Keywords

Tubectomy, bladder injury, intraperitoneal perforation, minilap, conservative management

Introduction

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 trans vaginal tape(TVT) procedure. We present a case of iatrogenic bladder injury following tubectomy (minilap) and managed by conservative management.

About the Authors

Shaveta Jain- Assistant professor, Department- Obstetrics and Gynecology, Pt. B.D Sharma, PGIMS Rohtak, India 124001

Roopa Malik- Associate professor, Department- Obstetrics and Gynecology, Pt. B.D Sharma, PGIMS Rohtak, India 124001

Smiti Nanda- Professor & Head, Department- Obstetrics and Gynecology, Pt. B.D Sharma, PGIMS Rohtak, India 124001

Nitin Jain Senior resident, Department- Radiology, Pt. B.D Sharma, PGIMS Rohtak, India 124001

Case report

A 27 years old,P5L5, female presented to gynecological emergency with complaints of not able to pass urine and abdominal distension for three days. She had history of undergoing tubectomy (minilap) at primary health centre three days back. Following tubectomy she was discharged same day but she returned with complaint of not able to pass urine next day. Abdominal distension was noticed and she was kept nil per oral and on intravenous fluids. In view of increasing abdominal distension she was referred to our hospital. She was pale, dyspnic, and having fever. Her pulse rate was 100/min and blood pressure was 110/70mm Hg. 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 haemogram (Hb 10gm%,TLC 9500/cc,DLC 66N,30L,M2,E2) ,blood sugar (96mg%),blood urea (36mg%),serum electrolytes (S.Na+ 138meq/ml,S.K+4.1meq/ml), S. creatinine (0.8mg%) were within normal limits. ADK (Abdominal drain kit) drain was put in abdominal cavity under local anesthesia which drained 900cc of pale colored fluid with ammonia like odor. Specific gravity of fluid was 1.013 and urea levels were 36mg%. and creatinine levels of 480 μmol/mL A diagnosis of urinary ascitis was made. On ultrasound examination ,uterus was normal ,bilateral adenexae were normal and free fluid was +++.On retrograde cystogram ,there was a rent of 5mm on left side of dome of urinary bladder from which dye could be seen leaking into peritoneal cavity suggesting intraperitoneal bladder injury. On 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 two days of Foley’s removal. Patient was followed up after two months and retrograde cystogram was done which was found to be normal.

Discussion

There are various immediate and delayed complications of tubectomy like low abdominal pain, dysperunia, menstrual pattern changes which constitutes what is known as postligation 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 mini lap, 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 transvaginal tape (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]. Pandayan etal reviewed retrospectively iatrogenic bladder injuries during obstetrics and gynecology procedures they found 90 % of injury during obstetrics procedures and only 15 % 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. 90 % of urological injury were recognized intraoperatively and managed [5]. Our case of bladder injury was diagnosed after four 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 then 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, haematuria, 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 two 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.

Conclusion

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.

References

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