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IJU Case Rep
IJU Case Rep
10.1002/(ISSN)2577-171X
IJU5
IJU Case Reports
2577-171X
John Wiley and Sons Inc. Hoboken

10.1002/iju5.12749
IJU512749
IJUCR-2024-0044.R1
Case Report
Case Report
A case of spontaneous bladder rupture successfully conservatively treated with transurethral debridement and hyperbaric oxygen therapy
A case of spontaneous bladder rupture
H Iijima et al.
Iijima Heisuke https://orcid.org/0000-0003-1049-3614
1
Someya Rikuri 1
Tanaka Eriko 1
Yamazaki Mami 1
Yokoi Tomoya 1
Takahashi Takehiro 1
Ueda Masakatsu 1
Shiraishi Yusuke 1
Yoshimura Koji https://orcid.org/0000-0001-6342-7691
1 ky7527@kuhp.kyoto-u.ac.jp

1 Department of Urology Shizuoka General Hospital Shizuoka Japan
* Correspondence: Koji Yoshimura M.D., Ph.D., Department of Urology, Shizuoka General Hospital, 4‐27‐1 Kitaando, Aoi‐ward, Shizuoka 420‐0881, Japan. Email: ky7527@kuhp.kyoto-u.ac.jp

11 7 2024
9 2024
7 5 10.1002/iju5.v7.5 351354
15 3 2024
14 5 2024
© 2024 The Author(s). IJU Case Reports published by John Wiley & Sons Australia, Ltd on behalf of Japanese Urological Association.
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Introduction

Spontaneous bladder rupture is a potentially life‐threatening condition. Its treatment often requires invasive strategies, mainly surgical closure, or cystectomy. We present a case where we successfully treated bladder rupture employing a less invasive technique of transurethral debridement and hyperbaric oxygen therapy.

Case presentation

A woman in her 80s presenting with lower abdominal pain was suspected of vesicoenteric fistula. Subsequent investigations confirmed bladder rupture to the abdominal wall, which eventually developed into a vesicocutaneous fistula. To minimize the invasiveness of treatment, a combined strategy of transurethral debridement of the fistula, and hyperbaric oxygen therapy was taken, resulting in successful outcome.

Conclusion

Our approach was unique for its tolerability in comparison to conventional surgical approaches taken towards this condition.

bladder rupture
cystectomy
laparoscopic surgery
vesicocutaneous fistula
source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:01.09.2024
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pmc Keynote message

A case of spontaneous bladder rupture treated successfully with a less invasive treatment strategy.

Abbreviations & Acronyms

CT computed tomography

HBOT hyperbaric oxygen therapy

Introduction

Spontaneous bladder rupture is a urological emergency with a potentially devastating outcome. It is often mistaken for an acute abdomen, which can delay diagnosis. Its treatment often requires a highly invasive strategy, usually surgical closure of the rupture, or cystectomy. 1 , 2 We present a case where we successfully treated a case of bladder rupture employing a more tolerable strategy of transurethral debridement and HBOT.

Case presentation

Our patient was a female in her 80s with multiple system atrophy, who recently underwent intramedullary nail placement surgery following left trochanteric fracture. She visited her clinic for lower abdominal pain, where her distended bladder raised suspicion of urinary retention. She was placed a urinary catheter, where highly odorous urine resembling fecal matter was collected. She was then referred to our hospital for suspected vesicoenteric fistula.

On admission, she had a 38.8°C fever, with blood pressure 160 mmHg/87 mmHg and heart rate 78 bpm. Along with marked leukocytosis white blood cell (WBC 20 000/μL) and elevated (C‐reactive protein) CRP (34.8 mg/dL), her serum creatinine level was elevated (1.72 mg/dL). Total protein was 6.0 g/dL, serum albumin, 1.7 g/dL, and urine dipstick, WBC 3+.

