Delayed bladder perforation is well recognised after augmentation cystoplasty (5-13% of patients) and adult urologists need to be aware of this and identify the best treatment at the time. Mortality rates and re-perforation rates can be up to 25% and over 50% respectively. These authors retrospectively looked at 10 patients with perforated augmentations. The conclusions from older publications suggest that perforations should be managed with exploratory laparotomy and closure. Four patients (mean age at augmentation 19 ± 6.3 years, mean age at perforation 23.7 ± 5.7 years) were treated with surgery and six non-operatively (mean age at augmentation 10.3 ± 5.4 years, mean age at perforation 16.5 ± 3 years). Non-operative treatment included bladder drainage via catheter only (3/6) or bladder drainage and peritoneal drain placed under image guidance (3/6). Two out of four operative cases had temperatures >38.5°C whereas none of the six managed conservatively had a temperature at this level. Two out of four in the operative group had peritonitis whereas none of the six non-operative cases had peritonitis. Re-perforation occurred in two out of four operative cases and two out of four non-operated cases (all in the bladder only drainage group). Mean time to re-perforation was 3 ± 3.7 years. All five re-perforations were treated operatively (of which one was not identified during laparotomy but the patient improved). The original perforations were alcohol related in four, due to trauma during sport in two, and down to non-compliant catheterisation in two. Two could not recall the incident. The authors conclude that younger patients may be treated preferentially with conservative management, that precautionary measures may help perforation prevention (emptying bladder pre sport, controlled alcohol / diuretic consumption / regular clean intermittent catheterisation), and that bimodal drainage (catheter and intraperitoneal drain) helps a perforation seal without laparotomy closure. They acknowledged that their series is small and retrospective.

Bladder perforation after augmentation cystoplasty: determining the best management option.
David T, Kozminski J, Bloom D, et al.
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Henrik Steinbrecher

Southampton University Hospital NHS Trust

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