{"paper_id":"ec7c1f6a-7ff6-4935-8fa2-d49ca3a8b0c5","body_text":"A\npreviously healthy 38-year-old\nwoman had undergone la-\nparoscopic left ovarian cystec-\ntomy because of endometriosis. She\nhad previously undergone 2 cesarean\nsections. Two months after the cystec-\ntomy, she had sudden onset of diffuse\nabdominal pain and distension as well\nas dysuria. Examination revealed no lo-\ncalized or peritoneal signs but did show\nsubstantial ascites. The laboratory test\nresults were normal except for an ele-\nvated serum creatinine level (198 [nor-\nmal < 133] µmol/L). Noncontrast CT\nscanning showed free fluid in her ab-\ndomen and a thickened omentum. One\nlitre of straw-coloured ascitic fluid was\naspirated; the leukocyte count was 0.50\n[normal < 0.25] ∞10\n9/L (lymphocytes\n55%, neutrophils 45%).\nTuberculosis of the abdomen was\nsuspected. However, this diagnosis was\nunlikely because the ascites, dysuria and\nabdominal pain resolved spontaneously\nwithin 48 hours after aspiration of the\nascitic fluid, and renal function re-\nturned to normal within 72 hours.\nOne month later the patient was re-\nassessed and found to have ascites with\ngeneralized abdominal tenderness and\nguarding in the hypogastrium, which\nworsened over 24 hours. Oliguria (se-\nrum creatinine level 180 µmol/L) and,\nsubsequently, anuria (serum creatinine\nlevel 675 µmol/L) developed. A catheter\nwas inserted, and brisk diuresis of\nmore than 5 L resulted in her renal\nfunction rapidly returning to normal.\nThe creatinine level of the ascitic fluid\nwas grossly elevated (2178 µmol/L),\nwhich confirmed the diagnosis of uri-\nnary ascites. Ultrasonography revealed\nkidneys of normal size, and noncon-\ntrast CT scanning did not show obvious\nbladder injury but did reveal a fat den-\nsity lesion in the bladder. Contrast-\nenhanced CT scanning showed normal\nkidneys and ureters and a tongue of fat,\nprobably omental tissue, adherent to\nthe anterior wall of the bladder. CT cys-\ntography did not reveal any urinary\nleak. Cystoscopy, performed to identify\nthe bladder perforation, revealed that\nomentum was plugging the defect at\nthe dome of the bladder (Fig. 1). La-\nparotomy was performed to close the\nbladder perforation, and the patient\nhad an uneventful recovery.\nBladder injury is a known complication\nof gynecologic laparoscopic surgery,\noccurring in up to 8.3% of cases,\n1 and\nis more common in women who have\nundergone previous pelvic operations.\nThe diagnosis of accidental intraperi-\ntoneal bladder injury may be delayed\n2 if\nthe injury is trivial or if omentum plugs\na larger defect, as was seen in our case.\nUnexplained ascites and decreased re-\nnal function in a previously healthy per-\nson with a recent history of pelvic sur-\ngery should raise the suspicion of\nintraperitoneal bladder rupture. Our\npatient’s first episode of ascites re-\nsolved without treatment, probably be-\ncause of spontaneous evacuation of\nurine through the bladder defect. A very\nhigh creatinine level in the ascitic fluid\nis diagnostic.\n3 Treatment should in-\nvolve conventional or CT cystography\nto localize the bladder perforation, fol-\nlowed by laparotomy to repair it.\nSamiran Adhikary\nDepartment of Urology\nPrasad Mathews\nDepartment of Medicine\nGanesh Gopalakrishnan\nDepartment of Urology\nChristian Medical College \nand Hospital\nVellore, Tamil Nadu\nIndia\nREFERENCES\n1. Ostrzenski A, Ostrzenska KM. Bladder injury dur-\ning laparoscopic surgery. Obstet Gynecol Surv\n1999;54(11):233-8.\n2. Lamaro VP, Broome JD, Vancaillie TG. Unrecog-\nnized bladder perforation during operative la-\nparoscopy. \nJ Am Assoc Gynecol Laparosc2000;7\n(3):417-9.\n3. Heyns CF, Rimington PD. Intraperitoneal rupture\nof the bladder causing the biochemical features of\nrenal failure. \nBr J Urol1987;60(3):217-22.\nCMAJ • November 22, 2005 • 173(11)     |      1323\n© 2005 CMA Media Inc. or its licensors\nPractice\nDOI:10.1503/cmaj.050915\nRenal failure andascites\nafter remote laparoscopy\nClinical Vistas","source_license":"CC0","license_restricted":false}