A Case of Bladder Perforation With Rectal Impalement Injury

Bladder perforation with rectal impalement injury: Usefulness of exploratory laparoscopy for excluding intraperitoneal perforation

The diversity of objects that can be found in the urinary bladder often surpasses the urologist's imagination and mostly they are introduced per urethrally. Impalement injuries of the rectum with...

Context:Impalement injuries of the rectum with bladder perforation have been rarely reported. Such lesions have been associated with increased postoperative morbidity. A well-conducted preoperative evaluation of the lesions tends to prevent such complications.Aims:To increase awareness about patients with rectal impalement that involve bladder injuries and to examine the significance of thorough clinical examination and complementary investigation for these patients’ management.Materials and Methods:Retrospectively, we identified three patients with rectal impalement and bladder perforation treated in University Hospital Hassan II, Fez, Morocco. We recorded the symptoms, subsequent management, and further follow-up for each patient. All available variables of published cases were reviewed and analyzed.Results:Evident urologic symptoms were present in only one patient. Bladder perforation was suspected in two other patients on the basis of anterior rectal perforation in digital exam. Retrograde uroscanner could definitely confirm the diagnosis of bladder perforation. Fecal and urine diversion was the basis of the treatment. No postoperative complications were noted. We have reviewed 14 previous reports. They are presented mainly with urine drainage through the rectum. Radiologic investigation (retrograde cystography and retrograde uroscanner) confirmed bladder perforation in 10 patients (71.4%). Unnecessary laparotomy was performed in six patients (42.8%). Fecal diversion and urinary bladder decompression using urethral catheter were the most performed procedures in bladder perforation [6/14 patients (42.8%)]. No specific postoperative complications were reported.Conclusions:A high index of clinical suspicion is required to make the diagnosis of bladder perforation while assessing patients presenting with rectal impalement. Meticulous preoperative assessment is the clue of successful management.

Despite bladder perforation (BP) is a frequent complication during transurethral resection of bladder (TURB) for bladder cancer (BCa), literature lacks systematic reviews focusing on this issue. We aimed to investigate incidence, diagnosis, therapy, and prognosis after BP during TURB for BCa; therapy was distinguished between conservative (without the need for bladder repair) and surgical management (requiring bladder wall closure). A systematic search was conducted up to April 2021 using PubMed, Scopus, Cochrane Database of Systematic Reviews, and Web of Science to identify articles focusing on incidence, detection, management, or survival outcomes after iatrogenic BP. The selection of articles followed the preferred reporting items for systematic review and meta-analyses process. We included 41 studies, involving 21,174 patients. Overall, 521 patients experienced BP during TURB for BCa, with a mean incidence of 2.4%, up to 58.3% when postoperative cystography is routinely performed after all TURB procedures. Risk factors were low body mass index (BMI) (P=0.01), resection depth (P=0.006 and P=0.03), and low surgical experience (P=0.006). Extraperitoneal BP (68.5%) were treated conservatively in 97.5% of patients; intraperitoneal BP were managed with surgical bladder closure in 56% of cases. Overall, three immediate BP-related deaths were recorded due to septic complications. Extravesical tumor seeding was observed after 6 intraperitoneal and 1 extraperitoneal BP (median time: 6.2 months). Intraperitoneal BP (P=0.0003) and bladder closure (P<0.001) were found as independent predictors of extravesical tumor recurrence. BP is more frequent than expected when proper diagnosis is routinely performed after all TURB procedures. Risk factors include low BMI, resection depth, and unexperienced surgeon. The risk of sepsis after BP suggests empirical antibiotic prophylaxis after BP.

Biochemical predictors for differentiating intraperitoneal and extraperitoneal bladder perforation

Recurrent spontaneous bladder perforation: a complication of laparoscopic colposuspension?

Extraperitoneal bladder perforation is a known complication of a commonly performed rigid cystoscopy. If unrecognized, this complication can lead to continuous intra-abdominal fluid leakage with consequent organ function impairment and symptoms. This is the first case report in literature of a transurethral bladder perforation causing an acute abdominal compartment syndrome, which was subsequently managed conservatively with supportive management only. Case Presentation. We describe a clinical course of a 73-year-old Caucasian female whose initial acute presentation involved urinary symptoms. Surgery and general anaesthesia during rigid cystoscopy were complicated by an initially unrecognized extraperitoneal bladder perforation, resulting in fluid extravasation. This extravasation resulted in transurethral bladder resection syndrome with acute intra-abdominal free fluid accumulation. This complication caused acute abdominal compartment syndrome resulting in respiratory end-organ compromise and immediate postextubation respiratory failure. Patient required an emergency reintubation. During the management, diagnosis was considered through the use of the point of care abdominal ultrasound. Postoperatively, patient was managed conservatively in intensive care. Postoperative course included an approximate nine liters of urinary diuresis and supportive ventilation for four days. Conclusion. There is equipoise in the clinical management of abdominal compartment syndrome with regard to supportive medical management alone or invasive surgical treatment.

