, Ambrosini L, Quereshy F, Jackson TD. procedure. Dan Med J 2017;64:3–8. Laparoscopic versus open surgical management of adhesive 10. Leahy OGJ. Splash! The spontaneous rupture of a bladder small bowel obstruction: a comparison of outcomes. Surg diverticulum: a rare cause of an acute abdomen. ANZ J Surg Endosc 2015;29:2525–32. 2013;83:792–3. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Laparoscopy management for spontaneous bladder rupture: a case report

Loading next page...
 
/lp/oxford-university-press/laparoscopy-management-for-spontaneous-bladder-rupture-a-case-report-ZDcKPFO8zA

References (13)

Publisher
Oxford University Press
Copyright
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2021.
eISSN
2042-8812
DOI
10.1093/jscr/rjaa570
Publisher site
See Article on Publisher Site

Abstract

We present a case of a 79-year-old man with lower abdominal pain and negative Blumberg sign. An indwelling bladder catheter was inserted for urinary retention due to a tight phimosis 2 months earlier. A contrast-enhanced computed tomography scan revealed a huge gastrectasia and small bowel distention due to a suspected adherent bridle. The clinical signs and the laboratory tests were highly suspicious for bowel obstruction and emergency surgery was indicated. Exploratory laparoscopy showed a bladder hole tamponade by an ileum loop. The perforation was sutured laparoscopically and the patient was discharged on the 14th postoperative day. In our case, emergency laparoscopic exploration was useful for the diagnosis and the treatment of spontaneous bladder rupture. We hope this case report can be useful to give these patients better outcomes. Notably we would like to emphasize that the presence of a urinary catheter can be a risk factor for intraperitoneal bladder rupture. tomography (CT) scans. A multidetector CT cystography is INTRODUCTION the gold standard for suspected bladder rupture evaluation Spontaneous bladder rupture is a rare and life-threatening event. [3]. Once the diagnosis is established, the management of The most common risk factors are chronic inflammation such spontaneous bladder rupture can be either non-operatively or as infections or irradiation, urinary retention due to outflow surgical. Surgery is indicated for intraperitoneal ruptures [4]. The obstruction or neurogenic bladder, and malignancies [1, 2]. In objective of this case report is to highlight the role of emergency these conditions, the development of bladder diverticula is eas- laparoscopic exploration. ier. Bladder diverticula are bulging sacs from weakness points on the bladder wall with a higher risk of perforation. The most frequent sites of diverticulum perforation described in the liter- CASE REPORT ature are intraperitoneal: bladder dome or posterior wall [1]. Patients with intraperitoneal bladder rupture present with A 79-year-old man was referred to our Emergency Department symptoms and signs of acute abdomen and the perforation (ED) for abdominal pain since morning without other symptoms. is often initially misdiagnosed even with the aid of computed His medical history consisted of Parkinson’s disease and recent Received: October 27, 2020. Revised: December 3, 2020. Accepted: December 10, 2020 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2021. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article/2021/01/rjaa570/6102031 by DeepDyve user on 26 January 2021 2 S. Celotti et al. Table 1. Preoperative laboratory tests in our ED Blood test Hemogasanalisis Leukocytes (×10 /l) 16.05 pCO2 (mmHg) 25.8 Hemoglobin (g/dl) 12.1 pO2 (mmHg) 71.4 Platelets (×10 /l) 188 BE (mmol/l) -5.6 C-Proteine Reactive (mg/dl) >7 HCO3- (mmol/l) 17 Creatinine (mg/dl) 1.3 Lactate (mmol/l) 1.10 PT-ratio (INR) 1.26 Sodium (mmol/l) 145.8 PTT-ratio 1.10 Potassium (mmol/l) 3.29 NG unintentionally, when a few hours later the tube was inserted again and 450 ml of fecal fluid were aspirated. The clinical signs and the worsened laboratory tests were highly suspicious for bowel obstruction and emergency