What is the next step for a 77-year-old woman undergoing Transurethral Resection of the Prostate (TURP) with fat near the trigone and left ureteral orifice, and abdominal distension?

Management of Bladder Perforation During TURBT

The next step for this 77-year-old woman with evidence of bladder perforation during TURBT (presence of fat near the trigone and left ureter orifice) and abdominal distension is immediate cessation of the procedure, placement of a large-caliber urethral catheter (20-24 Fr), and urgent surgical exploration for repair. 1

Immediate Assessment and Management

• The visualization of fat tissue near the trigone and left ureter orifice strongly indicates bladder perforation during the TURBT procedure, which requires immediate intervention 1
• The patient's abdominal distension further suggests possible intraperitoneal perforation with extravasation of irrigation fluid, which can rapidly lead to TURP syndrome 2, 3
• Place a large-caliber urethral catheter (20-24 Fr) with continuous bladder drainage to manage the perforation 1
• Immediately cease the resection procedure to prevent further damage, particularly given the proximity to the left ureter orifice 1

Definitive Management

• Urgent surgical exploration is indicated due to:

  • The location near the ureter orifice (high-risk anatomical area) 1
  • The presence of abdominal distension suggesting possible intraperitoneal perforation 1, 3
  • The patient's advanced age (77 years) which increases the risk of complications if management is delayed 1

• Surgical options include:

  • Laparoscopic repair of the perforation if the patient is hemodynamically stable 1
  • Open surgical repair with possible ureteral reimplantation if the ureteral orifice is compromised 1

Monitoring for TURP Syndrome

• The patient's abdominal distension suggests possible absorption of irrigation fluid, which can lead to TURP syndrome characterized by hyponatremia and fluid overload 2, 3
• Monitor for signs of hyponatremia including confusion, nausea, vomiting, hypertension, bradycardia, and visual disturbances 3
• Check serum electrolytes immediately, particularly sodium levels, which can drop to dangerous levels (as low as 90 mmol/L) in severe cases 3

Post-Procedure Management

• After surgical repair, a cystogram should be performed before catheter removal to confirm healing 1
• Once the perforation has healed, complete the tumor resection in a staged procedure using techniques that minimize the risk of repeat perforation (e.g., bipolar TURP or laser techniques) 1
• Consider DVT prophylaxis based on the patient's risk factors and the surgical approach selected 1

Potential Complications to Monitor

• Ureteral obstruction or stricture due to proximity of the perforation to the left ureteral orifice 1
• Urinary tract infection, which occurs more frequently following complicated procedures 1, 4
• Bladder neck contracture during healing 1, 5
• Long-term urethral stricture, which occurs in 2.2-9.8% of TURP procedures but may be higher in complicated cases 5, 4

Follow-up Plan

• Complete staging of the bladder tumors should be done once the perforation is addressed 1
• Long-term surveillance should be based on the pathology of the papillary tumors 1