腎臟鏡下修補醫源性膀胱破裂 : 病例報告

陳建凱、王百孚、石宏仁

彰化基督教醫院 外科部 泌尿科

Repair iatrogenic bladder rupture under nephroscopy : a case report

Jian-Kai Chen、Pai-Fu Wang、Hung-Jen Shih

Divisions of Urology, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan

Introduction:

    Iatrogenic bladder injury is an uncommon complication that occurs after obstetric and gynecologic surgery. The reported prevalence of iatrogenic urinary tract injuries significantly varies across research, ranging from 0.3% to 1.5%. Presently, there is an absence of consensus regarding the prevention, detection, and management of iatrogenic urinary tract injuries in emergency contexts. We present a case with iatrogenic bladder injury treated with nephroscopy.

Case report:

    This 46-year-old divorced woman with past history of diabetes mellitus, depressive disorder, Gravida 5 Para 2, had been in well condition before. According to her and reviewing the medical chart, her two child were born by vaginal delivery.  She reported had uterine tumor about 2-3 years at least. She did not regular follow up uterine tumor status. However, vulva itching and lower abdominal pain since middle March. Therefore,she came to hospital nearby for management. Where sonography revealed enlarged uterus tumor. Then she came to our Gynecology outpatient clinic for evaluation.  She had mild abdominal pain with toleration in menstrual periods. Blood clots noted in recent menstrual periods. By sonography revealed multiple uterine tumors,the largest one at anterior about 7-8 cm. The serum of hemoglobin was 12.3 g/dl. Under the impression of uterine tumors with pelvic pain, she received the laparoscopic assisted vaginal hysterectomy. During the surgery, bladder perforation was noted when dissecting vaginal mucosa. Therefore, we were consulted for the bladder perforation repair. The perforation site was about 1x1cm over left lateral wall near left ureteral orifice. We inserted the double J stent in to left ureter and established the working tunnel with 26Fr amplatz sheath through urethra. Then, we used laparoscopic needle holder and nephroscope to clamp the V-lock into bladder and repaired the perforation under nephroscopy. Foley’s catheter was inserted for one week. One month later, the bladder perforation healing and double J stent was removed smoothly.

Conclusion:

Bladder injuries may occur due to blunt, penetrating, or iatrogenic trauma. Management can involve conservative strategies focused on optimizing bladder drainage to extensive surgical interventions intended to directly repair the injury. If the perforation site is too deep to approach, the nephroscopic repair may be an effective option.