Gas Explosion during Transurethral Resection of Prostate(TURP) Result in Bladder Rupture: Case Report
Abstract: Intravesical gas explosion during transurethral resection of prostate resulted in bladder rupture is an extremely rare event. Only 25 cases were reported so far since 1926. Injury may range from simple mucosa tear to rupture of bladder. One case of intravesical gas explosion during TURP resulting in right posterior bladder wall rupture is described.
Introduction: TURP is considered as the golden standard surgical procedure for benign prostate hyperplasia. Intravesical gas explosion is a very rare complication. This happened due to the mixture of explosive gases ignited by the electrosurgical electrode loop during operation. Along with the case, we will discuss the mechanism of explosive gas formation and preventable strategies.
Case Presentation: This is a case of 66 years old male with elevated PSA level (9.82) and prostate enlargement (80 gram) underwent transrectal ultrasound of prostate biopsy(TRUS-P) and TUR-P. Spinal anesthesia was administered, TRUS-P biopsy was performed first and followed by monopolar TURP. The bladder was irrigated with distilled water during surgery. Surgery went smooth until a loud "pop" sound was heard during the last phase of surgery. A 3X2cm right posterior bladder wall rupture was found. Abdomen sonography showed fluid accumulation in pelvic cavity. Whole abdomen CT scan was arranged immediately and showed extraperitoneal fluid and air pocket shadow at the right side of lower abdomen and pelvic cavity, suggesting perforation of right posterior bladder base. Mild abdomen fullness sensation was complaint by the patient, mild tenderness over right lower quadrant of the abdomen but no rebounding pain. 22 French 3way foley was inserted. After foley irrigation for 2 weeks, cystography was done and showed no extravasation of contrast medium from bladder.
Discussion: Intravesical explosion with bladder rupture during TURP was reported as early as 1926, only 25 cases were reported so far. Hansen and Iversan described in vitro and in vivo gas formation during TURP which were analyzed by oxygen electrode and gas chromatographs. Hydrogen was formed during pyrolysis of prostate tissue and hydrolysis of intracellular water during TURP. Accumulation of hydrogen itself does not cause explosion. Intravesical gas explosion can only be ignited by accumulation of hydrogen which mixed with oxygen from the atmosphere entering the bladder and electrosurgical electrode loop contact with the mixed gaseous formation. The nature of the bladder irrigation fluid does not play an important role of hydrogen formation. Shortening the operation time and lowered the power of coagulation and cutting current leads to less hydrogen formation during operation. Oxygen may enter the bladder cavity by various method including: Leaking of the irrigation tube, improper use of evacuator bulb, replacement of irrigation fluid, opening of resectoscope during operation. To avoid intravesical gas explosion, air that entered the bladder cavity are recommended to evacuate, simply by angling the beak of the resectoscope sheath ventrally toward the dome of bladder while emptying the bladder. Apply suprapubic pressure to reposition the location of air bubble away from the interested area, especially operating the 12 o'clock position of prostate.
Conclusion: Intravesical gas explosion although rare but may cause severe damage to bladder. Urologist should always keep in mind that it may occur during all forms of transurethral resection procedures using electrosurgical electrode. Prevention method and strategies listed above can reduce the risk of this complication.