Laparoscopic Repair of Spontaneous Bladder Perforation Due to Endometriosis

Introduction: Spontaneous rupture of the bladder is a rare condition that is usually secondary to an underlying pathologic process. We report a rare case of spontaneous bladder rupture due to endometriosis in a young woman. Case Description: The patient presented with abdominal pain and features of acute renal injury in the absence of prior trauma. She underwent successful laparoscopic repair, and pathology confirmed the presence of endometriosis at the site of perforation.

The most important key to prompt diagnosis of bladder rupture is to keep in mind the potential for this disorder to arise in patients with peritonitis, especially in those with urologic symptoms and the features of acute renal failure. It requires immediate surgical treatment to avoid serious life-threatening peritonitis, preferentially by means of laparoscopy in patients with stable conditions. Key Words: Bladder endometriosis, Endometriosis lesion, Laparoscopic bladder repair, Urinary bladder perforation.

Spontaneous intraperitoneal rupture of the bladder is rare,1 with a reported incidence of 1:126 000. In most cases, there is an underlying pathologic process that has weakened the bladder wall, leading to the perforation. 2 In this article, we present an unusual case of spontaneous rupture of the bladder due to endometriosis. The report was approved by the local Institutional Review Board. CASE REPORT A 39-year-old woman was emergently admitted to the hospital with abdominal pain, nausea, and progressive abdominal distension. She had no hematuria or vaginal discharge. Physical examination revealed massive ascites and abdominal tenderness. Her white blood cell count was 11 900/ /H9262L. Serum urea was 116 mg/dL, creatinine 5.1 mg/dL, and C-reactive protein 93.2 mg/dL. An abdominal and pelvic computed tomographic scan showed severe ascites. She underwent a diagnostic laparoscopy with the intraop- erative finding of a large amount of urine (8 L) inside the abdomen ( Figure 1A and 1B), deep infiltrating endome- triosis lesions in the posterior pelvic compartment affect- ing the rectum, and a small perforation at the dome of the bladder ( Figure 1C ). The urine was aspirated and the edges of the perforated bladder were resected ( Figure 1D). A watertight bladder repair in 2 layers was conducted with 3-0 polydioxanone sutures ( Figure 1E and 1F). A peritoneal washout was performed, and a Foley catheter was placed for bladder drainage. She was discharged 17 hours after the procedure, with the Foley catheter remaining in place until its removal on postoperative day 10. Pathology of the bladder confirmed the presence of endo- metriosis at the site of the perforation ( Figures 2 and 3). Citation Kondo W, Zomer MT, Cavalcanti TCS. Laparoscopic repair of spontaneous bladder perforation due to endometriosis. CRSLS e2014.00258. DOI: 10.4293/CRSLS.2014.00258. Copyright © 2015 by SLS, Society of Laparoendoscopic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-ShareAlike 3.0 Unported license, which permits unrestricted noncommercial use, distribution, and reproduction in a ny medium, provided the original author and source are credited. Address correspondence to: William Kondo, MD, Av. Iguac ¸u 1236 sala 114, Curitiba, Parana ´, Brazil. Tel: 55-41-92221065, Fax: , E-mail: [email protected] 1e2014.00258 CRSLS MIS Case Reports from SLS.org CASE REPORT After 30 days of convalescence, the patient underwent abdominal and transvaginal pelvic ultrasound with bowel preparation for the complete mapping of the endometri- osis by our radiology team. 3 Findings were a deep, infil- trating endometriosis lesion affecting the retrocervical area, uterosacral ligaments, posterior vaginal fornix, pouch of Douglas, and rectosigmoid colon. There were 2 deep lesions on the bowel, the first one measuring 15 mm, infiltrated the muscular layer of the rectum, 9 cm from the anal verge, and the second one measuring 40 mm, infiltrated the muscular layer of the rectosigmoid colon, 12 cm from the anal verge. After a complete explanation of the disease and the options for treatment, the patient preferred to be referred for in vitro fertilization (IVF), because she had a 1-year infertility history and no pelvic pain symptoms.

