Successful Percutaneous Embolization of a Persistent Extraperitoneal Bladder Leak

Abstract

In contradistinction to intraperitoneal bladder injuries, isolated extraperitoneal bladder rupture (EPR) is traditionally managed nonoperatively via continuous decompression by transurethral or suprapubic catheterization [1, 2]. Once placed, such catheters are maintained anywhere from 10 to 21 days, thereby allowing evacuation of blood and healing by secondary intention of the bladder wall [3]. Although this treatment strategy is the accepted standard for EPR, only retrospective data exist to support its use [2]. Correire and Sandler’s [4] 1986 single-center study found 39 patients with EPR and a success rate of 87 % for catheterization alone. Kotkin and Koch’s [5] 1995 article included similar data from a single-center study with 85 % success of their 70 patients, identifying complex pelvic injuries as a major predictor of failure of nonoperative management. To our knowledge, there have been no reported cases of a percutaneous technique for the repair. A 53-year-old male presented to our trauma bay after falling 20 feet from a rooftop. The patient had a grossly deformed right hip and pelvic x-ray revealed an open-book pelvic fracture. In addition to retroperitoneal bleeding, CT cystography displayed an extraperitoneal bladder rupture (EPR, Fig. 1). Hemorrhage was controlled via embolotherapy and pelvic stabilization. The patient’s EPR was initially managed by transurethral catheter placement. Six weeks after the initial injury, repeat cystogram found persistent urinary extravasation from the bladder. The patient underwent attempt at operative repair of the bladder, but a third cystogram 2 weeks later again found persistent urinary extravasation into a contained cavity. The patient also had unremitting pain in this region. Further attempts at operative repair were felt to be futile. An ethylene vinyl chloride copolymer (Onyx 34, Covidien, Mansfield, MA) therefore was placed percutaneously into the pseudodiverticulum cavity via the following technique. Dilute contrast was infused through the existing Foley catheter to opacify the bladder. A cone beam CT was then performed to identify the precise location of the bladder pseudodiverticulum. Using the XperGuide CT system (Philips, Andover, MA), a 21-gauge micropuncture needle was advanced from the low anterior abdominal/pubic level into the pseudodiverticulum. There was free flow of contrast across the neck and into the bladder. A 0.014-in. SV-5 guidewire (Cordis, Bridgewater, NJ) was advanced through the access needle into the pseudodiverticulum, through its neck, and into the bladder. The Foley catheter was then backed out over a 0.035-in. hydrophilic guidewire and a 10-Fr sheath was advanced into the bladder through the penile urethra. Through the sheath, a 15-mm diameter gooseneck snare was advanced and used to capture the tip of the guidewire. The wire was then pulled out through the sheath and thus ‘‘through and through’’ access was M. Radomski (&) J. Messing B. Sarani Division of Trauma & General Surgery, George Washington University, 2150 Pennsylvania Ave. NW, Washington, DC 20037, USA e-mail: michal.radomski.1@gmail.com