{"paper_id":"2d61941a-5124-413e-983c-d6150aacbe38","body_text":"Laparoscopic Repair of Spontaneous Bladder\nPerforation Due to Endometriosis\nWilliam Kondo, MD, Monica Tessmann Zomer, MD, Teresa Cristina Santos Cavalcanti, MD\nDepartment of Gynecology, Vita Batel Hospital, Parana ´ , Brazil (Drs Kondo and Zomer).\nDepartment of Pathology, Citolab Laboratory, Parana ´ , Brazil (Dr Cavalcanti).\nABSTRACT\nIntroduction: Spontaneous rupture of the bladder is a rare condition that is usually secondary to an underlying\npathologic process. We report a rare case of spontaneous bladder rupture due to endometriosis in a young\nwoman.\nCase Description: The patient presented with abdominal pain and features of acute renal injury in the absence of prior\ntrauma. She underwent successful laparoscopic repair, and pathology confirmed the presence of endometriosis at the site\nof perforation.\nDiscussion: The most important key to prompt diagnosis of bladder rupture is to keep in mind the potential for this\ndisorder to arise in patients with peritonitis, especially in those with urologic symptoms and the features of acute renal\nfailure. It requires immediate surgical treatment to avoid serious life-threatening peritonitis, preferentially by means of\nlaparoscopy in patients with stable conditions.\nKey Words: Bladder endometriosis, Endometriosis lesion, Laparoscopic bladder repair, Urinary bladder perforation.\nINTRODUCTION\nSpontaneous intraperitoneal rupture of the bladder is\nrare,1 with a reported incidence of 1:126 000. In most\ncases, there is an underlying pathologic process that has\nweakened the bladder wall, leading to the perforation.\n2 In\nthis article, we present an unusual case of spontaneous\nrupture of the bladder due to endometriosis. The report\nwas approved by the local Institutional Review Board.\nCASE REPORT\nA 39-year-old woman was emergently admitted to the\nhospital with abdominal pain, nausea, and progressive\nabdominal distension. She had no hematuria or vaginal\ndischarge. Physical examination revealed massive ascites\nand abdominal tenderness. Her white blood cell count\nwas 11 900/\n/H9262L. Serum urea was 116 mg/dL, creatinine 5.1\nmg/dL, and C-reactive protein 93.2 mg/dL. An abdominal\nand pelvic computed tomographic scan showed severe\nascites.\nShe underwent a diagnostic laparoscopy with the intraop-\nerative finding of a large amount of urine (8 L) inside the\nabdomen ( Figure 1A and 1B), deep infiltrating endome-\ntriosis lesions in the posterior pelvic compartment affect-\ning the rectum, and a small perforation at the dome of the\nbladder ( Figure 1C ). The urine was aspirated and the\nedges of the perforated bladder were resected ( Figure\n1D). A watertight bladder repair in 2 layers was conducted\nwith 3-0 polydioxanone sutures ( Figure 1E and 1F). A\nperitoneal washout was performed, and a Foley catheter\nwas placed for bladder drainage.\nShe was discharged 17 hours after the procedure, with the\nFoley catheter remaining in place until its removal on\npostoperative day 10.\nPathology of the bladder confirmed the presence of endo-\nmetriosis at the site of the perforation ( Figures 2 and 3).\nCitation Kondo W, Zomer MT, Cavalcanti TCS. Laparoscopic repair of spontaneous bladder perforation due to endometriosis. CRSLS e2014.00258. DOI:\n10.4293/CRSLS.2014.00258.\nCopyright © 2015 by SLS, Society of Laparoendoscopic Surgeons. This is an open-access article distributed under the terms of the Creative Commons\nAttribution-Noncommercial-ShareAlike 3.0 Unported license, which permits unrestricted noncommercial use, distribution, and reproduction in a ny medium,\nprovided the original author and source are credited.\nAddress correspondence to: William Kondo, MD, Av. Iguac ¸u 1236 sala 114, Curitiba, Parana ´, Brazil. Tel: 55-41-92221065, Fax: , E-mail: williamkondo@yahoo.com\n1e2014.00258 CRSLS MIS Case Reports from SLS.org\nCASE REPORT\n\nAfter 30 days of convalescence, the patient underwent\nabdominal and transvaginal pelvic ultrasound with bowel\npreparation for the complete mapping of the endometri-\nosis by our radiology team.\n3 Findings were a deep, infil-\ntrating endometriosis lesion affecting the retrocervical\narea, uterosacral ligaments, posterior vaginal fornix,\npouch of Douglas, and rectosigmoid colon. There were 2\ndeep lesions on the bowel, the first one measuring 15 mm,\ninfiltrated the muscular layer of the rectum, 9 cm from the\nanal verge, and the second one measuring 40 mm, infiltrated\nthe muscular layer of the rectosigmoid colon, 12 cm from the\nanal verge. After a complete explanation of the disease and\nthe options for treatment, the patient preferred to be referred\nfor in vitro fertilization (IVF), because she had a 1-year\ninfertility history and no pelvic pain symptoms.