Downloaded from www.ajronline.org by Kasier Permenete on 11/07/15 from IP address 50.201.204.73. Copyright ARRS. For personal use only; all rights reserved
833
Delayed Spontaneous Augmented Bladder Diagnosis
Ronald
B. J. Glass1
H. Gil Rushton2
With
the
with
increasing
small-capacity,
Rupture of in Children:
Sonography
use
of augmentation
noncompliant
bladders,
and
enterocystoplasty
CT
to treat
patients
with
an increase in the number of cases of delayed
spontaneous intraperitoneal rupture of the augmented bladder has been reported. Although patients with a ruptured bladder usually will have an acute abdomen, these clinical signs and symptoms may be masked in spina bifida patients because of their
neurologic
deficit.
Cystography
and sonography
were
performed
in four spina
bifida
patients with delayed spontaneous rupture of an augmented bladder. One patient also had isotope cystography. Two patients were examined with CT. Cystographic findings were abnormal in only one case. Peritoneal fluid was identified sonographically in all four cases and also was seen in both CT studies. Our study reveals that enhanced cystography will frequently fail to show leakage from an augmented bladder. Sonography and CT are reliable in detecting free intraperitoneal fluid, a finding that can significantly aid in the diagnosis of ruptured bladder after
enterocystoplasty. sonography AJR
Therefore,
or CT in order
158:833-835,
cystography
to detect
with normal
extravasated
findings
must
be followed
by
urine.
April 1992
Bladder augmentation (enterocystoplasty) with an isolated loop of vascularized bowel or a patch of stomach is a procedure used to increase the capacity and improve the compliance of a pathologically small or contracted noncompliant bladder. Delayed spontaneous rupture of an augmented bladder is a recognized complication [1-5]. As an increasing number of patients undergo this surgery, one
can expect bladder
to encounter
rupture
this problem
is a potentially
[1 3]. In spina bifida patients, ,
more often.
Spontaneous
fatal condition
[4], and deaths
the diagnosis
of a ruptured
intraperitoneal
have been
bladder
reported
often may be
masked or delayed because of impaired sensation [3]. Contrast-enhanced cystography may not demonstrate leakage, and diagnosis may depend on sonographic and CT demonstration of intraperitoneal fluid. We
present Received revision
September 3, 1991 November 1 9, 1991.
1 Department ogy, Children’s
George
Washington
Lkiiversity
School
1 1 1 Michigan
Washington, DC 20010. to R. B. J. Glass.
Department
after
of Diagnostic Imaging and RadiolNational Medical Center and the
and Health Sciences,
2
accepted
;
Address
of Urology,
of Medicine
Ave., NW.,
reprint
Children’s
requests
National
Medical Center and the George Washington Wiversity School of Medicine and Health Sciences, Washington, DC 20010. 0361
-803x/92/1
C American
584-0833
Roentgen
Ray Society
our experience
with four previously
neous rupture of an augmented bladder, confirmed by sonographic and CT detection
Materials
report.
cases of delayed
sponta-
in which the clinical diagnosis of intraperitoneal fluid.
was
and Methods
Augmentation
patients
unreported
enterocystoplasty
with delayed The age range
noncompliant
bladder
spontaneous
has been
rupture
of the patients
augmented
was
performed
in 55 patients
of an augmented 7-21
years.
with a detubularized
at our
institution.
Four
bladder form the basis for this
All patients
segment
had spina
bifida
and a
of ileum. None of these
patients had an artificial urinary sphincter or other procedure to increase bladder outlet resistance. After enterocystoplasty, the bladder was emptied by clean intermittent catheterization. No attempt was made to maintain sterile urine with prophylactic antibiotics. After an interval ranging from 1 3 months to 4 years, each of these patients was seen with
834
GLASS
acute abdominal
pain and distension,
had hematuria.
The duration
vomiting,
of symptoms
and oliguria.
was
24-72
AND
None
hr. In two
RUSHTON
AJR:158, April 1992
tenacious mucus. Pathologic examination of the area adjacent to the tear revealed inflammatory cell infiltrate.
patients the diagnosis was delayed, and both underwent nondiagnostic laparotomy before they were referred to the urology department at our institution.
