Carbon dioxide insufflation to control intractable bleeding during transurethral resection of bladder tumor.

We describe a method to manage severe bleeding during transurethral resection (TUR) of a giant bladder tumor, in which vision was impaired by the bleeding. The use of carbon dioxide gas as an alternative to irrigation fluid for bladder inflation provided a better view to safely control the intractable bleeding.

INTRODUCTION

Transurethral resection (TUR) of a giant bladder tumor is challenging as there is difficulty in controlling severe hemorrhage. Here, we report a case of giant bladder tumor initially treated by TUR, in which intractable bleeding was successfully managed by electrocoagulation under carbon dioxide (CO2) insufflation of the urinary bladder.

CASE REPORT

A 34-year-old male presented with painless gross hematuria. A screening urine cytology was suggestive of urothelial cancer. Magnetic resonance imaging of the urinary bladder showed a giant pedunculated tumor (67 mm × 37 mm × 58 mm) on the anterior wall, with multiple daughter tumors up to 15 mm in size [Figure 1a], but all appeared to be non-muscle invasive. A cystoscopy confirmed extensive papillary tumors occupying almost the entire bladder cavity, except for a part of the right lateral wall. The prostatic urethra was also involved by the tumor. A contrast-enhanced computed tomography revealed normal upper tracts and absence of distant metastasis. The clinical tumor stage was ≤T1N0M0. TUR was performed with a curative intent using the standard mono-polar TUR system (Olympus Corporation; Tokyo, Japan). After resection of a number of daughter tumors, sequential resection was performed for the main tumor. The tumor was highly vascular and hemostatic coagulation was required after resection of every chip. As the resection continued closer to the tumor base, maintaining hemostasis became harder because of active bleeding and the papillary shape which covered the bleeding sites and prevented accurate pin point coagulation. All attempts of coagulation with the resection loop and the ball electrode were ineffective because the bleeding point could not be localised as the vision was impaired. Thus, we decided to insufflate the bladder with CO2 to achieve a clear cystoscopic view [Figure 1b]. The CO2 intravesical pressure was maintained at 12–15 mmHg by the laparoscopic CO2 insufflator (high flow insufflation unit UHI-4, Olympus Corporation; Tokyo, Japan), and the bleeding point was localised. Tumor resection was then continued with conventional pure cut mode with intermittent smoke evacuation to ensure visibility. Clots and resected tissues were removed intermittently by flushing with saline.

Figure 1

(a) Coronal section of magnetic resonance imaging showing the giant bladder tumor occupying the bladder cavity. (b) Carbon dioxide insufflation of the bladder provided a clear cystoscopic view despite severe bleeding during transurethral resection

The conventional coagulation mode often caused tissue carbonization, which was liable to dislodge from the coagulated surface, resulting in inadequate hemostasis. Instead, the soft coagulation mode provided a better hemostasis. These steps were repeated numerous times, and the exophytic portion of the tumor was finally resected. The operative time was 6 h, but there were no signs of hyponatremia or hypercapnia. Blood transfusion was not required and the hemoglobin fall was from 13.8 mg/dl to 12.9 mg/dl during the surgery. The postoperative course was uneventful and he was discharged on the 4th postoperative day. Although we attempted bladder preservation based on the preoperative imaging, he finally underwent radical cystectomy as the histopathology showed muscle invasive urothelial cancer (high grade, pT2).

DISCUSSION

The major advantage of aggressive TUR for a giant bladder tumors is bladder preservation but comes at the cost of increased blood loss and long operating time. A couple of methods have been described to reduce bleeding during transurethral procedures for large bladder tumors. Transurethral bipolar plasma vaporization with the button-shaped electrode has been shown to completely vaporize very large tumors with minimal blood loss without risk of bladder perforation.[1] A large bladder hemangioma was successfully treated with serial endoscopic yttrium–aluminum–garnet laser irradiation.[2]

CO2 insufflation into the bladder has long been known to provide a better view during cystoscopy in patients with hematuria as compared to standard fluid irrigation.[3] However, to the best of our knowledge, there are no reports of CO2 insufflation of the bladder during TUR. The clear vision achieved under gas cystoscopy may be partly due to hemostatic effect of the gas pressure. The main disadvantage of TUR in CO2 gas is prolonged operative time, as the tumor chips and blood clots need to be flushed out at regular intervals and the need to frequently exchange gas to evacuate smoke produced by electrocoagulation. Actually, it took about 2 h for the part of TUR in CO2 gas. The major concerns about the use of CO2 insufflation during TUR are overheating and gas embolism. It is not difficult to imagine that TUR in CO2 gas will heat the bladder tissue more as compared with the standard TUR in fluid. Therefore, we lowered the power of cutting and coagulation mode to 50 W and 30–50 W, respectively. Intermittent flushing of the resected tumor surface with saline might also help to reduce overheating. The risk of gas embolism by CO2 insufflation of the bladder is another concern. However, we believe that the risk is very low because gas embolism is a rare complication during laparoscopic surgery,[4] and the urinary bladder lacks large vessels and sinuses.

CONCLUSION

The application of CO2 gas to insufflate the bladder is a novel method but should be used as the last resort during TUR for giant bladder tumors, where the vision is compromised with standard cystoscopy because of intractable bleeding. Although effective, there are associated concerns of gas embolism, overheating of bladder surface, and prolonged operative time.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.