surgery was indicated. A supra-umbilical Hasson’s port was inserted and exploratory laparoscopy showed turbid effusion in Morrison’s pouch, spleno- renal pouch and pouch of Douglas. Two more trocars of 10 mm were inserted. Running the small bowel, a loop appeared densely adherent to the bladder and releasing the bowel from adhe- sions a bladder hole was found out (Fig. 3). The rupture of a bladder diverticulum was tamponade by an ileal loop and was critically inflaming the peritoneal cavity. An accurate laparo- scopic adhesiolysis was performed. The ileal loops appeared vital and no bowel resection was necessary. The bladder hole was sutured with a knotless barbed suture. Dilute methylene blue was injected into the urinary catheter to check the watertight closure. No blue spreading was seen and a drain was inserted into pelvis. The surgery was performed by a skilled general surgeon and the consultant urologist wasn’t necessary. The postoperative course was characterized by Enterobac- ter aerogenes and Pseudomonas aeruginosa positive urine culture results. The drain was removed on the fifth postoperative day Figure 1: Plain abdomen radiography shows distended stomach and dilatated and the patient was discharged on the 14th postoperative day loops of bowel without free gas in the peritoneal cavity. in good general conditions with the indwelling bladder catheter. The patient went to a rehabilitation center for 3 months and then he returned to his residential home for elderly. The follow-up was only by phone. He had an episode of urinary tract infection onset of Alzheimer’s disease. Bilateral hydronephrosis secondary 4 months later due to the indwelling catheter. The Klebsiella of a tight phimosis occurred 2 months earlier. An indwelling pneumoniae urinary infection was treated with antibiotics with- bladder catheter was inserted for urinary retention and routinely out sequelae. Considering his conditions without symptoms, a changed. The patient had not prior surgical history. postoperative cystography wasn’t performed. His vital signs were blood pressure 115/60 mmHg, rhythmic pulse rate of 99 beats per minute, oxygen saturation 94% on room air and body temperature of 37.1 C. His urine output was 80 ml/h by a well-functioning catheter. DISCUSSION The physical examination showed a painful distended abdomen especially in the lower quadrants with a weak Spontaneous bladder perforation is a rare event and represents peristalsis and negative Blumberg sign. Laboratory analysis a challenging diagnosis even with the aid of CT imaging. The showed elevated white blood cells count and C-reactive protein risks of the rapture may be attributed to chronic inflammation (Table 1). such as infections or irradiation, to urinary retention due to Plain abdomen radiography was performed at the ED and outflow obstruction or neurogenic bladder, and to malignancies showed distended stomach and small bowel with air-fluid levels [1, 2]. Patients present acute abdominal pain and abdominal (Fig. 1). No free gas in the peritoneal cavity was seen. A contrast- distension due to free fluid in peritoneal space. Most of the enhanced CT scan revealed a huge gastrectasia with liquids, time, the diagnosis is intraoperatively as in our case. The mis- small bowel distention due to a suspected adherent bridle. Some diagnosis or delayed diagnosis of spontaneous bladder perfora- loops of the ileum showed emphysematous walls (Fig. 2). A min- tion can be life-threatening [5, 6]. Traumatic bladder ruptures imal perihepatic liquid effusion was observed due to suffering are more common extraperitoneal and strictly connected with bowel. pelvic fractures, whereas the most frequent site of spontaneous A conservative approach was performed with antibiotic ther- ruptures is intraperitoneal. The guidelines of bladder perforation apy, nasogastric (NG) and rectal tube insertion. Immediately management suggest a conservative approach with the insertion 2000 ml of enterobiliary fluid came out from the NG tube and the of bladder