Combined intra- and extra-peritoneal bladder perforation following rectal impalement injury

Pediatric anorectal impalement with bladder rupture: case report and review of the literature

Impalement injury of the urinary bladder, especially secondary to rectal impalement, is extremely rare. In this case, a 31-year-old man sustained a steel pipe impalement injury through his perirectal region. He presented with gross hematuria, abdominal defense, and a penetrating wound. On the basis of the computed tomography findings and abdominal defense, we suspected a through-and-through bladder perforation from the rectal space to the intraperitoneum. Laparotomy revealed a through-and-through bladder perforation as well as damage to the right ureter, 3 distinct ileal injuries, and rectal anterior, anal, and right seminal vesicle injuries. Surgical repair of each damaged site was undertaken. The prompt diagnosis and surgical repair ensured good postoperative recovery.

Structural Allograft Implantation for Thoracic Spinal Impalement

Continuous Ambulatory Peritoneal Dialysis is a recommended mode of renal replacement therapy in those with vascular access failures. Complications of Surgical placement of catheter and Percutaneous technique by Nephrologist are well described. Complications may occur during the procedure or after the procedure. During the placement of the catheter, hollow viscus perforation is known to occur. Patients are given instructions of using laxative , emptying bladder before surgery in order to avoid bladder or bowel injury. Bladder perforation is one of the rare complication of CAPD technique.It is expected to occur commonly with rigid catheters than the soft catheters used in CAPD. Herein we report a case of bladder perforation during the procedure of placement of percutaneous CAPD catheterization.

Stage 5 kidney disease requires renal function replacement therapy, either through hemodialysis or peritoneal dialysis. Among the complications related to the placement of a peritoneal dialysis catheter are the mechanical ones, that include flow obstruction, peritoneal fluid leak, hernias, inadequate catheter position or injury to an intra-abdominal organ. A rare complication is the accidental catheter placement in the urinary bladder. Bladder perforation is favored when there is incomplete emptying of the bladder, a surgical history, and alterations in the lower urinary tract. A case of bladder perforation after catheter placement and a review of this subject is presented. 64-year-old female patient presented with Tenckhoff catheter dysfunction. She was scheduled for catheter removal and placement. During the start of the infusion of dialysis solution, the patient started to feel the urgent need to urinate. A simple abdominal tomography was requested, confirming the catheter in the bladder. The risk factors for bladder injury after catheter placement are diabetes, neurogenic bladder, urinary obstruction and previous abdominal surgeries. In the presence of them, a careful approach to the cavity must be made, including bladder catheterization in cases where complete bladder emptying is not guaranteed.

IntroductionAlthough vascular anatomy of the rectum is complex, pseudoaneurysm followed by massive hemoperitoneum after rectal impalement injury is extremely rare. Case presentationA 43-year-old man presented with abdominal distension. One day earlier, he had undergone sigmoid loop colostomy for rectal implement injury at a local hospital. After the operation, he had become hemodynamically unstable. Digital rectal examination showed a penny-sized anterior rectal wall defect 6 cm from the anal verge. Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with bleeding in the pelvic cavity and an adjacent pseudoaneurysm in the rectum. A large amount of blood and massive hematoma were evacuated by surgery. The Hartmann procedure was performed, but the pseudoaneurysm was not resected. On the 11th postoperative day, hemoglobin decreased (11.6 g/dL–7.9 g/dL), and CT revealed a recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity, with a residual pseudoaneurysm. Angiography failed to localize the pseudoaneurysm. Consequently, prophylactic embolization at the anterior branch of both the internal iliac arteries was performed. The subsequent hospitalization course was uneventful. DiscussionRectal impalement injury may result in pseudoaneurysm of the rectal arteries. However, pseudoaneurysm rupture of the mid rectal artery, followed by massive hemoperitoneum, has not been reported in the English literature. From our experience, preoperative diagnosis of a pseudoaneurysm is crucial for definite surgical management. When surgical resection is indicated, it should include the underlying pseudoaneurysm. ConclusionAlthough pseudoaneurysm rupture causing hemoperitoneum after a rectal impalement injury is extremely rare, meticulous preoperative evaluation is necessary for correct management.

Impalement injuries are a unique form of penetrating trauma and are typically associated with a fall onto the object (Steele, 2006). We present the case of a 45-year-old man who reportedly slipped in his bathtub and fell onto a broomstick. Radiographic examination revealed a slender mass extending from his rectum to the right side of his neck. A review of English literature suggests that this is the second reported case in the last 100 years describing the successful management of an impalement injury traversing the pelvic, abdominal, and thoracic cavities. The management of this case is described.