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Bladder Perforations Secondary to Surgical Drains
0022-534 7/79/1214-0521$2 .00/0 Vol. 121, April
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1979 by The Williams & Wilkins Co.
BLADDER PERFORATIONS SECONDARY TO SURGICAL DRAINS JOHN G. HUBBARD, MOHAMMAD AMIN* AND HIRAM C. POLK, JR. From the Section of Urology, Department of Surgery, University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky
ABSTRACT
Three patients with complications secondary to pelvic surgical drains are described. The mechanism and management of complication as well as methods of prevention are discussed. Use of a variety of drains in the pelvis is not only advisable but frequently essential for the success of complicated surgical procedures. However, complications secondary to placement of these drains occur occasionally. Herein are described 3 such cases, with emphasis upon the prevention of these particular complications. Perforation of the bladder is an uncommon occurrence when external trauma and urologic instrumentation are excluded as etiologic factors. Occasionally, Foley catheter drainage causes bladder perforation. 1- 3 Laparoscopy, 4 uterine curettage5 and intrauterine devices6 have been reported to cause bladder perforation. Raghavaiah and Devi observed a 22 per cent incidence of bladder injury in cases of uterine rupture, a commonly encountered obstetrical problem in developing countries. 7 Spontaneous rupture of the bladder is a rare phenomenon that may be idiopathic or attributable to a pathologic process in the bladder. 8 CASE REPORTS
Case 1 . A 22-year-old woman was admitted to the hospital with a 1-week history of right lower quadrant abdominal pain. Exploratory laparotomy revealed a large pelvic abscess, presumably the result of a ruptured appendix. Definite diagnosis could not be obtained because of marked inflammatory reaction and obliteration of anatomic structures. Postoperatively, the patient had a septic course and re-exploration was necessary. A ruptured retrocecal appendix was removed and a large pelvic abscess was drained with a sump and 2 Penrose drains. Wound dehiscence developed 8 days postoperatively. Large amounts of serous fluid then began to drain from the lower portion of the wound. An excretory urogram (IVP) disclosed minimal dilatation of the right ureter and a cystogram showed extravasation from the posterior part of the bladder (fig. 1). Cystoscopy disclosed the 2 Penrose drains to be inside the bladder adjacent to the right ureteral orifice. The drains were pulled to a position outside the bladder and Foley catheter drainage of the bladder was instituted. Drainage from the incision diminished gradually and the incision was healed completely within 2 weeks. An IVP 6 months later was normal and the patient was free of symptoms. Case 2. A 43-year-old woman underwent hysterectomy followed by radiation therapy for a stage 11-B carcinoma of the cervix in 1967. Later that year left nephrectomy was done for a perinephric abscess. The patient had no further problems until August 1975, when she presented with a painful left flank mass. A large abscess was drained and 2 sump and 2 Penrose drains were left in the cavity. IVP, cystoscopy, retrograde ureterogram of the left ureteral stump, sigmoidoscopy, barium enema contrast study and sinogram were not
diagnostic. The abscess cavity healed and the patient was discharged from the hospital. She was rehospitalized 6 weeks later with purulent drainage from the left flank wound. A sinogram revealed a communication to the sigmoid colon. A right transverse colostomy was performed. Two sump drains were placed in the abscess, which changed little in size. The patient was discharged from the hospital 1 month later with the sump drains still in place. She did well for 6 weeks with a gradual decrease in abscess drainage. However, she was then rehospitalized with watery drainage accompanied by decreased urinary output. She became anuric during the first 24 hours after admission but the blood urea nitrogen value remained normal. An IVP showed a normal right kidney with surgical absence of the left kidney. Cystoscopy disclosed 2 sump drains protruding into the bladder. The drains were advanced to a position outside the bladder but remained on continuous suction. Bladder drainage with a Foley catheter was instituted. A repeat cystogram 2 days later showed remaining extravasation with contrast material being suctioned out of the bladder by the drains (fig. 2). The sump drains were withdrawn further and suction was discontinued. Complete cessation of sump drainage occurred 3 weeks later and urinary output from the bladder catheter was normal. Case 3. A 59-year-old woman had exploratory laparotomy in 1968 for pseudomucinous cystadenocarcinoma of the left ovary. The tumor was locally extensive and, thus, not amenable to total removal. Therefore, a course of radiation therapy was instituted. The pelvic mass persisted after radiation therapy and extensive resection, including the small intestine, left side of the bladder and left distal ureter, was done. The
Accepted for publication July 28, 1978. Read at annual meeting of Southeastern Section, American Urological Association, Louisville, Kentucky, April 8-12, 1978. * Requests for reprints: Department of Surgery, University of Fm. 1. Case 1. Cystogram shows extravasation from posterior Louisville School of Medicine, Health Sciences Center, P.O. Box part of bladder. 35260, Louisville, Kentucky 40232. 521
522
HUBBARD, AMIN AND POLK
Fm. 3. Case 3. Cystogram shows extravasation from left side of bladder near tip of Foley catheter.