Urinary bladder perforation can occur spontaneously in the setting of a weakened bladder wall. 4 It can be second- ary to radiotherapy, inflammation, urinary tract infection, malignant disease, neurogenic dysfunction, or bladder outlet obstruction. 5–12 The urinary bladder is the most common site of genito- urinary endometriosis. 13 It may be affected in 14% of women with deep infiltrating endometriosis, 14 and the lesion usually evolves from the serosal surface of the bladder toward the mucosa. 13 The symptoms of urinary bladder perforation are often nonspecific, and misdiagnosis is common. 12 Intraperito- neal perforation of the bladder typically manifests with Figure 1. A and B, Aspiration of the free liquid (urine) in the abdominopelvic cavity. C, Instillation of normal saline 0.9% (150 mL) and methylene blue (5 mL) into the bladder through a Foley catheter demonstrated the area of the bladder perforation. D, Excision of the edges of the perforation. E and F, Double-layer closure of the bladder wall. Figure 2. A , Focus of stromal and glandular endometriosis in the bladder serosa adjacent to the area of perforation (hematoxylin and eosin, /H11003100). B, Congestion in the bladder mucosa adjacent to the perforation (hematoxylin and eosin, /H11003100). Laparoscopic Repair of Spontaneous Bladder Perforation Due to Endometriosis, Kondo W et al. 2e2014.00258 CRSLS MIS Case Reports from SLS.org abdominal pain and tenderness due to peritonitis and difficulty in voiding urine. 15 A discrepancy between blad- der irrigation and recovery of a measured amount of saline through a Foley catheter can be suggestive of blad- der perforation. 15,16 Any delay in diagnosis results in sig- nificant reabsorption of urea and creatinine via peritoneal self-dialysis, causing a significant elevation in serum urea and creatinine levels. 2,17 Also, the clinician may observe elevated serum potassium and decreased serum sodium and CO 2 content, mimicking the biochemical features of renal failure. 17 On ultrasound, there is evidence of free intraperitoneal fluid. 2 A computed tomographic scan may show not only free intraperitoneal fluid, but also free air under the diaphragm, a thickened bladder wall, and an ab- scess. 5,6,8,11,18 A cystogram is useful to confirm the diag- nosis, but may be falsely negative if the perforation has sealed with surrounding tissues—for example, the omen- tum or blood clots. 5,6,8,10,11,18 Invariably, most patients must undergo laparotomy to confirm the diagnosis and repair the perforation. 2,7,9 –11,18 In the present case, the diagnosis was established during the laparoscopic explo- ration of the abdomen. Because there was no definite causative factor for the bladder perforation, we believe that spontaneous perforation occurred. During surgery, multiple lesions of endometriosis in the posterior com- partment of the pelvis were identified. The pathology of the area of the perforation in the bladder confirmed the presence of endometriotic tissue. Large endometriosis lesions usually promote thickening of the muscle layer of the bladder, resulting in a low probability of perforation. However, small lesions may lead to inflammation of the peritoneum overlying the bladder and the detrusor muscle, making them a pos- sible cause of bladder perforation. A previous surgical procedure for the treatment of endometriosis affecting the bladder may weaken the bladder wall, thus increas- ing the risk of bladder perforation in the case of a recurrence of the disease at the same place, especially if the bladder closure was not performed properly. Intraperitoneal rupture of the urinary bladder usually re- quires immediate surgical treatment to avoid serious life- threatening peritonitis. 15 Recently, some authors have de- scribed successful laparoscopic repair of intraperitoneal urinary bladder rupture in stable patients. 19,20 In our pa- tient, the repair was conducted successfully, and she had an uneventful postoperative course.

Although rare, spontaneous bladder perforation may oc- cur in patients with bladder endometriosis. This diagnosis must be considered, particularly in those patients present- ing to the emergency department with signs of peritonitis, along with urologic symptoms and features of acute renal failure.

