What is the management for a 77-year-old woman undergoing Transurethral Resection of the Prostate (TURP) who is found to have fat near the trigone and left ureteral orifice?

Management of Fat Near Trigone and Left Ureter Orifice During TURBT in a 77-Year-Old Woman

The presence of fat near the trigone and left ureter orifice during transurethral resection of bladder tumors (TURBT) indicates bladder perforation requiring immediate cessation of the procedure, urological consultation, and consideration for surgical repair to prevent serious complications. 1

Assessment of Perforation

• The visualization of fat tissue near the trigone and left ureter orifice strongly suggests a bladder perforation during the TURBT procedure 1
• This location is particularly concerning due to its proximity to the left ureter, which increases risk of ureteral injury and subsequent complications 1
• Perforations in this area are classified as intraperitoneal perforations, which carry higher morbidity and mortality risk than extraperitoneal perforations 2

Immediate Management Steps

• Immediately terminate the resection procedure to prevent further damage 2
• Place a large-caliber urethral catheter (20-24 Fr) with continuous bladder drainage 1
• Monitor vital signs closely for signs of hemodynamic instability 3
• Assess for symptoms of TURP syndrome (hyponatremia, mental status changes, visual disturbances) as irrigation fluid may have been absorbed through the perforation 4, 5
• Obtain urgent laboratory studies including electrolytes to rule out hyponatremia 5

Imaging Assessment

• Obtain immediate CT imaging with contrast to:
  • Assess the extent of the perforation 2
  • Evaluate for urine extravasation 3
  • Confirm left ureteral integrity 1
  • Rule out injury to adjacent structures 2

Definitive Management Options

1. Conservative management (for small, uncomplicated perforations):

   • Continuous bladder drainage for 7-14 days 2
   • Broad-spectrum antibiotics to prevent infection 6
   • Serial imaging to confirm healing 2

2. Surgical intervention (recommended for this case due to location):

   • Immediate surgical exploration is indicated due to the location near the ureter orifice 1
   • Options include:
     • Laparoscopic repair of the perforation 1
     • Open surgical repair with possible ureteral reimplantation if the ureteral orifice is compromised 1
     • Placement of ureteral stent to maintain ureteral patency 2

Special Considerations for This Case

• The patient's advanced age (77 years) increases surgical risk and may influence management decisions 1
• The presence of multiple papillary tumors suggests possible bladder cancer, requiring complete staging and follow-up once the perforation is addressed 1
• DVT prophylaxis should be considered based on the patient's risk factors and the surgical approach selected 1

Post-Procedure Management

• Close monitoring of urine output and character 6
• Regular assessment of electrolyte balance 5
• Follow-up cystogram before catheter removal to confirm healing 2
• Once the perforation has healed, complete the tumor resection in a staged procedure 1
• Consider alternative approaches for completing the tumor resection such as bipolar TURP or laser techniques to minimize risk of repeat perforation 1

Potential Complications to Monitor

• Urinary extravasation and peritonitis 2
• Ureteral obstruction or stricture 1
• Persistent urinary leak 2
• Secondary infection 6
• Bladder neck contracture during healing 7

This case represents a surgical emergency requiring prompt intervention to prevent serious complications including peritonitis, ureteral injury, and long-term bladder dysfunction. The location near the trigone and ureter orifice makes this a high-risk perforation that typically requires surgical repair rather than conservative management alone.