the bladder, weakened because of a previous operation, was the site of perforation in the third case. Suction had a definite role in the non-healing of the bladder fistula and also may have been responsible for pressure necrosis and, hence, perfoFm. 2. Case 2. Cystogram shows contrast material being suc- ration. The perforations sealed in 10, 21 and 28 days, respectively. Cases 2 and 3 had prolonged drainage because of tioned from bladder by 2 sump drains. continuation of suction. Injudicious placement and retention of drains of all types resected end of the left ureter was ligated to close off the left may cause erosion of vital structures. The possibility of urinary system completely. Postoperatively, a left vesicovaginal fistula required 2 addi- bladder perforation should be kept in mind when draining a tional operations for repair. The patient remained free of pelvic abscess. An empty bladder is less amenable to perforasymptoms until June 1975, when she was admitted to the tion. Therefore, an indwelling catheter in the bladder may hospital with acute obstruction of the small intestine. Explor- prevent injury from perivesical drains. The patients described atory laparotomy showed multiple adhesions but no evidence herein were treated conservatively by gradual withdrawal of of tumor recurrence. A segment of ileum was necrotic and was the drains and drainage of the bladder with a Foley catheter, resected with end-to-end anastomosis. Postoperatively, wound plus discontinuation of suction. No recurrence of bladder dehiscence and an enterocutaneous fistula developed. Laparot- fistula has been observed in these patients. omy was done to resect the fistula and a large pelvic abscess REFERENCES was drained with a 24F 3-way Foley catheter placed on low 1. Hughes, J. P., Gambee, J. and Edwards, C.: Perforation of the Gomco suction. Postoperatively, drainage from the abscess bladder: a complication of long-dwelling Foley catheter. J. increased while urinary output decreased. Cystography 4 days Urol., 109: 237, 1973, later showed extravasation of contrast material from the left 2. Milles, G.: Catheter-induced hemorrhagic pseudopolyps of the side of the bladder near the tip of the Foley catheter (fig. 3). urinary bladder. J.A.M.A., 193: 968, 1965. The Foley catheter was pulled back but suction was continued. 3. Rubinstein, A., Benaroya, Y. and Rubinstein, E.: Letter: Foley Urinary leakage persisted until the suction was discontinued catheter perforation of the urinary bladder. J.A.M.A., 236: and a Penrose drain was substituted for the Foley catheter. 822, 1976. During the next week the drainage ceased completely and the 4. Georgy, F. M., Fetterman, H. H. and Chefetz, M. D.: Complication of laparoscopy: two cases of perforated urinary bladder. patient was discharged from the hospital with an indwelling Amer. J. Obst. Gynec., 120: 1121, 1974. bladder catheter. A cystogram 6 weeks later showed no 5. Rous, S. N., Major, F. and Gordon, M.: Rupture of the bladder leakage and the catheter was removed. This patient has secondary to uterine vacuum curettage: a case report and remained free of symptoms. DISCUSSION
In the 3 patients described 3 different types of drains were involved: 1) Penrose, 2) Saratoga sump and 3) 24F 3-way Foley catheter. Multiple factors presumably facilitated bladder perforation in these patients. Perivesical inflammatory reaction, which may weaken the bladder wall, was a factor in all 3 cases. In the first case extensive perivesical inflammation for a prolonged period facilitated bladder perforation by a soft (Penrose) drain. Radiation therapy to the pelvis in the second case may have had a part in causing erosion of the bladder by a hard (sump) drain during prolonged drainage. An area of
review of the literature. J. Urol., 106: 685, 1971. 6. Saronwala, K. C., Singh, R. and Dass, H.: Lippes loop perforation of the uterus and urinary bladder with stone formation. Obst. Gynec., 44: 424, 1974. 7. Raghavaiah, N. V. and Devi, A. I.: Bladder injury associated with rupture of the uterus. Obst. Gynec., 46: 573, 1975. 8. Evans, R. A., Reece, R. W. and Smith, M. J. V.: Idiopathic rupture of the bladder. J. Urol., 116: 565, 1976.
EDITORIAL COMMENT A word of caution regarding the placement of drains in the pelvis is well worthwhile and I would emphasize the inadvisability of using drains made of material with any degree of stiffness. J.J.M.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1979 by The Williams & Wilkins Co.
