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FATAL BLADDER EXPLOSION DURING TRANSURETHRAL RESECTION OF PROSTATE: CASE REPORT AND LITERATURE REVIEW.

Byline: Debora De Bartolo, Francesco Ausania, Umberto De Gennaro, Emilo D'Oro, Santo Gratteri and Pietrantonio Ricci

ABSTRACT

The transurethral resection of the prostate (TURP) is the gold standard in the operative management of benign prostatic hypertrophy. In the last decade, the technological improvements have reduced perioperative and postoperative complications. The intravesical explosion is one of the most infrequent complications of transurethral procedures. We present the case of a man with bladder outlet obstruction who underwent TURP. After complete resection of the adenoma, an audible blast and a sudden movement were felt at the lower abdomen. Inspection showed posterior wall bladder perforation that was repaired. Postoperative course was complicated by transurethral resection syndrome.

This work show an evaluation of the relevant scientific literature available about bladder explosion to define the etiology of this complication, we point out the prevention strategies and discuss the possible connection between these unusual complications.

Key Words: Transurethral resection, Bladder explosion, Transurethral resection syndrome, Prevention

INTRODUCTION

Benign prostatic hypertrophy (BPH) is a frequent disease, affecting 12% of the male population over 65 years of age; about 20-30% of patients will require prostatectomy. Despite introduction of newer techniques, transurethral resection of the prostate (TURP) still represents the gold standard in the operative management of BPH 1. Several complications of this surgical procedure have been reported in literature 2,3, but the latest technological improvements such as microprocessor-controlled units, better armamentarium like video TUR and training helped to reduce perioperative (recent vs. early) and postoperative complications 4.

Intravesical explosion is one of the most infrequent complications of transurethral procedures with an incidence of 0.01-0.02% 5,6 ; this event can be characterized by different degrees of the bladder mucosa lesions. After transurethral resection, a very small percentage of patients can develop Transurethral resection syndrome (TURP syndrome). It is an iatrogenic form of water intoxication with multifactorial pathophysiology. The diagnosis is based on various signs and symptoms, in association with an excessive absorption of the irrigation liquid that produces cardiovascular, central nervous system (CNS) and metabolic changes. It may happen from as early as 15 minutes after the start of prostatic resection 7 up to 24 hours post-operatively 8.

Recent use of bipolar circuitry, together with advances in training techniques and use of modern irrigation fluids, have reduced the risk of developing this syndrome 9 that have lower incidence rates of between 0.78% and 1.4% 10,11. However, the most serious forms of the TUR syndrome have a mortality rate that has been quoted as high as 25% 12,13. In this work, we describe a case of intravesical explosion during TURP, followed by fatal transurethral resection syndrome, in a patient with BPH. Furthermore we carried out a literature review about bladder rupture to define the etiology of this complication, we point out the prevention strategies and discuss the possible connection between these unusual complications.

CASE REPORT

A 66-year-old man with obstruction of urine flow, caused by prostate enlargement, underwent TURP. On digital rectal examination (DRE), the prostate had a benign feel and on ultrasound it was 44g. The patient was suffering from hypertensive heart disease and pulmonary emphysema. The pre-operative chest X-ray and electrocardiogram (ECG) were within normal range. Other pre-operative measurements included: plasma sodium 141.5 mmol/L, potassium 4.5 mmol/L and hemoglobin of 13.3 gm/dl.

The anaesthetists selected spinal anaesthesia during the pre-operative visits, but despite adequate explanation, the patient refused this anaesthetic technique and general anaesthesia has been used from the start.

A continuous flow resectoscope, like the Iglesias model with 1.5% glycine, was used as irrigant. The urethrocystoscopy showed normal anterior urethra in morphology and size and posterior urethra deformed by prostatic lobes. During the last phase of the procedure the area was coagulated to control bleeding. On initiation of the removal of fragments and blood clots with Ellik evacuator, an audible blast and a sudden movement were felt at the suprapubic area by the surgeons.

Endoscopically, a wide laceration in the bladder wall was noticed. The patient was immediately referred to the open operating theatre. Intestines and other intra-abdominal structures were intact. During surgery his hematocrit decreased and required blood transfusion. During laparotomy exploration, the rupture of bladder was confirmed and the wall was sutured. Time of surgery (prostate resection and bladder repair) has been about 3 hours.

Post-operative course was complicated by hypothermia (34degC), bradycardia, arterial hypotension and hypoxemia. The patient was intubated and moved to intensive care. The electrolytes analysis revealed acute hyponatremia (sodium concentration 110 mmol/L) and ultrasound scan showed accumulation of fluid in the abdominal cavity. A leakage of serosanguineous fluid from draines and metabolic acidosis were noted. Therapeutic intervention was hypertonic saline solution 3%, volume expansion, blood transfusions and tracheal intubation with mechanical ventilation.

