Costas D. Lallas, MD, FACS
Leonard G. Gomella, MD, FACS
BASICS
DESCRIPTION
• Bladder injury during surgery can be either intraperitoneal or extraperitoneal.
• The bladder is the urologic organ most subjected to iatrogenic injury.
• Described during open, endoscopic, laparoscopic, or robotic procedures.
• May be blunt/sharp dissection, trocar, or electrocautery injury.
• Needle or trocar passage during transvaginal tape or pubovaginal sling procedures are particularly high-risk procedures.
• Cystoscopy with overdistension and transurethral bladder tumor resections are also high risk for bladder perforation injury.
EPIDEMIOLOGY
Incidence (1,2)
• Intraoperative bladder injuries account for:
– Laparoscopic injuries (0.2–8.3%)
– Laparoscopic injuries intraoperative diagnosis: 53.2%
• Location:
– Intraperitoneal (38–40%)
– Extraperitoneal (54–56%) of injuries
Prevalence
N/A
RISK FACTORS
• General factors
– Inexperienced surgeon
– Over aggressive TURBT or bladder biopsy
– Complex surgical anatomy (prior surgery or radiation therapy)
– Poor laparoscopic visualization
– Full/overdistended bladder
– Thin bladder wall (transurethral injury) more common in older females due to thin bladder wall
• Risk factors associated with specific conditions and procedures based on EAU review
– Cesarean delivery
Previous caesarean delivery
Previous pelvic surgery
Presence of labor
Station of presenting fet al part >+1
Fet al weight >4 kg
– Hysterectomy
Malignancy
Endometriosis
Prior pelvic surgery
Concomitant anti-incontinence or pelvic organ prolapse surgery
– General surgery
Malignancy
Diverticulitis
Inflammatory bowel disease
– Midurethral sling operations
Retropubic route
Previous caesarean delivery
Previous colposuspension
BMI <30 kg/m2
Rectocele
Procedures under local anesthesia
Inexperienced surgeon
– TURBT
Tumor size
Elderly patients
Pretreated bladder (previous TURB, intravesical instillation, radiotherapy)
Tumor location at the dome or in diverticulum
Genetics
N/A
PATHOPHYSIOLOGY
• Bladder injury with urinary leakage is consistent with complete tear through mucosa, submucosa, and muscularis
• Leakage of urine can be into the extra- or intraperitoneal space
• Perforation of the bladder dome during Veress needle or trocar insertion
• Large bladder perforations during TURBT requiring intervention are rare (0.16–0.57%)
– Extraperitoneal TURBT perforations are more frequent than intraperitoneal ones
ASSOCIATED CONDITIONS
• Bladder cancer
• Prostate benign and malignant tumors
• Pelvic anatomic anomalies
• Prior pelvic surgery or radiation
• Pelvic trauma
• Tissue fibrosis or inflammation (eg, radiation, chronic catheter)
GENERAL PREVENTION
• Decompress bladder with a catheter placed before initial incision or trocar placement for laparoscopic cases
• Initial use of Veress needle for insufflation
– Small bladder perforation not as significant as with trocar injury
– Open “Hasson” trocar technique
• Familiarity with bladder anatomy can minimize risk:
– Pediatric bladder is primarily intraperitoneal.
– Adult bladder is retropubic and extraperitoneal.
– Peritoneum is cephalad to bladder.
– Bladder is attached laterally and at bladder neck
– Bladder wall consists of 3 layers: Mucosa, submucosa, muscularis
– Ureters attached posterolateral in trigone
• Perform bladder biopsy or TURBT with bladder at mid filling
– Avoid over or underdistention that can increase risk of perforation of bladder
DIAGNOSIS
HISTORY
• Determine any prior surgical or other interventions that can increase the risk of intraoperative bladder injury
– Past surgical history such as bladder neck suspension, cesarean section, radical prostatectomy, partial cystectomy, ureteral reimplantation, any lower abdominal surgery that may result in the bladder adhering to the posterior fascia
– Prior pelvic radiation
– History of neurogenic bladder
PHYSICAL EXAM
• Intraoperative:
– Findings may be subtle. Need high degree of suspicion
– Blood or gas in Foley, especially during transperitoneal laparoscopic procedure
Anesthesia may be first to recognize if monitoring catheter collection bag
– Urine in wound
– For transurethral surgery: Intraoperative abdominal distension/rigidity may be noted or if hypotonic irrigation is being used, patient may develop signs/symptoms of TUR syndrome
• Postoperative:
– Distended abdomen
– Peritonitis and abdominal rebound pain
– Decreased urine production; oliguria or anuria
– Abdominopelvic ascites
– Urinoma
– Urine leakage from wound
– Bloody urine
– Fever
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• With urinary ascites elevation in serum BUN and creatinine as well as hyperkalemia and hyponatremia can be seen
– Elevated creatinine over serum level observed with urine leak due to systemic absorption
• Drain fluid sent for creatinine
– Urine vs. serum
Imaging
• Postoperative diagnosis (3):
– Extraperitoneal injury: Contrast contained in the extraperitoneal space
– Intraperitoneal injury: Contrast extravasates between loops of small bowel and the anterior pararenal fascia
• Cystogram can be done using standard technique or CT imaging with postcontrast evacuation (3)
– 300 cc gravity filling
– 3-view cystogram or CT cystogram
– All cystograms must include a postcontrast evacuation study to evaluate for residual contrast outside of the bladder
• US can identify urinoma
• CT for pelvic “urinary” ascites or urinoma
• Intraoperative diagnosis during transurethral surgery: Intraoperative cystogram can be obtained
Diagnostic Procedures/Surgery (1,4)
• Intraoperative diagnosis:
– Normal saline with indigo carmine into Foley and observe for extravasation (blue staining)
– Avoid use of methylene blue due to extensive tissue staining risk
• Intraoperative cystoscopy can be useful in selected situations and may be the most reliable method of immediately assessing bladder wall integrity
• Cystoscopy
– Recommended after suburethral sling operations via the retropubic route
– May be considered after sling insertion via the obturator route (controversial as bladder injuries are rare with this technique).
