Perforation during TURBT?

• 25 Apr 2020 05:29:45 PM
• |Onco Urology

Q. Does Bladder perforation ( either intraperitoneal or extraperitoneal) while doing TURBT upstage the disease ? How to proceed in such a case particularly if the perforation is identified well before completing the resection? 

Comments(2)

• 

  Dr. Anil Takvani

  25 Apr 2020 05:40:05 PM

  Bladder perforation :

  How big?

  Retrovesical/retroperitoneal?

  Peritoneal perforation and bladder content leak in peritoneum?

  Thanks

  
  

• 

  Pankaj N Maheshwari

  01 May 2020 01:42:22 PM

  Bladder perforation is a known TURBT complication. it is common and usually underreported and under diagnosed  In one study where post-op cystogram were done, 58% patients showed extravasation (J Urol 2005;174:2260-2). 

  Large perforations needing open surgery are luckily rare. 

  
  

  Associated risk factors include previous resection, elderly patients, lateral bladder wall tumors (causing obturator stimulation), and presence of bladder diverticula. Factors that help prevent these complications include surgeon experience, empty bladder and obturator nerve block. 

  
  

  Problems with perforation:

  1. Residual tumor in bladder (incomplete procedure)
  2. Risk of thermal injury to surrounding organs especially bowel (BJU Int. 2011;107:1065-8)
  3. Risk of cancer cell dessimination via the perforation and increased risk of pelvic and distant recurrence. 
  4. If indicated, post-op bladder instillation of chemotherapeutic agents (mitomicin) can not be done. 

  Management of bladder perforation is dependent on whether the perforation is extraperitoneal or intraperitoneal. Stage the TUR-BT procedure and achieve a good hemostasis. Extra-peritoneal perforations are treated by conservative treatment while for intravesical large perforations, surgical repair may be needed. The surgical repair is preferably by open laparotomy where bladder and bowel injury can be managed. Even laparoscopic repair has been reported. The morbidity and risk of such repair are high. 

  
  

  Patient needs to be followed regularly for extravesical recurrence after perforation.