On the basis
Downloaded from www.ajronline.org by Kasier Permenete on 11/07/15 from IP address 50.201.204.73. Copyright ARRS. For personal use only; all rights reserved
rupture of the augmented sonography
distended
and with
cystography.
more
than
of clinical
bladder, The
evidence
all patients augmented
350 ml of contrast
of spontaneous
were evaluated bladder
medium
was
in three
with cases
and 300 ml in one case. Images of the full bladder were made from intermittent fluoroscopic examinations in the anteroposterior, lateral, and both oblique
projections.
from the bladder,
After the contrast
an anteroposterior
material
overhead
was drained
Bucky
view of the
abdomen was obtained. An isotope cystogram was also obtained in one patient. CT with IV contrast medium was performed in two cases.
Three acutely ill patients underwent laparotomy for repair of the ruptured bladder. One patient was treated nonsurgically by means of indwelling Foley catheter drainage and broad-spectrum He responded so well to conservative therapy that
considered
antibiotics. surgery was
unnecessary.
Augmentation enterocystoplasty is undertaken for a wide spectrum of conditions associated with a small or noncompliant bladder. Extravasation of urine from the bladder may occur early or late in the postoperative course. Early leakage
usually occurs at the anastomosis of bladder and bowel. Delayed rupture, which may take place 5 weeks to 59 months after surgery, has occurred in the augmented bladder, regardless of the segment of bowel used [2, 3]. Peritonitis, septic shock, and even death have ensued from extravasation of the chronically infected urine into the peritoneal cavity.
The etiology
of spontaneous
is incompletely understood. intravesical pressure caused
Results
mented
Cystography failed to demonstrate leakage from the bladder in three cases. Leakage into the peritoneal cavity was demonstrated in one patient after the bladder had been distended with 300 ml of contrast material. The one isotope cystogram also failed to show leakage. Sonography showed intraperitoneal fluid in all four cases (Figs. 1 and 2). In one child the intraperitoneal fluid was loculated; this was distant from the site of the ventriculoperitoneal shunt tube (Fig. 3). Sonographically, the fluid was anechoic.
Discussion
fully
In both
CT
studies,
the
fluid
had
uniformly
low
attenuation, with no extravasation of injected IV contrast medium from the bladder (Fig. 3). In the three cases that required laparotomy, the ruptures were identified in the enteric component of the augmented bladder. In one case the perforation was occluded by thick
Fig. 1-21-year-old woman with pentonitis. Longitudinal sonogram of upper abdomen reveals free fluid. k = hydronephrotic left kidney.
Fig. dominal
bladder
sions or traumatic
and kidney.
that elevated of the aug-
compromise
and ischemia
the augmented bladder to rupture of rupture due to perivesical adhe-
catheterization
are no longer
considered
investigators.
Once the bladder
so reliable augmented
has ruptured,
when evaluating bladders
may be nondiagnostic seals itself or becomes
2.-7-year-old febnle boy with abpain. Transverse sonogram of left spleen
rupture of the bladder
patients
may have acute
onset of abdominal discomfort or pain accompanied by abdominal distension, nausea, fever, and anorexia. Although nonspecific, these findings become highly suggestive of rupture in a patient with previous enterocystoplasty. The role of cystography in diagnosing traumatic rupture of normal bladders is well established [7]. Unfortunately, cystography is not
upper quadrant of abdomen shows fluid soparating
leads to vascular
of the bowel, predisposing [4-6]. Previous theories valid by most
delayed
It is suggested by overdistension
[1 -3].
delayed
spontaneous
Contrast-enhanced
rupture
of
cystography
if the tear in the augmented occluded by mucus.
bladder
Fig. 3.-1O-year-old boy with feverand abdominal pain. Enhanced CT scan through level of augmented bladder shows layered contrast material in dependent bowel component of augmented bladder (asterisk). urine and loculated fluid collection (white similar attenuation. Right ureter is filled material (black arrow).