BLADDER PERFORATIONS SECONDARY TO SURGICAL DRAINS JOHN G. HUBBARD, MOHAMMAD AMIN* AND HIRAM C. POLK, JR. From the Section of Urology, Department of Surgery, University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky
ABSTRACT
Three patients with complications secondary to pelvic surgical drains are described. The mechanism and management of complication as well as methods of prevention are discussed. Use of a variety of drains in the pelvis is not only advisable but frequently essential for the success of complicated surgical procedures. However, complications secondary to placement of these drains occur occasionally. Herein are described 3 such cases, with emphasis upon the prevention of these particular complications. Perforation of the bladder is an uncommon occurrence when external trauma and urologic instrumentation are excluded as etiologic factors. Occasionally, Foley catheter drainage causes bladder perforation. 1- 3 Laparoscopy, 4 uterine curettage5 and intrauterine devices6 have been reported to cause bladder perforation. Raghavaiah and Devi observed a 22 per cent incidence of bladder injury in cases of uterine rupture, a commonly encountered obstetrical problem in developing countries. 7 Spontaneous rupture of the bladder is a rare phenomenon that may be idiopathic or attributable to a pathologic process in the bladder. 8 CASE REPORTS
Case 1 . A 22-year-old woman was admitted to the hospital with a 1-week history of right lower quadrant abdominal pain. Exploratory laparotomy revealed a large pelvic abscess, presumably the result of a ruptured appendix. Definite diagnosis could not be obtained because of marked inflammatory reaction and obliteration of anatomic structures. Postoperatively, the patient had a septic course and re-exploration was necessary. A ruptured retrocecal appendix was removed and a large pelvic abscess was drained with a sump and 2 Penrose drains. Wound dehiscence developed 8 days postoperatively. Large amounts of serous fluid then began to drain from the lower portion of the wound. An excretory urogram (IVP) disclosed minimal dilatation of the right ureter and a cystogram showed extravasation from the posterior part of the bladder (fig. 1). Cystoscopy disclosed the 2 Penrose drains to be inside the bladder adjacent to the right ureteral orifice. The drains were pulled to a position outside the bladder and Foley catheter drainage of the bladder was instituted. Drainage from the incision diminished gradually and the incision was healed completely within 2 weeks. An IVP 6 months later was normal and the patient was free of symptoms. Case 2. A 43-year-old woman underwent hysterectomy followed by radiation therapy for a stage 11-B carcinoma of the cervix in 1967. Later that year left nephrectomy was done for a perinephric abscess. The patient had no further problems until August 1975, when she presented with a painful left flank mass. A large abscess was drained and 2 sump and 2 Penrose drains were left in the cavity. IVP, cystoscopy, retrograde ureterogram of the left ureteral stump, sigmoidoscopy, barium enema contrast study and sinogram were not
diagnostic. The abscess cavity healed and the patient was discharged from the hospital. She was rehospitalized 6 weeks later with purulent drainage from the left flank wound. A sinogram revealed a communication to the sigmoid colon. A right transverse colostomy was performed. Two sump drains were placed in the abscess, which changed little in size. The patient was discharged from the hospital 1 month later with the sump drains still in place. She did well for 6 weeks with a gradual decrease in abscess drainage. However, she was then rehospitalized with watery drainage accompanied by decreased urinary output. She became anuric during the first 24 hours after admission but the blood urea nitrogen value remained normal. An IVP showed a normal right kidney with surgical absence of the left kidney. Cystoscopy disclosed 2 sump drains protruding into the bladder. The drains were advanced to a position outside the bladder but remained on continuous suction. Bladder drainage with a Foley catheter was instituted. A repeat cystogram 2 days later showed remaining extravasation with contrast material being suctioned out of the bladder by the drains (fig. 2). The sump drains were withdrawn further and suction was discontinued. Complete cessation of sump drainage occurred 3 weeks later and urinary output from the bladder catheter was normal. Case 3. A 59-year-old woman had exploratory laparotomy in 1968 for pseudomucinous cystadenocarcinoma of the left ovary. The tumor was locally extensive and, thus, not amenable to total removal. Therefore, a course of radiation therapy was instituted. The pelvic mass persisted after radiation therapy and extensive resection, including the small intestine, left side of the bladder and left distal ureter, was done. The
Accepted for publication July 28, 1978. Read at annual meeting of Southeastern Section, American Urological Association, Louisville, Kentucky, April 8-12, 1978. * Requests for reprints: Department of Surgery, University of Fm. 1. Case 1. Cystogram shows extravasation from posterior Louisville School of Medicine, Health Sciences Center, P.O. Box part of bladder. 35260, Louisville, Kentucky 40232. 521
522
HUBBARD, AMIN AND POLK
Fm. 3. Case 3. Cystogram shows extravasation from left side of bladder near tip of Foley catheter.
