Urinary bladder perforation after TUR bladder of polyps

Clinical History

The patient was referred to the emergency because of acute abdominal pain and anuria, three days after transurethral resection of bladder polyps.
There was no postoperative haematuria.
There was mild leukocytosis.
A CT examination of the abdomen was performed.

Imaging Findings

Due to acute kidney failure, no intravenous contrast agent was administered. Additionally, a retrograde CT cystography with instillation of 300cc contrast dilution in the urine bladder was performed.

Axial slices through the pelvis demonstrate apparent complete removal of the urinary bladder polyps.
A 15mm large defect in the anterolateral left part of the urinary bladder wall can be appreciated.
There is concomitant perivesical free fluid of low density (5 Hounsfield Units).

After retrograde contrast filling of the urine bladder via a transurethral Foley catheter, there is leakage of contrast material through the bladder wall defect into the extraperitoneal space.
There is no contrast leakage to the intraperitoneal space.

Imaging findings are consistent with a urinary bladder perforation.

Discussion

Transurethral bladder resection is a well-established, first choice procedure for treatment of bladder polyps or superficial bladder tumours, with complications (5%) being uncommon [1].
The most common complication is bleeding (2.8%), bladder perforation after TUR bladder is reported in 1.3% [1].

Early postoperative bladder voiding complaints can include dysuria, frequency and urgency and are considered normal in the first weeks after procedure, as well as first stream haematuria.
Postoperative anuria is always concerning and is due to urethral blood clot formation or, less common, due to bladder perforation.
Further exploration is necessary to avoid delaying the diagnosis of bladder perforation and possible subsequent chemical peritonitis [2].

Conventional cystography is a valid tool to detect bladder perforation, but is time-consuming and gives no information on other pelvic structures.
When a CT scanner is available, retrograde CT cystography is the preferred imaging modality [2]. CT cystography has a near 100% sensitivity in detecting full thickness bladder wall perforations, provided the bladder has been sufficiently expanded with contrast medium dilution (at least 300cc is advised) [3].
Moreover, CT cystography allows for multiplanar evaluation of the bladder and has the advantage of being able to provide a possible alternative diagnosis [2].

Treatment can be conservative or surgical, the decision being largely dependent on the type of rupture [4].
Rupture of the urinary bladder can be intraperitoneal, extraperitoneal, or both [3].
In case of extraperitoneal rupture treatment should be conservative, whereas intraperitoneal rupture usually necessitates surgical repair [1].
The American Association for the Surgery of Trauma proposes an easy to use grading scale system for bladder trauma [5].
Long term outcome after iatrogenic bladder rupture is generally good, assuming there was no significant diagnostic or therapeutic delay [5]. The most frequent long term complication is fistulisation [5].

In conclusion, the following symptoms after recent TUR should alarm you for possible bladder perforation and warrant further evaluation with retrograde CT cystography: abdominal pain, haematuria, oliguria or anuria with increasing serum creatinine levels.

Differential Diagnosis List

Final Diagnosis

Urinary bladder perforation after TUR bladder.

URL:	https://www.eurorad.org/case/11808
DOI:	10.1594/EURORAD/CASE.11808
ISSN:	1563-4086