1. Fugikawa K, Yamamichi F, Nonomura M, Soeda A, Takeuchi H. Spontaneous rupture of the urinary bladder is not a rare complication of radiotherapy for cervical cancer: report of six cases. Gynecol Oncol. 1999;73:439 – 442. 2. Kong CH, Ali SA, Singam P, Hong GE, Cheok LB, Zainud- din ZM. Spontaneous bladder perforation: a rare complication of tuberculosis. Int J Infect Dis. 2010;14(suppl 3):e250 – e252. 3. Kondo W, Zomer MT, Pinto EP, et al. Deep infiltrating endometriosis: imaging features and laparoscopic correlation. J Endometr. 2011;3:197–212. Figure 3. A , Epithelial cells of the bladder serosa were positive for cytokeratin 7 (CK7) (immunohistochemical staining, /H11003400). B,I n the bladder serosa, CK7-positive cells demonstrated multifocal positivity for estrogen receptors, not only in the cell surface but also in endometrial-like stromal cells (immunohistochemical staining, /H11003400). C, Mesothelial cells were present in the bladder serosa (immu- nohistochemical staining for inhibin, /H11003400). 3e2014.00258 CRSLS MIS Case Reports from SLS.org 4. Ogawa S, Date T, Muraki O. Intraperitoneal urinary bladder perforation observed in a patient with an indwelling urethral catheter. Case Rep Urol. 2013;2013:765704. 5. Ishii T, Kadowaki T, Sugiyama T. Intraperitoneal spontaneous rupture of the bladder subsequent to irradiation of the uterus: a case report [in Japanese].Hinyokika Kiyo.1988;34:2185–2188. 6. Hagiwara N, Nishida Y, Fujimoto Y, Isogai K, Fujihiro S, Deguchi T. Recurrent spontaneous bladder rupture cured by conservative therapy: a case report [in Japanese]. Hinyokika Kiyo. 2002;48:367–370. 7. Jayathillake A, Robinson R, Al-Samarii A, Manoharan M. Spon- taneous rupture of bladder presenting as peritonitis. N Z Med J. 2002;115:U222. 8. Basiri A, Radfar MH. Conservative management of early blad- der rupture after postoperative radiotherapy for prostate cancer. Urol J. 2008;5:269 –271. 9. Mardani M, Shahzadi M, Rakhshani N, Rahnavardi M, Rezvani J, Sharifinejad A. Spontaneous perforation of urinary bladder secondary to Candida cystitis: acute abdomen of urologic origin. Surg Infect (Larchmt). 2008;9:525–527. 10. Gomes CA, de Figueiredo AA, Soares Ju ´ nior C, Bastos Netto JM, Tassi FR. Acute abdomen: spontaneous bladder rupture as an important differential diagnosis [in Portuguese]. Rev Col Bras Cir. 2009;36:364 –365. 11. Ahmed J, Mallick IH, Ahmad SM. Rupture of urinary bladder: a case report and review of literature. Cases J. 2009;2:7004. 12. Limon O, Unluer EE, Unay FC, Oyar O, Sener A. An unusual cause of death: spontaneous urinary bladder perforation. Am J Emerg Med . 2012;30:2081.e3– e5. 13. Maccagnano C, Pellucchi F, Rocchini L, et al. Diagnosis and treatment of bladder endometriosis: state of the art. Urol Int. 2012;89:249 –258. 14. Kondo W, Ribeiro R, Trippia C, Zomer MT. Deep infiltrating endometriosis: anatomical distribution and surgical treatment [in Portuguese]. Rev Bras Ginecol Obstet. 2012;34:278 –284. 15. Tabaru A, Endou M, Miura Y, Otsuki M. Generalized peri- tonitis caused by spontaneous intraperitoneal rupture of the urinary bladder. Intern Med. 1996;35:880 – 882. 16. Raheem OA, Jeong YB. Intraperitoneally placed Foley cath- eter via verumontanum initially presenting as a bladder rupture. J Korean Med Sci. 2011;26:1241–1243. 17. Heyns CF, Rimington PD. Intraperitoneal rupture of the bladder causing the biochemical features of renal failure. Br J Urol. 1987;60:217–222. 18. Rogers CJ, Barber DB, Wade WH. Spontaneous bladder perforation in paraplegia as a late complication of augmentation enterocystoplasty: case report. Arch Phys Med Rehabil. 1996;77: 1198 –1200. 19. Zonca P, Cambal M, Jacobi CA. Laparoscopic management of spontaneous intraperitoneal perforation of urinary bladder. Bratisl Lek Listy. 2011;112:282–286. 20. Marchand TD, Cuadra RH, Ricchiuti DJ. Laparoscopic repair of a traumatic bladder rupture. JSLS. 2012;16:155–158. Laparoscopic Repair of Spontaneous Bladder Perforation Due to Endometriosis, Kondo W et al. 4e2014.00258 CRSLS MIS Case Reports from SLS.org