\nDISCUSSION\nUrinary bladder perforation can occur spontaneously in\nthe setting of a weakened bladder wall. 4 It can be second-\nary to radiotherapy, inflammation, urinary tract infection,\nmalignant disease, neurogenic dysfunction, or bladder\noutlet obstruction.\n5–12\nThe urinary bladder is the most common site of genito-\nurinary endometriosis.\n13 It may be affected in 14% of\nwomen with deep infiltrating endometriosis, 14 and the\nlesion usually evolves from the serosal surface of the\nbladder toward the mucosa.\n13\nThe symptoms of urinary bladder perforation are often\nnonspecific, and misdiagnosis is common.\n12 Intraperito-\nneal perforation of the bladder typically manifests with\nFigure 1. A and B, Aspiration of the free liquid (urine) in the abdominopelvic cavity. C, Instillation of normal saline 0.9% (150 mL) and\nmethylene blue (5 mL) into the bladder through a Foley catheter demonstrated the area of the bladder perforation. D, Excision of the\nedges of the perforation. E and F, Double-layer closure of the bladder wall.\nFigure 2. A , Focus of stromal and glandular endometriosis in the bladder serosa adjacent to the area of perforation (hematoxylin and\neosin, /H11003100). B, Congestion in the bladder mucosa adjacent to the perforation (hematoxylin and eosin, /H11003100).\nLaparoscopic Repair of Spontaneous Bladder Perforation Due to Endometriosis, Kondo W et al.\n2e2014.00258 CRSLS MIS Case Reports from SLS.org\n\nabdominal pain and tenderness due to peritonitis and\ndifficulty in voiding urine. 15 A discrepancy between blad-\nder irrigation and recovery of a measured amount of\nsaline through a Foley catheter can be suggestive of blad-\nder perforation.\n15,16 Any delay in diagnosis results in sig-\nnificant reabsorption of urea and creatinine via peritoneal\nself-dialysis, causing a significant elevation in serum urea\nand creatinine levels.\n2,17 Also, the clinician may observe\nelevated serum potassium and decreased serum sodium\nand CO\n2 content, mimicking the biochemical features of\nrenal failure. 17\nOn ultrasound, there is evidence of free intraperitoneal\nfluid.\n2 A computed tomographic scan may show not only\nfree intraperitoneal fluid, but also free air under the\ndiaphragm, a thickened bladder wall, and an ab-\nscess.\n5,6,8,11,18 A cystogram is useful to confirm the diag-\nnosis, but may be falsely negative if the perforation has\nsealed with surrounding tissues—for example, the omen-\ntum or blood clots.\n5,6,8,10,11,18 Invariably, most patients\nmust undergo laparotomy to confirm the diagnosis and\nrepair the perforation.\n2,7,9 –11,18 In the present case, the\ndiagnosis was established during the laparoscopic explo-\nration of the abdomen. Because there was no definite\ncausative factor for the bladder perforation, we believe\nthat spontaneous perforation occurred. During surgery,\nmultiple lesions of endometriosis in the posterior com-\npartment of the pelvis were identified. The pathology of\nthe area of the perforation in the bladder confirmed the\npresence of endometriotic tissue.\nLarge endometriosis lesions usually promote thickening\nof the muscle layer of the bladder, resulting in a low\nprobability of perforation. However, small lesions may\nlead to inflammation of the peritoneum overlying the\nbladder and the detrusor muscle, making them a pos-\nsible cause of bladder perforation. A previous surgical\nprocedure for the treatment of endometriosis affecting\nthe bladder may weaken the bladder wall, thus increas-\ning the risk of bladder perforation in the case of a\nrecurrence of the disease at the same place, especially\nif the bladder closure was not performed properly.\nIntraperitoneal rupture of the urinary bladder usually re-\nquires immediate surgical treatment to avoid serious life-\nthreatening peritonitis.\n15 Recently, some authors have de-\nscribed successful laparoscopic repair of intraperitoneal\nurinary bladder rupture in stable patients.\n19,20 In our pa-\ntient, the repair was conducted successfully, and she had\nan uneventful postoperative course.