Unopacified arrows) have with contrast
AJR:158,
Urine
that
has extravasated
mechanical
occlusion
diography,
into
OF
AUGMENTED
the peritoneum
prior
will not be seen with conventional
but will be readily
CT. Therefore, Downloaded from www.ajronline.org by Kasier Permenete on 11/07/15 from IP address 50.201.204.73. Copyright ARRS. For personal use only; all rights reserved
RUPTURE
April 1992
demonstrated
a normal appearance
by sonography
on the cystogram
to
raor
should
befollowed by abdominal sonography or CT in this population. CT may be more helpful than sonography in demonstrating that intraperitoneal fluid is not contiguous with a ventriculo-
peritoneal shunt, suggesting that this fluid does not represent CSF. Infected urine in the bladder may have increased echogenicity
and may
contain
debris;
we assume
appearance may also be encountered the peritoneum. CT did not help detect
that
with infected
the site of bladder
rupture
a similar
urine in in our
two patients. Peritoneal fluid was identified as easily with CT as with sonography. The extravasated urine had low attenuation,
with
no evidence
to suggest
intraperitoneal
leakage
from the contrast-filled augmented bladder. Delayed spontaneous rupture of an augmented bladder is associated with significant morbidity, and deaths have been reported [1 3, 4]. We stress the importance of sonography together with a high index of suspicion in the diagnosis of a ,
ruptured
cases
augmented
to confirm
bladder. Sonography will suffice in most the diagnosis, but when visualization is
BLADDER
IN CHILDREN
compromised
followed
by overlying
835
bowel
by CT examination.
gas, sonography
Prompt
diagnosis
should
be
of sponta-
neous ruptured bladder after enterocystoplasty is crucial minimize morbidity and ensure successful treatment.
to
REFERENCES 1 . Rushton HG, Woodard JR, Parrott TS, Jells RD, Gearhart JP. Delayed bladder rupture after augmentation enterocystoplasty. J Uro! 1988;140: 344-346 2. Sheiner JR, Kaplan GW. Spontaneous bladder rupture following enterocystoplasty. J Urol 1988;140: 1157-1158 3. EIder JS, Snyder HM, Hulbert WC, Duckett JW. Perforation of the augmented bladder in patients undergoing clean intermittent catheterization. J Uro! 1988;140:1159-1162 4. Essig KA, Sheldon CA, Brandt MT, Wacksman J, Silverman DG. Elevated intravesical pressure causes arterial hypoperfusion in canine colocystoplasty: a fluorometric assessment. J Uro! 1991:146:551-553 5. Dixon CM, Filmer RB, Chang CH, Perimutter AD. Spontaneous perforation of bladder augmentation in pediatric patients. J Uro! 1989;1 41 : 1 95A 6. Crane JM, Scherz HS, Billman GF, Kaplan GW. lschemic necrosis: a hypothesis to explain the pathogenesis of spontaneously ruptured enterocystoplasty. J Uro! 1991:146:141-144 7. Cass AS. Diagnostic studies in bladder rupture. Indications and techniques. Urol Clin North Am 1989;16:267-273
833
Delayed Spontaneous Augmented Bladder Diagnosis
Ronald
B. J. Glass1
H. Gil Rushton2
With
the
with
increasing
small-capacity,
Rupture of in Children:
Sonography
use
of augmentation
noncompliant
bladders,
and
enterocystoplasty
CT
to treat
patients
with
an increase in the number of cases of delayed
spontaneous intraperitoneal rupture of the augmented bladder has been reported. Although patients with a ruptured bladder usually will have an acute abdomen, these clinical signs and symptoms may be masked in spina bifida patients because of their
neurologic
deficit.
Cystography
and sonography
were
performed
in four spina
bifida
patients with delayed spontaneous rupture of an augmented bladder. One patient also had isotope cystography. Two patients were examined with CT. Cystographic findings were abnormal in only one case. Peritoneal fluid was identified sonographically in all four cases and also was seen in both CT studies. Our study reveals that enhanced cystography will frequently fail to show leakage from an augmented bladder. Sonography and CT are reliable in detecting free intraperitoneal fluid, a finding that can significantly aid in the diagnosis of ruptured bladder after
enterocystoplasty. sonography AJR
Therefore,
or CT in order
158:833-835,
cystography
to detect
with normal
extravasated
findings
must
be followed
by
urine.
April 1992
Bladder augmentation (enterocystoplasty) with an isolated loop of vascularized bowel or a patch of stomach is a procedure used to increase the capacity and improve the compliance of a pathologically small or contracted noncompliant bladder. Delayed spontaneous rupture of an augmented bladder is a recognized complication [1-5]. As an increasing number of patients undergo this surgery, one
can expect bladder
to encounter
rupture
this problem
is a potentially
[1 3]. In spina bifida patients, ,
more often.
Spontaneous
fatal condition
[4], and deaths
the diagnosis
of a ruptured
intraperitoneal
have been
bladder
reported
often may be
masked or delayed because of impaired sensation [3]. Contrast-enhanced cystography may not demonstrate leakage, and diagnosis may depend on sonographic and CT demonstration of intraperitoneal fluid. We
present Received revision
September 3, 1991 November 1 9, 1991.