CT scan suggested rupture at the bladder apex, with urine leakage into the abdominal wall (Fig. 1a). In addition, intra‐abdominal fluid collection was present, with edematous changes along the adjacent intestinal lining (Fig. 1b). From these studies, a ruptured bladder wall, with possible presence of a vesicoenteric fistula was suspected.

Fig. 1 (a) CT of the pelvis, axial plane. Site of bladder rupture seen at the bladder apex, and urine leakage into the retroperitoneum. The bladder is indicated by an asterisk, and the arrow indicates site of rupture. (b) CT of the lower abdomen, coronal plane. Ascites and intestinal wall edema visible proximal to the bladder rupture site. Arrow indicates edematous intestinal wall. Arrowheads indicate ascites. Location of the bladder indicated by an asterisk.

She had been mostly bedridden post‐femur surgery, and her poor performance status limited the extent of our intervention. Therefore, she was managed conservatively with urethral catheterization (14Fr Foley catheter) and intravenous antibiotics. The urine culture revealed multiple species of Escherichia coli, Enterococcus faecalis, and Aerococcus sp., all of which were sensitive to tazobactam/piperacillin, our initial antibiotic of choice. Blood culture turned out negative.

An exploratory laparoscopy was planned on a later date. However, she contracted COVID‐19 3 days post‐admission, which required quarantine according to regulations at that time. Her laparoscopy, as well as considerations for surgery (open closure or urinary diversion) were abandoned, and conservative treatment continued.

Her overall condition did not improve, with abdominal symptoms remaining, and stagnant CRP levels. A tender erythematous skin change began to form on the suprapubic region 7 days post‐admission.

A CT scan confirmed a subcutaneous abscess at this site, owing to urine leakage from the poorly healing bladder, and insufficient urinary drainage from the catheter due to debris (Fig. 2), despite a 1–1.5 L yield of daily urine. There was no evidence of a vesicoentric fistula. She underwent a percutaneous drainage to treat the subcutaneous infection, and a cystoscopy to remove bladder debris. The catheter size was increased to a 22Fr nephrostomy tube for better drainage.

Fig. 2 CT of the lower abdomen, sagittal plane. Subcutaneous abscess formation visible within the lower abdominal wall. Arrows show area of abscess. The bladder is indicated by an asterisk.

Her symptoms improved, achieving defervescence and decreased CRP levels. Vesicoenteric fistula was ruled out by colonoscopy on Day 16, and oral feeding was resumed. Laboratory data and the subcutaneous infection site continued to improve. However, despite these promising signs, 200–800 mL daily urine leakage continued from the subumbilical wound, which by then had developed into a vesicocutaneous fistula.

A cystoscopy was performed on Day 17. A fistula was visible with its walls lined with pale, ischemic tissue suggestive of necrotic tissue. A repeat cystoscopy 20 days later showed little change (Fig. 3a). Further aggressive treatment was deemed necessary, although her physical condition made conventional surgical approaches difficult. After thorough discussion, we decided upon a transurethral debridement of the fistula, combined with HBOT.

Fig. 3 (a) Cystoscopy image. Intravesicular view of the fistula. Fistula wall lining seen as a pale, avascular surface. (b) Intraoperative image. Fistula cavity post‐transurethral debridement. Vascularized adipose tissue visible in yellow. (c) Photo of abdominal wall post‐HBOT. Closure of the subumbilical wound is confirmed. Arrowhead indicates the umbilicus, and the arrow shows former site of fistula. (d) Cystoscopy image. Post‐HBOT, showing regrowth of bladder mucosal tissue.

The surgery was performed under lumbar anesthesia in the lithotripsy position. The tissue lining the fistula was removed using electrocautery and transurethral forceps until viable adipose tissue were visible (Fig. 3b). The operation time was 50 min, with negligible blood loss.

Twenty daily sessions of HBOT commenced 2 days post‐surgery, each lasting 1.5 h, under 2 atm at 240 L/min. Urine leakage from the wound ceased on the fourth day of HBOT. Skin and fistula closure, as well as regrowth of bladder mucosa was confirmed post‐HBOT (Fig. 3c,d). An illustration detailing the clinical course is provided on Figure 4. She was discharged 63 days post‐admission, with continued urinary catheterization.

