Management of Bladder Perforation During TURBT in a 77-Year-Old Woman
The visualization of fat near the trigone and left ureter orifice during TURBT indicates a bladder perforation that requires immediate surgical exploration due to the critical location near the ureter orifice. 1
Immediate Management
- Immediately cease the procedure to prevent further damage to surrounding structures 1
- Place a large-caliber urethral catheter (20-24 Fr) with continuous bladder drainage 1
- Assess the patient for signs of fluid overload and electrolyte imbalances, as abdominal distension may indicate significant extravasation of irrigation fluid 2, 3
- Obtain urgent laboratory studies including serum electrolytes to rule out TURP syndrome, which can occur in approximately 2% of transurethral procedures 2
- Monitor vital signs closely for signs of hemodynamic instability 3
Definitive Management
Surgical exploration is indicated due to:
Surgical options include:
Rationale for Surgical Intervention
- Perforations near the trigone and ureteral orifice are considered extraperitoneal but can quickly become intraperitoneal if not addressed promptly 4
- The presence of abdominal distension suggests significant fluid extravasation that may not resolve with catheter drainage alone 1
- The patient's advanced age (77) increases surgical risk but does not preclude intervention when necessary 1
- Conservative management with catheter drainage alone is insufficient when perforation occurs near critical structures like the ureter 1
Post-Procedure Management
- Continue bladder drainage for 7-14 days following repair 1
- Monitor renal function and perform imaging to ensure ureteral patency 1
- 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
- Ureteral obstruction or stricture 1
- Bladder neck contracture during healing 1
- Urinary tract infection, which occurs more frequently following complicated procedures 4, 5
- Urethral stricture, which can occur in 2.2-9.8% of cases following transurethral procedures 6
Follow-up Plan
- Cystogram before catheter removal to confirm healing 4
- Complete staging of the bladder tumors once the perforation is addressed 4
- Long-term surveillance based on the pathology of the papillary tumors 4
Remember that immediate surgical exploration is critical in this case due to the location of the perforation and the patient's presentation with abdominal distension, which suggests significant extravasation requiring prompt intervention.