Renal failure and ascites after remote laparoscopy

were normal except for an ele- vated serum creatinine level (198 [nor- mal < 133] µmol/L). Noncontrast CT scanning showed free fluid in her ab- domen and a thickened omentum. One litre of straw-coloured ascitic fluid was aspirated; the leukocyte count was 0.50 [normal < 0.25] ∞10 9/L (lymphocytes 55%, neutrophils 45%). Tuberculosis of the abdomen was suspected. However, this diagnosis was unlikely because the ascites, dysuria and abdominal pain resolved spontaneously within 48 hours after aspiration of the ascitic fluid, and renal function re- turned to normal within 72 hours. One month later the patient was re- assessed and found to have ascites with generalized abdominal tenderness and guarding in the hypogastrium, which worsened over 24 hours. Oliguria (se- rum creatinine level 180 µmol/L) and, subsequently, anuria (serum creatinine level 675 µmol/L) developed. A catheter was inserted, and brisk diuresis of more than 5 L resulted in her renal function rapidly returning to normal. The creatinine level of the ascitic fluid was grossly elevated (2178 µmol/L), which confirmed the diagnosis of uri- nary ascites. Ultrasonography revealed kidneys of normal size, and noncon- trast CT scanning did not show obvious bladder injury but did reveal a fat den- sity lesion in the bladder. Contrast- enhanced CT scanning showed normal kidneys and ureters and a tongue of fat, probably omental tissue, adherent to the anterior wall of the bladder. CT cys- tography did not reveal any urinary leak. Cystoscopy, performed to identify the bladder perforation, revealed that omentum was plugging the defect at the dome of the bladder (Fig. 1). La- parotomy was performed to close the bladder perforation, and the patient had an uneventful recovery. Bladder injury is a known complication of gynecologic laparoscopic surgery, occurring in up to 8.3% of cases, 1 and is more common in women who have undergone previous pelvic operations. The diagnosis of accidental intraperi- toneal bladder injury may be delayed 2 if the injury is trivial or if omentum plugs a larger defect, as was seen in our case. Unexplained ascites and decreased re- nal function in a previously healthy per- son with a recent history of pelvic sur- gery should raise the suspicion of intraperitoneal bladder rupture. Our patient’s first episode of ascites re- solved without treatment, probably be- cause of spontaneous evacuation of urine through the bladder defect. A very high creatinine level in the ascitic fluid is diagnostic. 3 Treatment should in- volve conventional or CT cystography to localize the bladder perforation, fol- lowed by laparotomy to repair it. Samiran Adhikary Department of Urology Prasad Mathews Department of Medicine Ganesh Gopalakrishnan Department of Urology Christian Medical College and Hospital Vellore, Tamil Nadu India

1. Ostrzenski A, Ostrzenska KM. Bladder injury dur- ing laparoscopic surgery. Obstet Gynecol Surv 1999;54(11):233-8. 2. Lamaro VP, Broome JD, Vancaillie TG. Unrecog- nized bladder perforation during operative la- paroscopy. J Am Assoc Gynecol Laparosc2000;7 (3):417-9. 3. Heyns CF, Rimington PD. Intraperitoneal rupture of the bladder causing the biochemical features of renal failure. Br J Urol1987;60(3):217-22. CMAJ • November 22, 2005 • 173(11) | 1323 © 2005 CMA Media Inc. or its licensors Practice DOI:10.1503/cmaj.050915 Renal failure andascites after remote laparoscopy Clinical Vistas