catheter for extraperitoneal ruptures and surgery for symptoms improved. During the night, the patient removed the intraperitoneal ones [7]. Exploratory laparoscopy can be safely Downloaded from https://academic.oup.com/jscr/article/2021/01/rjaa570/6102031 by DeepDyve user on 26 January 2021 Laparoscopy management for spontaneous bladder rupture 3 Figure 2: Axial CT scans of abdomen show gastrectasia with the NG tube just inserted (A) and a suspected image of bowel emphysematous walls (B). Figure 3: Intraoperative findings of the bladder diverticulum, before (A)and after(B) suture. performed also in emergency surgery and may offer a safe proce- INFORMED CONSENT dure with a high rate of correct identification in acute disease in Informed consent was obtained for all the patients enrolled in many abdominal emergencies [8, 9]. Laparoscopy improves post- clinical research studies. operative outcomes reducing the number of non-therapeutic laparotomies and days of recovery. CT cystography is recom- mended for a correct evaluation of each case when rupture is REFERENCES suspected [3]. In our case, the suspected preoperatively diagnosis 1. Ahmed J, Mallick IH, Ahmad SM. Rupture of urinary bladder: was a bowel obstruction and exploratory laparoscopy turned out a case report and review of literature. Cases J 2009;3:15–7. to be the therapeutic solution [4, 6, 10]. In the present patient, 2. Mitchell T, Al-hayek S, Patel B, Court F, Gilbert H. Acute the tight phimosis with urinary retention and the indwelling abdomen caused by bladder rupture attributable to neuro- catheter could be the greatest risk factors. We would like to genic bladder dysfunction following a stroke: a case report. J emphasize that the presence of a urinary catheter does not Med Case Reports 2011;5:254. preclude ruptures [2] and can hide urinary symptoms. Moreover, 3. Chan DPN, Abujudeh HH, Cushing GL, Novelline RA. CT in our patient, we suspect that the bladder perforation probably cystography with multiplanar reformation for suspected occurred long before the gastro-intestinal symptoms. bladder rupture: experience in 234 cases. Am J Roentgenol 2006;187:1296–302. 4. Parker H, Hoonpongsimanont W, Vace F, Lotfipour S. Spon- taneous bladder rupture in assosiation with alcoholic binge: CONCLUSION a case report and review of the literature. J Emerg Med In conclusion, emergency laparoscopic exploration is useful for 2009;37:386–9. the diagnosis and the treatment of spontaneous rupture of 5. Limon O, Unluer EE, Cakalagaoglu Unay F, Oyar O, Asli S. Case bladder diverticula. Urinary catheterization can be a risk factor report—an unusual cause of death: spontaneous urinary of intraperitoneal bladder rupture. We hope that this case report bladder perforation. Am J Emerg Med 2012;30:2081.e3–5. can be useful to give these patients better outcomes. 6. Sung C, Chang C, Chen S, Tseng W. Spontaneous rupture of urinary bladder diverticulum with pseudo-acute renal failure. Intern Emerg Med 2018;13:619–22. 7. Yeung LL, McDonald AA, Como JJ, Robinson B, Knight CONFLICT OF INTEREST STATEMENT J, Person MA, et al. Management of blunt force bladder None declared. injuries: a practice management guideline from the eastern Downloaded from https://academic.oup.com/jscr/article/2021/01/rjaa570/6102031 by DeepDyve user on 26 January 2021 4 S. Celotti et al. Association for the Surgery of trauma. J Trauma Acute Care 9. Nielsen LBJ, Tengberg LT, Bay-Nielsen M. Laparoscopy in Surg 2019;86:326–36. major abdominal emergency surgery seems to be a safe 8. Byrne J, Saleh F, Ambrosini L, Quereshy F, Jackson TD. procedure. Dan Med J 2017;64:3–8. Laparoscopic versus open surgical management of adhesive 10. Leahy OGJ. Splash! The spontaneous rupture of a bladder small bowel obstruction: a comparison of outcomes. Surg diverticulum: a rare cause of an acute abdomen. ANZ J Surg Endosc 2015;29:2525–32. 2013;83:792–3.

Journal

Journal of Surgical Case ReportsOxford University Press

Published: Jan 1, 2021

There are no references for this article.