In the following days the patient appeared in a comatose state, with progressive deterioration of clinical condition, cardiovascular instability and neurological disorders. The patient died 15 days after the surgical procedure.

An autopsy was performed to prove a possible medical malpractice and to find other pathological conditions. Macroscopically we found the bladder wall with a large full-thickness laceration and segments of suture material. Examination of other organs was negative. The histological examination showed intense inflammatory infiltration in the edges of suture and plurivisceral stasis of the blood.

DISCUSSION

In the present case, bladder perforation during bipolar TURP was followed by the onset of a transurethral resection syndrome that caused the death of patient.

The etiology of intravesical explosions during the endoscopic procedure is due to formation of explosive gases in the bladder, especially oxygen (O 2 ) and hydrogen (H 2 ) 3,14. Oxygen can penetrate into the bladder during endoscopic procedures 15. In vitro experiments have shown that hydrogen is formed by pyrolysis of bladder tissue and the higher temperature of the resectoscope cause greater accumulation of this gas 16,17. Hydrogen gas alone is not explosive, but the mixture of these two gases is potentially very explosive 17,18 and the sparks from the cutting electrode may ignite the mixture of gases 19. Furthermore, the amount of gas formed and the risk of explosion are proportional to the operating time and the use of high power current for cutting and coagulation while the nature of the bladder irrigation liquid does not appear to play an important role 20.

We report an additional possible cause of bladder perforation; the present patient had a low vesical compliance for chronic lower urinary tract obstruction which may have resulted in stretching and thinning of the bladder wall. In these conditions an overdistension of the bladder using the Ellik evacuator and an inadequate evacuation of accumulated air can result in explosion.

Major intravesical explosion is a rare, but potentially devastating complication of transurethral endoscopic resections and in the literature few cases are described. We have carried out an evaluation of scientific literature and this complication has been previously described in 28 reports; a total of 36 patients who underwent transurethral resection have had a bladder rupture as a complication, but the patients have developed transurethral resection syndrome after bladder rupture in three reports only.

The first case of bladder explosion has been signaled by Cassuto in 1926 21. Next, Kretschmer 22 described two cases of a bladder rupture following TURP as early as 1934. Another single report was published by Bobbitt 23 in 1950, until in 1975 16 two cases; single cases of bladder explosion were reported in 1979 24, 1984 25 and 1987 26. Since then no further case was published until 2001 when Dublin et al 15 presented two cases, followed by 26 cases described in 21 reports through 2015.

We have analyzed only the reports published in English language, after the year 2000, to identify the pre-disposing factors for bladder explosion and the prevention strategies approved by the scientific literature.

Table 1: Reports evaluated

###Authors###Cases###Age###Case of Surgery###Type of Anesthesia###Methodology - Irrigant

###Dublin et al###82###BPH###N.A.###N.A.

###2

###(2001)###80###BPH###N.A.###N.A.

###Di Tonno et al

###1###67###PH###N.A.###1.5% Glycin Solution

###(2003)

###72###Bladder tumor###General Anesthesia###5% Glycin Solution

###Dorotta et al###68###Bladder tumor###Spinal Anesthesia###Sterile Water

###4

###(2003)###81###Bladder tumor###General Anesthesia###Sterile Water

###77###Bladder tumor###Spinal Anesthesia###Glycine 1.5% Solution

###Horger et al

###1###56###Bladder tumor###N.A.###Sterile Water

###(2004)

###Ribeirp da Silva

###1###71###BPH###N.A.###3% Mannitol Solution

###et al (2006)

###Srivastava et al

###1###61###BPH###N.A.###1.5% Glycine as Irrigant

###(2006)

###Rezaee et al

###3###N.A.###BPH###Spinal anesthesia###N.A.

###(2006)

###Seitz et al###1###73###BPH###N.A.###1.5 % Glycocoll Solution

###3.3% Mixed Solution of

###Kim et al (2009)###1###74###BPH###General Anesthesia

###Mannitol and Sorbitol

###Sataa Sallami et

###1###73###BPH###Spinal Anesthesia###Glycocoll Solution

###al (2011)

###Gonca et al###Prostatic

###1###82###Spinal Anesthesia###Glycine as Irrigant

###(2013)###carcinoma

###T. Shindo et al

###1###79###Bladder tumor###N.A.###N.A.

###(2013)

###Spinal Anesthesia

###Sun-Kyung et al

###1###84###BPH###(Switched to General###0.9% Saline Solution

###(2013)

###Anesthesia)

###Baldvinsdottir et

###1###83###BPH###Spinal Anesthesia###N.A.

###al (2014)

###Adiyat et al

###1###72###BPH###Spinal Anesthesia###Sterile Water

###(2014)

###Ibrahim et al###Saline Solution

###1###73###BPH###Spinal Anesthesia

###(2015)###(0.9% Nac1)

###Georgios et al

###1###79###Bladder tumor###N.A.###N.A.

###(2015)

###Eiko et al (2015)###1###64###BPH###Spinal Anesthesia###N.A.

