Combination injuries of diaphragm and urinary bladder resulting urinothorax.

Isolated diaphragmatic or urinary bladder injuries are uncommon, but rare are combination of these injuries. We report a rare case of urinothorax occurred as a result of combination injury of diaphragm and urinary bladder and our successful laparoscopic only management. A 26-year-old male presented with a history of trauma and features suggestive of bilateral pleural effusion. Radiological investigations revealed diaphragmatic and urinary bladder rupture. Laparoscopic examination of the abdomen confirmed the presence of ruptures and successful repair of both defects were done laparoscopically. High index of suspicion and early diagnosis are crucial for a better outcome in the management of diaphragmatic rupture. Laparoscopic management is a feasible and successful method in trained hands.

INTRODUCTION

Urinothorax, first described in 1968, refers to the presence of urine within the pleural cavity, results from either traumatic or obstructive causes.[1] In 2004, Garcia-Pachon and Padilla-Navas found only 53 cases of urinothorax documented in the literature.[2] Isolated diaphragmatic injuries are uncommon and occur only in 4-5% of cases requiring laparotomy, but combined injuries of diaphragm and urinary bladder seldom occur. No single investigation provides a reliable diagnosis, but high index of suspicion and careful clinical evaluation with appropriate radiological investigations will help. Once diagnosis is confirmed, the management depends on the general condition of the patient and the local surgical expertise available. Even though open laparotomy still plays a major role in the management of combination intraabdominal injuries, laparoscopy is evolving both as a good diagnostic and therapeutic tool.

CASE REPORT

A 25-year-old male, presented in the emergency, with a history of road traffic accident with complaints of severe pain right side chest, breathing difficulty and not able to void. Relevant clinical findings were contusion and decreased air entry in the right chest. Abdomen was clinically soft. Chest X-ray revealed bilateral hydrothorax. Bilateral intercostal tube drains were placed, drained 1500 ml and urethral catheter drained 400 ml of blood-stained urine. Contrast-enhanced computed tomography (CECT) scan demonstrated bilateral hydrothorax, diaphragmatic rupture with stomach inside thorax and intraperitoneal rupture of the urinary bladder. Diagnostic laparoscopy confirmed diaphragmatic and urinary bladder rupture [Figure 1]. Laparoscopic repair of bladder rupture was done with interrupted 00 absorbable suture [Figure 2a]. With the placement of extra ports for liver retraction, stomach reduced from the thorax. Diaphragmatic defect identified and closed with interrupted 0 non-absorbable suture [Figure 2b]. Abdominal drain and both intercostal drains were removed, and patient was discharged on day 6th. Urethral catheter removed after 3 weeks. He had no complaints in breathing or voiding 12 months after surgery.

Figure 1

Per-operative picture showing defects in the urinary bladder and diaphragm

Figure 2

Per-operative picture showing laparoscopic repair of (a) urinary bladder and (b) diaphragm

DISCUSSION

Urinothorax most commonly develops after obstructive uropathy with hydronephrosis or traumatic diaphragmatic disruption by blunt abdominal trauma. Diaphragmatic injury is a marker of severity of trauma, but frequently overlooked. In our case, the mechanism involved is “blow out” type: as a result of a sudden increase in intra-abdominal pressure due to blunt abdominal injury with a full urinary bladder.

Physical examination and history play very little role in diagnostic accuracy in patients with multiple trauma, and injuries involving diaphragm or bladder can be easily missed without high index of suspicion. In patients with difficulty in voiding urine with or without hematuria, always bladder injuries should be suspected. Role of chest X-ray is limited. High reliability of CECT scan in diagnosing diaphragmatic rupture and bladder rupture has been proved but has no role in haemodynamically unstable patient. Meticulous inspection and proper visualisation of every part of the abdominal cavity have to be done, not to miss minor defects.

The bladder injury usually occurs at its dome, giving the advantage of easy amenability for repair. In the past, the standard of care for bladder injury is laparotomy, considering the usual occurrence of associated other abdominal organ injuries.[3] With the advancement of laparoscopic surgery, even in multiple trauma patients, laparoscopic repair of multiple abdominal organ injuries has become the appropriate first-line management in selected group of patients.[4] In the literature, 21 cases have been reported so far for laparoscopic isolated bladder repair, but none with an associated diaphragmatic repair.[5] Very few cases of isolated diaphragmatic repair are reported.

The appeal of laparoscopy has many advantages. As a diagnostic tool, it can be quickly and safely performed. In polytrauma patients, the role of laparoscopy has been expanded from a mere diagnostic tool into playing a major therapeutic role. Laparoscopic evaluation of the blunt abdominal trauma in selected cases is a rewarding procedure for both the patient and the doctor. Being a wonderful diagnostic tool, it can double up as a treatment procedure as in our case. Even in cases where laparotomy is inevitable, it may assist to plan the site and reduce the size of the incision. With increasing experience of the surgeon, it offers to accomplish surgical therapeutic goals with minimal somatic and psychological trauma. We recommend this technique should be used more frequently in selected patients with multiple organ injuries.