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Iatrogenic bladder injury is a recognized rare complication of gynecological surgery and may result in significant morbidity when associated with intraperitoneal perforation. We present a case of iatrogenic bladder injury following tubectomy (minilap). We have also discussed conservative management of small intra-abdominal bladder injury, which could prevent unnecessary laparotomy. A 27-year-old, female presented to gynecological emergency with complaints of not being able to pass urine and abdominal distension for 3 days. She had history of undergoing tubectomy (minilap) at primary health center 3 days back. On CT scan, contrast could be seen in between bowel loops suggesting intraperitoneal bladder injury. Patient was managed conservatively. Simple step of evacuating bladder before any gynecological procedure may prevent devastating occurrence of bladder injury, which may go undiagnosed while doing minilap.
Iatrogenic bladder injury is a recognized complication of gynecological surgery and may result in significant morbidity when associated with intraperitoneal perforation. Most commonly it is seen during total laparoscopic hysterectomy (3%),1 transabdominal hysterectomy (0.4%),2 vaginal hysterectomy or during transvaginal tape (TVT) procedure. We present a case of iatrogenic bladder injury following tubectomy (minilap) and managed by conservative management.
A 27-year-old, P5L5, female presented to gynecological emergency with complaints of not being able to pass urine and abdominal distension for 3 days. She had history of undergoing tubectomy (minilap) at primary health center 3 days back. Following tubectomy, she was discharged same day but she returned with complaints of not being able to pass urine next day. Abdominal distension was noticed and she was kept nil per oral and put on intravenous fluids. In view of increasing abdominal distension, she was referred to our hospital. She was pale, dyspneic and having fever. Her pulse rate was 100/min and blood pressure was 110/70 mmHg.
On systemic examination, chest and cardiovascular system was normal. On per abdominal examination, there was generalized distension. Shifting dullness was present suggesting of free fluid and bowel sounds were absent. There were no signs of muscular guarding or rigidity. Foley’s catheterization was done and 200 cc of clear urine collected in urobag.
On investigations, all biochemical investigations like complete hemogram (Hb - 10 g/dL, TLC - 9,500/cc, DLC - 66N,30L,M2,E2), blood sugar (96 mg%), blood urea (36 mg%), serum electrolytes (serum Na+ - 138 mEq/mL, serum K+ - 4.1 mEq/mL), serum creatinine (0.8 mg%) were within normal limits. Abdominal drain kit (ADK) was put in abdominal cavity under local anesthesia, which drained 900 cc of pale-colored fluid with ammonia like odor. Specific gravity of fluid was 1.013 and urea levels were 36 mg% and creatinine levels of 480 µmol/mL. A diagnosis of urinary ascitis was made.
On ultrasound examination, uterus was normal, bilateral adnexae were normal and free fluid was +++. On retrograde cystogram, there was a rent of 5 mm on left side of dome of urinary bladder from which dye could be seen leaking into peritoneal cavity suggesting intraperitoneal bladder injury. On computed tomography (CT) scan, same findings were confirmed and contrast could be seen in between bowel loops (Fig. 1). Laparoscopic suturing of bladder was not done in view of late presentation and small leak. Patient was kept on intake output charting and was counseled for mobilization. Foley’s catheter was removed after 3 weeks and abdominal drain was removed after 2 days of Foley’s removal. Patient was followed up after 2 months and retrograde cystogram was done, which was found to be normal.
There are various immediate and delayed complications of tubectomy like low abdominal pain, dyspareunia and menstrual pattern changes which constitutes what is known as post-ligation syndrome, and technical failure (0.1-0.12/100 women years).3
Visceral injuries including gut and bladder are known to occur during laparoscopic tubectomy but rare with minilap tubectomy.4 Injury might have occurred due to small abdominal incision of minilap, less visibility and less expertise of the operating surgeon. Most of the bladder injuries described in the literature in gynecology are during dissection of bladder from cervix during vaginal or abdominal hysterectomy. Recently bladder injuries are also described during TVT procedure.
The anatomic proximity of the reproductive tract and lower urinary tract predisposes them to iatrogenic trauma during obstetric and gynecological surgeries. Bladder and distal ureters are most commonly involved organs.5 Risk factors for bladder injuries include previous surgical interventions, pelvic inflammatory disease, endometriosis, anatomic anomalies and pelvic adhesions.6 Pandyan et al reviewed retrospectively iatrogenic bladder injuries during obstetrics and gynecology procedures, they found 90% of injuries during obstetrics procedures and only 15% during gynecological procedures.5 Thus, though iatrogenic ureteric and bladder injuries are globally rare in gynecological procedures, they are liable to occur due to inherent anatomic and pathological factors in the pelvis. Ninety percent of urological injuries were recognized intraoperatively and managed.5 Our case of bladder injury was diagnosed after 4 days of tubectomy.7 The probability of injury varies according to degree of bladder distension, therefore, a full bladder is more likely to become injured than an empty one. When in doubt regarding iatrogenic bladder injury, methylene blue test should be done and if indicated surgical opinion should be taken regarding cystoscopy.
Repair of the bladder injury at the time of primary surgery is easier, more successful and less morbid for the patient and medicolegally advantageous for the surgeon. Delayed diagnosis is suspected when postoperatively there is oliguria, hematuria, elevated urea/creatinine ratio, lower abdominal pain, distension, paralytic ileus or urinary ascites as was seen in the present case.8 Thus, unexplained ascites and decreased renal function in a previously healthy person with a recent history of pelvic surgery should raise the suspicion of intraperitoneal bladder leak. A very high creatinine level in ascitic fluid is diagnostic of urinary ascites. An ascitic fluid creatinine: serum creatinine ratio >1 is highly suggestive of intraperitoneal urine leak.9
The management of bladder perforations has been a controversial issue. Usually, extraperitoneal perforations are managed by conservative management with temporary bladder drainage and intraperitoneal ruptures on the other hand, are usually managed primarily by open repair, mostly because of concern about communication between the environment and peritoneal cavity. Our case illustrates that even a conservative approach in the treatment of small intraperitoneal ruptures may be considered if a number of conditions are maintained: urinary antibiotic prophylaxis and continued urinary drainage through an indwelling catheter for a minimum of 2 weeks until closure of the perforation is evident on CT cystogram. Patients should be warned, however, that an unsuccessful result with persistent communication to the peritoneal cavity is possible.
Urinary bladder injury should be considered in the differential diagnosis of ascites in patients who have had recent pelvic surgery. Serum and ascites biochemistry in conjunction with CT cystography are key to diagnosis. Our case illustrates that a conservative approach is possible, even in cases with intraperitoneal rupture. Simple step of evacuating bladder before any gynecological procedure may prevent devastating occurrence of bladder injury, which may go undiagnosed while doing minilap. As part of tubectomy training more emphasis should be laid on how to suspect and diagnose bladder injuries during minilap tubectomy to avoid morbidity.
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Rapp de, corman jm. Conservative management of iatrogenic bladder injury with foreign body. Int urogynecol j pelvic floor dysfunct. 2008;19(9):1319-21.
Gomez rg, ceballos l, coburn m, corriere jn jr,dixon cm, lobel b, et al. Consensus statement on bladder injuries. Bju int. 2004;94(1):27-32.
Heyns cf, rimington pd. Intraperitoneal rupture of the bladder causing the biochemical features of renal failure. Br j urol. 1987;60(3):217-22.