\nCONCLUSION\nAlthough rare, spontaneous bladder perforation may oc-\ncur in patients with bladder endometriosis. This diagnosis\nmust be considered, particularly in those patients present-\ning to the emergency department with signs of peritonitis,\nalong with urologic symptoms and features of acute renal\nfailure.\nReferences:\n1. Fugikawa K, Yamamichi F, Nonomura M, Soeda A, Takeuchi\nH. Spontaneous rupture of the urinary bladder is not a rare\ncomplication of radiotherapy for cervical cancer: report of six\ncases. Gynecol Oncol. 1999;73:439 – 442.\n2. Kong CH, Ali SA, Singam P, Hong GE, Cheok LB, Zainud-\ndin ZM. Spontaneous bladder perforation: a rare complication\nof tuberculosis. Int J Infect Dis. 2010;14(suppl 3):e250 – e252.\n3. Kondo W, Zomer MT, Pinto EP, et al. Deep infiltrating\nendometriosis: imaging features and laparoscopic correlation. J\nEndometr. 2011;3:197–212.\nFigure 3. A , Epithelial cells of the bladder serosa were positive for cytokeratin 7 (CK7) (immunohistochemical staining, /H11003400). B,I n\nthe bladder serosa, CK7-positive cells demonstrated multifocal positivity for estrogen receptors, not only in the cell surface but also in\nendometrial-like stromal cells (immunohistochemical staining, /H11003400). C, Mesothelial cells were present in the bladder serosa (immu-\nnohistochemical staining for inhibin, /H11003400).\n3e2014.00258 CRSLS MIS Case Reports from SLS.org\n\n4. Ogawa S, Date T, Muraki O. Intraperitoneal urinary bladder\nperforation observed in a patient with an indwelling urethral\ncatheter. Case Rep Urol. 2013;2013:765704.\n5. Ishii T, Kadowaki T, Sugiyama T. Intraperitoneal spontaneous\nrupture of the bladder subsequent to irradiation of the uterus: a case\nreport [in Japanese].Hinyokika Kiyo.1988;34:2185–2188.\n6. Hagiwara N, Nishida Y, Fujimoto Y, Isogai K, Fujihiro S,\nDeguchi T. Recurrent spontaneous bladder rupture cured by\nconservative therapy: a case report [in Japanese]. Hinyokika\nKiyo. 2002;48:367–370.\n7. Jayathillake A, Robinson R, Al-Samarii A, Manoharan M. Spon-\ntaneous rupture of bladder presenting as peritonitis. N Z Med J.\n2002;115:U222.\n8. Basiri A, Radfar MH. Conservative management of early blad-\nder rupture after postoperative radiotherapy for prostate cancer.\nUrol J. 2008;5:269 –271.\n9. Mardani M, Shahzadi M, Rakhshani N, Rahnavardi M, Rezvani\nJ, Sharifinejad A. Spontaneous perforation of urinary bladder\nsecondary to Candida cystitis: acute abdomen of urologic origin.\nSurg Infect (Larchmt). 2008;9:525–527.\n10. Gomes CA, de Figueiredo AA, Soares Ju ´ nior C, Bastos Netto\nJM, Tassi FR. Acute abdomen: spontaneous bladder rupture as\nan important differential diagnosis [in Portuguese]. Rev Col Bras\nCir. 2009;36:364 –365.\n11. Ahmed J, Mallick IH, Ahmad SM. Rupture of urinary bladder:\na case report and review of literature. Cases J. 2009;2:7004.\n12. Limon O, Unluer EE, Unay FC, Oyar O, Sener A. An unusual\ncause of death: spontaneous urinary bladder perforation. Am J\nEmerg Med . 2012;30:2081.e3– e5.\n13. Maccagnano C, Pellucchi F, Rocchini L, et al. Diagnosis and\ntreatment of bladder endometriosis: state of the art. Urol Int.\n2012;89:249 –258.\n14. Kondo W, Ribeiro R, Trippia C, Zomer MT. Deep infiltrating\nendometriosis: anatomical distribution and surgical treatment [in\nPortuguese]. Rev Bras Ginecol Obstet. 2012;34:278 –284.\n15. Tabaru A, Endou M, Miura Y, Otsuki M. Generalized peri-\ntonitis caused by spontaneous intraperitoneal rupture of the\nurinary bladder. Intern Med. 1996;35:880 – 882.\n16. Raheem OA, Jeong YB. Intraperitoneally placed Foley cath-\neter via verumontanum initially presenting as a bladder rupture.\nJ Korean Med Sci. 2011;26:1241–1243.\n17. Heyns CF, Rimington PD. Intraperitoneal rupture of the\nbladder causing the biochemical features of renal failure. Br J\nUrol. 1987;60:217–222.\n18. Rogers CJ, Barber DB, Wade WH. Spontaneous bladder\nperforation in paraplegia as a late complication of augmentation\nenterocystoplasty: case report. Arch Phys Med Rehabil. 1996;77:\n1198 –1200.\n19. Zonca P, Cambal M, Jacobi CA. Laparoscopic management\nof spontaneous intraperitoneal perforation of urinary bladder.\nBratisl Lek Listy. 2011;112:282–286.\n20. Marchand TD, Cuadra RH, Ricchiuti DJ. Laparoscopic repair\nof a traumatic bladder rupture. JSLS. 2012;16:155–158.\nLaparoscopic Repair of Spontaneous Bladder Perforation Due to Endometriosis, Kondo W et al.\n4e2014.00258 CRSLS MIS Case Reports from SLS.org","source_license":"CC0","license_restricted":false}