Fig. 4 Graphic illustration of the patient's hospital course. Line graph in orange depicts the patient's body temperature, WBC in blue, CRP in red. Each image study is marked by a black arrow, with corresponding figure number, when appropriate. The duration of each antibiotic use is indicated as green bars, each at optimal dosage, and sensitivity against its most recent urine culture findings. Duration of HBOT is indicated by a red bar, and the duration of urine leakage from the abdominal wound (vesicocutaneous fistula) is indicated by an orange bar.

Discussion

Bladder rupture is most frequently associated with trauma or iatrogenic causes, leading to devastating clinical consequences. Spontaneous bladder rupture is less common, though its outcome may be equally critical. Due to its rarity, it may be initially misdiagnosed, and delay of treatment may potentially be fatal, with reported mortality rates as high as 8%. 1 Bladder rupture may be classified as either intraperitoneal or extraperitoneal rupture, according to the rupture location. 1 , 2

Rupture of the bladder wall occurs when the intravesicular pressure exceeds the structural capability of the bladder. Therefore, its underlying causes include conditions that weaken the bladder's structural integrity. Connective tissue disease, chronic lower urinary tract infection, history of pelvic surgery and radiotherapy have been linked to lowering bladder wall strength. 3 , 4 , 5 Our patient had multiple histories of pelvic surgery, and a debilitating neurodegenerative disease, which suggests her bladder structure was likely compromised.

Diagnosing bladder rupture is approached by combining imaging techniques such as CT, cystography, and cystoscopy. However, imaging alone may not be sufficient, and exploratory laparoscopy may ultimately be necessary for confirmation. 1 , 2 , 4 , 5

Management of bladder rupture may vary from conservative treatment such as catheterization, to invasive approaches such as laparoscopic or open surgery. In general, catheterization alone may be sufficient to treat extraperitoneal ruptures, whereas surgery is often necessary for intraperitoneal ruptures. Factors such as presence of infection, bleeding, and other organ damage should play into decision making. 1 , 3 Our case was complicated by her overall condition, as well as the development of a vesicocutaenous fistula, which required additional approaches to improve wound healing.

Vesicocutaneous fistulas, which in this case formed from inadequate bladder and surface wound healing, may be caused by a multitude of conditions, such as trauma, extensive pelvic surgery, and irradiation. Treatment is often tailored according to each patients underlying condition. Previously reported strategies include percutaneous nephrostomy placement, urinary diversion, and skin grafts. 6

Since our initial drainage of subcutaneous abscess was not sufficient for adequate healing, we decided to include HBOT following transurethral debridement of the fistula. Although the precise mechanism is not completely understood, tissue hyperoxygenation from HBOT is said to modulate various signaling cascades, stimulating production of growth factors, thus improving wound healing of post‐ischemic and post‐inflammatory tissue. 7 To the best of our knowledge, this is the first reported case combining the two strategies. An alternative option worth considering is Vacuum‐assisted closure therapy. 8 , 9

Conclusion

We report our experience on a case of spontaneous bladder rupture, successfully managed with transurethral debridement and HBOT. Our treatment strategy was unique for its less invasive nature, in comparison to conventional treatment.

Author contributions

Heisuke Iijima: Writing – original draft. Rikuri Someya: Validation. Eriko Tanaka: Validation. Mami Yamazaki: Validation. Tomoya Yokoi: Validation. Takehiro Takahashi: Validation. Masakatsu Ueda: Validation. Yusuke Shiraishi: Validation. Koji Yoshimura: Supervision; writing – review and editing.

Conflict of interest

The authors declare no conflict of interest.

Approval of the research protocol by an Institutional Reviewer Board

Not applicable.

Informed consent

Not applicable.

Registry and the Registration No. of the study/trial

Not applicable.
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