Laparoscopic repair in children with traumatic bladder perforation.

Here, we report two patients with a traumatic intraperitoneal bladder dome rupture repaired by laparoscopic intracorporeal sutures. The first patient was a 3-year old boy was admitted with a history of road accident. He had a traumatic lesion on his lower abdomen and a pelvic fracture. Computed tomography (CT) scan revealed free intraabdominal fluid. The urethragram showed spreading contrast material into the abdominal cavity. Laparoscopic exploration revealed a 3-cm-length perforation at the top of the bladder. The injury was repaired in a two fold fashion. Post-operative follow-up was uneventful. The second case was a 3-year-old boy fell from the second floor of his house on the ground. He had traumatic lesion on his lower abdomen and a pelvic fracture. Due to bloody urine drainage, a cystography was performed and an extravasation from the dome of the bladder into the peritoneum was detected. On laparoscopy, a 3-cm long vertical perforation at the dome of the bladder was found. The perforation was repaired in two layers with intracorporeal suture technique. The post-operative course was uneventful. Laparoscopic repair of traumatic perforation of the bladder dome is a safe, effective and minimally invasive method. The cosmetic outcome is superior.

INTRODUCTION

Bladder perforation in childhood is rare, accounting for only 0.05-2.0% of all pelvic trauma cases.[1] In children of a younger age, the bladder is located somewhat intraperitoneally, making it vulnerable to perforation when full at the time of trauma. Blunt injury is more common in patients with bladder perforation (greater than 80-95%).[1] The bladder dome is the most common perforation site and is also the weakest point. Before the introduction of laparoscopy, open surgery was the only treatment option for adults and children with intraperitoneal bladder perforation. To our knowledge, laparoscopic repair of traumatic bladder perforation in children has not been reported in the literature. This present report discusses the laparoscopic repair of traumatic bladder perforation due to blunt abdominal trauma in two children.

CASE REPORTS

Case 1

A 3-year-old boy who was involved in a road accident presented with a pelvic fracture and skin abrasion on the right inguinal region. Abdominal computed tomography (CT) revealed intraperitoneal fluid. A bladder catheter was inserted. A cystography was performed 36 h after admission due to persistent haematuria, revealing an intraperitoneal bladder perforation. A laparoscopy was carried out with a 5-mm 30° telescope through the navel and two additional 3-mm ports. A 3-cm long intraperitoneal bladder perforation was identified. Using 3-0 polyglactin running sutures, the perforation was repaired in two layers. The bladder was filled with saline to test for leakage. The post-operative period was uneventful and the patient was discharged on post-operative day 5.

Case 2

A 3-year-old boy fell from a second storey building onto hard ground. The child presented with a pelvic fracture and abdominal skin abrasions. The abdominal CT ruled out any other solid organ injury. A cystography was done due to haematuria and an intraperitoneal bladder perforation was discovered. On laparoscopy, a 3-cm vertical bladder perforation was found and repaired in two layers with 3-0 ETHIBOND EXCEL®(Somerville, NJ, USA) running sutures using an intracorporeal suturing technique [Figure 1a–c]. The post-operative course was uneventful and the boy was discharged on post-operative day 6.

Figure 1

Stages of the bladder repair (a) perforation on the bladder (b) suturing of the perforation site and (c) completed repair

DISCUSSION

Intraperitoneal bladder perforation is rare in children but it is more common than in adults. Blunt injury of the urinary bladder is well-known and usually associated with pelvic fractures.[1] Less than 2% of all blunt abdominal trauma results in traumatic intraperitoneal bladder rupture. Haematuria is the most common onset of bladder perforation.[1] Regional trauma signs such as skin abrasions and abdominal distension are also common. In Case 2, gross haematuria was present as an initial sign; thus, diagnosis was done early. However, in Case 1 the patient had no gross haematuria and the CT examination did not reveal the perforation; moreover, the urinary catheter was inserted early on allowed urine drainage, making the symptoms of intraperitoneal leak subtle, which led to a delayed diagnosis. The diagnosis of bladder perforation is confirmed with regular cystography or CT-assisted cystography. The contrast medium should be filled slowly and anterior-posterior (AP) and oblique x-rays should be obtained. It is possible that an over-full bladder may mask the leak. Therefore, an x-ray after emptying should also be obtained.

For the diagnosis, retrograde cystography is mandatory; antegrade contrast studies fail to detect the perforation.[2] Quagliano et al. found no difference in sensitivity and specificity between conventional cystography and CT-assisted cystography in the diagnosis of traumatic bladder perforation.[3] They recommended CT cystography in patients with blunt abdominal trauma and the suspicion of bladder perforation.

In Case 1, the CT cystography failed to show the bladder perforation accurately since, we think, the bladder was empty and the contrast medium did not reach the bladder during the CT examination. Haematuria necessitated a conventional cystography, which revealed the bladder perforation.

Bladder perforations are either intraperitoneal or extraperitoneal. In extraperitoneal perforation, drainage with a urinary or suprapubic catheter is sufficient. In contrast, intraperitoneal bladder perforation requires surgical repair. Although some investigators suggest conservative treatment in intraperitoneal bladder perforation, surgery is the method of choice in the current literature.[4] The type of surgery for intraperitoneal bladder perforation is classical open repair. In the opinions of the authors, laparoscopic repair is a reasonable alternative to laparotomy. In trauma patients, laparoscopy is sometimes challenging or contraindicated. Intestinal dilatation, intraperitoneal bleeding and massive intraperitoneal fluid in trauma may deteriorate vision and lead to difficulties in surgery. Therefore, some conditions must be met before a laparoscopy in trauma is performed. The patient should be stable and no extra-organ injury should be present. The site of bladder injury should be accessible by the laparoscope. Urethra and bladder neck injuries cannot be managed by laparoscopy. Therefore, some authors recommend a cystoscopic examination prior to laparoscopy.

The first successful laparoscopic repair of an iatrogenic bladder perforation was performed in 1990[2] and in 1997, the first traumatic bladder perforation was repaired by laparoscopy.[2] In the literature, there are 10 cases of laparoscopic repair of traumatic bladder perforation. Recent literature revealed eight articles with laparoscopic bladder perforation solely in adults.[2] According to these studies, the length of perforation was usually less than 4 cm and there was no difference between single- and double-layer repairs. There was also no difference between running and separate suturing techniques.[5] Whatever the surgical technique, checking for leaks by means of filling the bladder, as was performed in Cases 1 and 2, is mandatory. To our knowledge, Cases 1 and 2 represent the first cases of laparoscopic repair of traumatic bladder perforation in children.

CONCLUSION

In conclusion, laparoscopic repair of traumatic bladder perforation is a reliable alternative to open technique in stable patients unless there is bladder neck injury or inaccessible sites of bladder injury. For repair, single- or double-layer suturing techniques may be used. Laparoscopy provides diminished post-operative pain, shortened length of stay and cosmetic superiority.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.