1 Department ogy, Children’s
George
Washington
Lkiiversity
School
1 1 1 Michigan
Washington, DC 20010. to R. B. J. Glass.
Department
after
of Diagnostic Imaging and RadiolNational Medical Center and the
and Health Sciences,
2
accepted
;
Address
of Urology,
of Medicine
Ave., NW.,
reprint
Children’s
requests
National
Medical Center and the George Washington Wiversity School of Medicine and Health Sciences, Washington, DC 20010. 0361
-803x/92/1
C American
584-0833
Roentgen
Ray Society
our experience
with four previously
neous rupture of an augmented bladder, confirmed by sonographic and CT detection
Materials
report.
cases of delayed
sponta-
in which the clinical diagnosis of intraperitoneal fluid.
was
and Methods
Augmentation
patients
unreported
enterocystoplasty
with delayed The age range
noncompliant
bladder
spontaneous
has been
rupture
of the patients
augmented
was
performed
in 55 patients
of an augmented 7-21
years.
with a detubularized
at our
institution.
Four
bladder form the basis for this
All patients
segment
had spina
bifida
and a
of ileum. None of these
patients had an artificial urinary sphincter or other procedure to increase bladder outlet resistance. After enterocystoplasty, the bladder was emptied by clean intermittent catheterization. No attempt was made to maintain sterile urine with prophylactic antibiotics. After an interval ranging from 1 3 months to 4 years, each of these patients was seen with
834
GLASS
acute abdominal
pain and distension,
had hematuria.
The duration
vomiting,
of symptoms
and oliguria.
was
24-72
AND
None
hr. In two
RUSHTON
AJR:158, April 1992
tenacious mucus. Pathologic examination of the area adjacent to the tear revealed inflammatory cell infiltrate.
patients the diagnosis was delayed, and both underwent nondiagnostic laparotomy before they were referred to the urology department at our institution.
On the basis
Downloaded from www.ajronline.org by Kasier Permenete on 11/07/15 from IP address 50.201.204.73. Copyright ARRS. For personal use only; all rights reserved
rupture of the augmented sonography
distended
and with
cystography.
more
than
of clinical
bladder, The
evidence
all patients augmented
350 ml of contrast
of spontaneous
were evaluated bladder
medium
was
in three
with cases
and 300 ml in one case. Images of the full bladder were made from intermittent fluoroscopic examinations in the anteroposterior, lateral, and both oblique
projections.
from the bladder,
After the contrast
an anteroposterior
material
overhead
was drained
Bucky
view of the
abdomen was obtained. An isotope cystogram was also obtained in one patient. CT with IV contrast medium was performed in two cases.
Three acutely ill patients underwent laparotomy for repair of the ruptured bladder. One patient was treated nonsurgically by means of indwelling Foley catheter drainage and broad-spectrum He responded so well to conservative therapy that
considered
antibiotics. surgery was
unnecessary.
Augmentation enterocystoplasty is undertaken for a wide spectrum of conditions associated with a small or noncompliant bladder. Extravasation of urine from the bladder may occur early or late in the postoperative course. Early leakage
usually occurs at the anastomosis of bladder and bowel. Delayed rupture, which may take place 5 weeks to 59 months after surgery, has occurred in the augmented bladder, regardless of the segment of bowel used [2, 3]. Peritonitis, septic shock, and even death have ensued from extravasation of the chronically infected urine into the peritoneal cavity.
The etiology
of spontaneous
is incompletely understood. intravesical pressure caused
Results
mented
Cystography failed to demonstrate leakage from the bladder in three cases. Leakage into the peritoneal cavity was demonstrated in one patient after the bladder had been distended with 300 ml of contrast material. The one isotope cystogram also failed to show leakage. Sonography showed intraperitoneal fluid in all four cases (Figs. 1 and 2). In one child the intraperitoneal fluid was loculated; this was distant from the site of the ventriculoperitoneal shunt tube (Fig. 3). Sonographically, the fluid was anechoic.
Discussion
fully
In both
CT
studies,
the
fluid
had
uniformly
low
attenuation, with no extravasation of injected IV contrast medium from the bladder (Fig. 3). In the three cases that required laparotomy, the ruptures were identified in the enteric component of the augmented bladder. In one case the perforation was occluded by thick
Fig. 1-21-year-old woman with pentonitis. Longitudinal sonogram of upper abdomen reveals free fluid. k = hydronephrotic left kidney.