• Cystoscopy after transvaginal mesh procedures is preferable.
• Some authors have recommended routine cystoscopy due to the higher risk of bladder injuries during hysterectomy or after any major gynecologic procedure.
Pathologic Findings
Rupture through mucosa, submucosa, and muscularis of detrusor usually causes urine leak
DIFFERENTIAL DIAGNOSIS
• Prostatourethral injury
• Small or large bowel injury
• Ureteral injury
• Vascular injury
TREATMENT
GENERAL MEASURES
• Prompt recognition improves opportunity for improved outcome.
• Bladder injury can be found intraoperatively or postoperatively, and will be intraperitoneal or extraperitoneal.
• For most bladder injures Foley catheter for 10–14 days with follow-up cystogram is recommended
MEDICATION
First Line
• Consider antibiotics: Gentamicin or fluoroquinolone for 24 hr
• Anticholinergic for postoperative bladder spasm: Oral or suppository
Second Line
N/A
SURGERY/OTHER PROCEDURES (5)
• Laparoscopic or robotic injury:
– 1-layer laparoscopic or robotic repair
• Intraoperative intraperitoneal injury:
– Open bladder/2-layer repair
• Intraoperative extraperitoneal injury:
– Foley or 2-layer repair
• Postoperative intraperitoneal injury:
– Exploratory laparotomy with repair
• Postoperative extraperitoneal injury:
– Initial catheter drainage with antibiotics
• Transurethral procedure:
– Extraperitoneal perforation
Exploratory laparotomy with repair for large perforation. Carefully inspect bowel for potential injury
Small leak can be initially managed with catheter drainage and close monitoring
– Extraperitoneal perforation
– Usually managed with catheter drainage
– Large perforations complicated by symptomatic collections require drainage, with or without formal closure of the perforation
• Bladder perforation during midurethral sling or transvaginal mesh placement
– Sling reinsertion and urethral catheterization (1–2 days) should be performed (4,6).
ADDITIONAL TREATMENT
In the setting of any bladder perforation during TURBT intravesical postoperative chemotherapy should not be administered
ONGOING CARE
PROGNOSIS
• Extraperitoneal: Usually heals with Foley catheter drainage and without further intervention
• Intraperitoneal: Good prognosis if identified intraoperatively and repaired. Prognosis worse if delayed diagnosis
COMPLICATIONS
• Peritonitis or abscess
• Ileus
• Fistula
• Reoperation
FOLLOW-UP
Patient Monitoring
• Foley catheter or suprapubic tube to monitor urine output
• Usually no need for outpatient antibiotics
REFERENCES
1. Vakili B, Chesson RR, Kyle BL, et al. The incidence of urinary tract injury during hysterectomy: A prospective analysis based on universal cystoscopy. Am J Obstet Gynecol. 2005;192:1599–1604.
2. Ostrzenski, Ostrzenska KM. Bladder injury during laparoscopic surgery. Obstet Gynecol Surv. 1998;53(3):175–180.
3. Cass AS. Diagnostic studies in bladder rupture. Urolog Clinc North Am. 1989;16:267–273.
4. Gomez, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int. 2004;94(1):27–32.
5. Corriere JN, Sandler CM. Diagnosis and management of bladder injuries. Urol Clin North Am. 2006;33:67–71.
6. Stav K, Dwyer PL, Rosamilia A, et al. Risk factors for trocar injury to the bladder during mid urethral sling procedures. J Urol. 2009;182:174–179.
ADDITIONAL READING
EAU Guidelines on Iatrogenic Trauma - European Association of Urology www.uroweb.org, Accessed February 2, 2014.
See Also (Topic, Algorithm, Media)
• Bladder Trauma
• TUR Syndrome
• Ureter, Intraoperative Injury
• Ureter, Trauma
CODES
ICD9
• 867.0 Injury to bladder and urethra, without mention of open wound into cavity
• 867.1 Injury to bladder and urethra, with open wound into cavity
• 998.2 Accidental puncture or laceration during a procedure, not elsewhere classified
ICD10
• N99.71 Acc pnctr & lac of a GU sys org during a GU sys procedure
• N99.72 Accidental pnctr & lac of a GU sys org during oth procedure
• S37.23×A Laceration of bladder, initial encounter
CLINICAL/SURGICAL PEARLS
• Intraoperatively, visual inspection is a reliable method of assessing bladder injury.
• Extraperitoneal: Usually heals with Foley catheter drainage and without further intervention.
• Intraperitoneal: Good prognosis if identified intraoperatively and repaired. Prognosis worse if delayed diagnosis.
• All cystograms must include a postcontrast evacuation study to evaluate for residual contrast outside of the bladder.