Eighteen case reports, in which 24 cases of bladder explosion are reported following transurethral endoscopy, were included in our analysis (Table 1). The mean age of the patients was 74 years and the cause of surgery was BPH (14 cases), bladder tumor (6 cases), one case of bladder biopsy and prostatic carcinoma. In all reported cases, as in ours, the authors were sure that they made no bladder perforations.

The degree of bladder injury secondary to an explosion varies from a loud "pop" sound only to a ruptured bladder needing surgical repair 19. Only in three of the reported cases, the explosion was not accompanied by a bladder perforation 14,27. However, the bladder rupture may lead to severe consequences especially when the surgeon does not notice the rupture and the treatment is delayed.

Table 2: Recommendations for the prevention of intravesical explosion

###S. No.

###Recommendations

###1###Avoidance of high-temperature cautery

###2###Decreasing the duration of resection with judicious coagulating of tissue

###3###Reduction in the use of a cutting and coagulation current of moderate power

###Use of continuous irrigation sheets (because with intermittent sheet, some air enters the bladder during

###4

###its evacuation that causes explosion)

###Perform frequent evacuation of the gas bubble in the bladder (ureteral catheter, suprapubic trocar or

###5

###supra pubic pressure)

###6###Placement of the patient in the trendelenburg position may shift the air bubble more caudally

###7###Emptying the bladder ilntermittently during the TUR procedure

###8###Constantly changing the position during resection will also dislodge the air bubble

###Prefer regional anesthesia (to facilitate the early detection of mental status change or diaphragmatic

###9

###irritation)

###10###Give more attention to elderly patients with over distended and thinned bladder walls

###In patients with diseased bladder due to radiation, cystitis, tuberculosis etc., extra cation need to be

###11

###taken to avoid hyper-distension

###12###Good interaction between surgeon and anesthetist

###Closely monitored patient care to recognize the complication and make the necessary intervention

###13

###immediately

The diagnosis of a bladder injury have been facilitated by the patient's ability to report the sudden onset of mental status change, severe abdominal pain and discomfort. Therefore the choice in the type of anesthesia is very important to early detection of bladder damage. In previously reported cases, various types of anesthesia have been used. General anesthesia was used from start in three cases 28,29, while in one case spinal anesthesia was changed to general anesthesia during surgery because the patient complained of pain on operative site, considered to be caused by a low level of anesthesia 30. Spinal anesthesia was used in nine cases 14,28,31-34. In the remaining 9 reported cases 3,15,20,36-40 the type of anesthesia was not reported.

Spinal anesthesia is to be preferred for transurethral resection of the prostate because it decreases blood loss, it reduces the onset of pulmonary edema; unlike general anesthesia, it allows early detection of any change in mental status and permits early recognition of the typical syndrome. The patients developed worst complications when general anesthesia has been used, in particular bladder perforation was associated with ascites 30, retroperitoneal air and fluid accumulation 29.

The surgery was complicated in 5 patients with bladder explosion and transurethral resection syndrome, 3 of which were under general anesthesia 28,30.

Only one case (as well in general anesthesia) has had negative outcome. The bladder perforation was diagnosed in a considerable delay and postoperative course was complicated by renal failure and the patient needed permanent hemodialysis 28. In all other reported cases the post-operative course was uneventful and no patient died from complications of transurethral endoscopy.

The bladder injuries were identified by cystoscopy or computed tomography scan and then repaired with open surgery; in 2014 33 the first case where laparoscopy was offered as a treatment option was reported. Values of the electrocautery current (for cutting and coagulation) was not reported by all authors. The mean of cutting current was 127.5 watts and that for coagulation was 69 watts. We report several strategies suggested by many authors to limit the probability of bladder explosion (Table 2).

About the transurethral resection syndrome, several authors have shown that injuries on venous sinus or perforation of prostatic capsule in the course of resection increases the incidence of this complication 41, but there aren't papers that emphasize the correlation between the explosion of bladder and the etiology of this syndrome. However, it should be emphasized that the irrigating fluid is most frequently absorbed directly into the vascular system when a vein has been severed by electrosurgery.

In our case, the bladder rupture has provoked, concurrently, extravasation and an intravascular absorption; these conditions have generated a fatal TUR syndrome.

CONCLUSION

Bladder rupture, although rare, should be kept in mind by those who perform transurethral resections in daily practice.

RECOMMENDATIONS

Through this work, we emphasize the importance of knowledge of bladder rupture and possible prevention strategies. Furthermore, we underline the key role of an early recognition and prompt treatment of TUR syndrome. This syndrome cannot be protocol driven; high index of suspicion, optimal interaction between clinicians (surgeon and anesthetist) during surgery, intensive monitoring, prevention of large fluid extravasation and multidisciplinary approach are required to recognize the complication and make the necessary intervention immediately.

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Publication:Journal of Postgraduate Medical Institute
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Date:Jun 30, 2017
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