Fig. dominal
bladder
sions or traumatic
and kidney.
that elevated of the aug-
compromise
and ischemia
the augmented bladder to rupture of rupture due to perivesical adhe-
catheterization
are no longer
considered
investigators.
Once the bladder
so reliable augmented
has ruptured,
when evaluating bladders
may be nondiagnostic seals itself or becomes
2.-7-year-old febnle boy with abpain. Transverse sonogram of left spleen
rupture of the bladder
patients
may have acute
onset of abdominal discomfort or pain accompanied by abdominal distension, nausea, fever, and anorexia. Although nonspecific, these findings become highly suggestive of rupture in a patient with previous enterocystoplasty. The role of cystography in diagnosing traumatic rupture of normal bladders is well established [7]. Unfortunately, cystography is not
upper quadrant of abdomen shows fluid soparating
leads to vascular
of the bowel, predisposing [4-6]. Previous theories valid by most
delayed
It is suggested by overdistension
[1 -3].
delayed
spontaneous
Contrast-enhanced
rupture
of
cystography
if the tear in the augmented occluded by mucus.
bladder
Fig. 3.-1O-year-old boy with feverand abdominal pain. Enhanced CT scan through level of augmented bladder shows layered contrast material in dependent bowel component of augmented bladder (asterisk). urine and loculated fluid collection (white similar attenuation. Right ureter is filled material (black arrow).
Unopacified arrows) have with contrast
AJR:158,
Urine
that
has extravasated
mechanical
occlusion
diography,
into
OF
AUGMENTED
the peritoneum
prior
will not be seen with conventional
but will be readily
CT. Therefore, Downloaded from www.ajronline.org by Kasier Permenete on 11/07/15 from IP address 50.201.204.73. Copyright ARRS. For personal use only; all rights reserved
RUPTURE
April 1992
demonstrated
a normal appearance
by sonography
on the cystogram
to
raor
should
befollowed by abdominal sonography or CT in this population. CT may be more helpful than sonography in demonstrating that intraperitoneal fluid is not contiguous with a ventriculo-
peritoneal shunt, suggesting that this fluid does not represent CSF. Infected urine in the bladder may have increased echogenicity
and may
contain
debris;
we assume
appearance may also be encountered the peritoneum. CT did not help detect
that
with infected
the site of bladder
rupture
a similar
urine in in our
two patients. Peritoneal fluid was identified as easily with CT as with sonography. The extravasated urine had low attenuation,
with
no evidence
to suggest
intraperitoneal
leakage
from the contrast-filled augmented bladder. Delayed spontaneous rupture of an augmented bladder is associated with significant morbidity, and deaths have been reported [1 3, 4]. We stress the importance of sonography together with a high index of suspicion in the diagnosis of a ,
ruptured
cases
augmented
to confirm
bladder. Sonography will suffice in most the diagnosis, but when visualization is
BLADDER
IN CHILDREN
compromised
followed
by overlying
835
bowel
by CT examination.
gas, sonography
Prompt
diagnosis
should
be
of sponta-
neous ruptured bladder after enterocystoplasty is crucial minimize morbidity and ensure successful treatment.
to
REFERENCES 1 . Rushton HG, Woodard JR, Parrott TS, Jells RD, Gearhart JP. Delayed bladder rupture after augmentation enterocystoplasty. J Uro! 1988;140: 344-346 2. Sheiner JR, Kaplan GW. Spontaneous bladder rupture following enterocystoplasty. J Urol 1988;140: 1157-1158 3. EIder JS, Snyder HM, Hulbert WC, Duckett JW. Perforation of the augmented bladder in patients undergoing clean intermittent catheterization. J Uro! 1988;140:1159-1162 4. Essig KA, Sheldon CA, Brandt MT, Wacksman J, Silverman DG. Elevated intravesical pressure causes arterial hypoperfusion in canine colocystoplasty: a fluorometric assessment. J Uro! 1991:146:551-553 5. Dixon CM, Filmer RB, Chang CH, Perimutter AD. Spontaneous perforation of bladder augmentation in pediatric patients. J Uro! 1989;1 41 : 1 95A 6. Crane JM, Scherz HS, Billman GF, Kaplan GW. lschemic necrosis: a hypothesis to explain the pathogenesis of spontaneously ruptured enterocystoplasty. J Uro! 1991:146:141-144 7. Cass AS. Diagnostic studies in bladder rupture. Indications and techniques. Urol Clin North Am 1989;16:267-273