the bladder, weakened because of a previous operation, was the site of perforation in the third case. Suction had a definite role in the non-healing of the bladder fistula and also may have been responsible for pressure necrosis and, hence, perfoFm. 2. Case 2. Cystogram shows contrast material being suc- ration. The perforations sealed in 10, 21 and 28 days, respectively. Cases 2 and 3 had prolonged drainage because of tioned from bladder by 2 sump drains. continuation of suction. Injudicious placement and retention of drains of all types resected end of the left ureter was ligated to close off the left may cause erosion of vital structures. The possibility of urinary system completely. Postoperatively, a left vesicovaginal fistula required 2 addi- bladder perforation should be kept in mind when draining a tional operations for repair. The patient remained free of pelvic abscess. An empty bladder is less amenable to perforasymptoms until June 1975, when she was admitted to the tion. Therefore, an indwelling catheter in the bladder may hospital with acute obstruction of the small intestine. Explor- prevent injury from perivesical drains. The patients described atory laparotomy showed multiple adhesions but no evidence herein were treated conservatively by gradual withdrawal of of tumor recurrence. A segment of ileum was necrotic and was the drains and drainage of the bladder with a Foley catheter, resected with end-to-end anastomosis. Postoperatively, wound plus discontinuation of suction. No recurrence of bladder dehiscence and an enterocutaneous fistula developed. Laparot- fistula has been observed in these patients. omy was done to resect the fistula and a large pelvic abscess REFERENCES was drained with a 24F 3-way Foley catheter placed on low 1. Hughes, J. P., Gambee, J. and Edwards, C.: Perforation of the Gomco suction. Postoperatively, drainage from the abscess bladder: a complication of long-dwelling Foley catheter. J. increased while urinary output decreased. Cystography 4 days Urol., 109: 237, 1973, later showed extravasation of contrast material from the left 2. Milles, G.: Catheter-induced hemorrhagic pseudopolyps of the side of the bladder near the tip of the Foley catheter (fig. 3). urinary bladder. J.A.M.A., 193: 968, 1965. The Foley catheter was pulled back but suction was continued. 3. Rubinstein, A., Benaroya, Y. and Rubinstein, E.: Letter: Foley Urinary leakage persisted until the suction was discontinued catheter perforation of the urinary bladder. J.A.M.A., 236: and a Penrose drain was substituted for the Foley catheter. 822, 1976. During the next week the drainage ceased completely and the 4. Georgy, F. M., Fetterman, H. H. and Chefetz, M. D.: Complication of laparoscopy: two cases of perforated urinary bladder. patient was discharged from the hospital with an indwelling Amer. J. Obst. Gynec., 120: 1121, 1974. bladder catheter. A cystogram 6 weeks later showed no 5. Rous, S. N., Major, F. and Gordon, M.: Rupture of the bladder leakage and the catheter was removed. This patient has secondary to uterine vacuum curettage: a case report and remained free of symptoms. DISCUSSION
In the 3 patients described 3 different types of drains were involved: 1) Penrose, 2) Saratoga sump and 3) 24F 3-way Foley catheter. Multiple factors presumably facilitated bladder perforation in these patients. Perivesical inflammatory reaction, which may weaken the bladder wall, was a factor in all 3 cases. In the first case extensive perivesical inflammation for a prolonged period facilitated bladder perforation by a soft (Penrose) drain. Radiation therapy to the pelvis in the second case may have had a part in causing erosion of the bladder by a hard (sump) drain during prolonged drainage. An area of
review of the literature. J. Urol., 106: 685, 1971. 6. Saronwala, K. C., Singh, R. and Dass, H.: Lippes loop perforation of the uterus and urinary bladder with stone formation. Obst. Gynec., 44: 424, 1974. 7. Raghavaiah, N. V. and Devi, A. I.: Bladder injury associated with rupture of the uterus. Obst. Gynec., 46: 573, 1975. 8. Evans, R. A., Reece, R. W. and Smith, M. J. V.: Idiopathic rupture of the bladder. J. Urol., 116: 565, 1976.
EDITORIAL COMMENT A word of caution regarding the placement of drains in the pelvis is well worthwhile and I would emphasize the inadvisability of using drains made of material with any degree of stiffness. J.J.M.