高正立^1,2、查岱龍¹、孫光煥¹、于大雄¹、張聖原¹、吳勝堂¹、高建璋¹

三軍總醫院 外科部 泌尿外科¹；

國軍桃園總醫院 外科部 泌尿外科²

Cheng-Li Kao^1,2、Tai-Lung Cha¹、Guang-Haun Sun¹、Dah-Shyong Yu¹、Sun-Yran Chang³, Seng-Tang Wu¹ 、Chien-Chang Kao¹

Division of Urology, Departments of Surgery, Tri-Service General Hospital,

National Defense Medical Center, Taipei, Taiwan¹；

Divisions of Urology, Department of Surgery, Taoyuan Armed Forces General Hospital²

 

Intraperitoneal bladder rupture is usually associated with blunt abdominal trauma and involves the dome of the bladder in contrast to extraperitoneal rupture, which is usually associated with pelvic fractures and is located in the lateral walls. Biochemical features of renal failure following intraperitoneal rupture of the urinary bladder are well elucidated and result mainly from the peritoneal diffusion of various solutes excreted in the urine toward the concentration gradient (also termed as reverse autodialysis). The longer the time to presentation, the more severe will be the biochemical abnormalities. A retrospective clinical study was performed to find out whether serum biochemistry alterations may serve to differentiate the traumatic bladder perforation to be either intraperitoneal or extraperitoneal.

12 patient treated for traumatic bladder perforation between 2005 and 2012 who had baseline creatinine data before trauma were included in this study group. Patients were divided into two groups: intraperitoneal bladder perforation (IBP) and extraperitoneal bladder perforation (EBP) groups. The groups were compared with regard to age, mechanism of injuryat presentation. This two groups were compared with each other with respect to serum concentrations of urea, creatinine.

There were 6 patients in intraperitoneal group and 6 patients in extraperitoenal group with a mean age of 44.5 and 43.2 in each group. Mechanisms of injury were blunt abdominal trauma and pelvic fracture. There was no significant difference between the IBP and EBP groups with regard to age, mechanism of injury, baseline creatinine and blood urea nitrogen(BUN). The biochemical parameters were found to be within normal range in the EBP group, whereas significantly higher levels of creatinine, BUN were noted in IBP group (p=0.01 and 0.06)

In patients with intraperitoneal bladder perforation, progressive urinary ascites with the development of abdominal discomfort will soon follow. This is because the excretion function of the kidney greatly exceeds the subdiaphragmatic lymph flow, which provides the principal means for the removal of intraperitoneal fluid. Stasis of urine in the peritoneal cavity allows for reversed intraperitoneal autodialysis to take place. The higher concentration of creatinine and nitrogenous waste products in the urine as compared to plasma allows for concentration gradient diffusion when the urine is in contact with the peritoneum, functioning as a semipermeable membrane. As illustrated in this study, the patient's serum creatinine and BUN will rise. But because the glomerular filtration rate is intact, the raise of serum creatinine is referred to as pseudorenal failure. When pseudorenal failure based on reversed autodialysis is suspected, the intraperitoneal bladder perforation should be considered in differential diagnosis. Further study such as cystography is warranted in these patient and it can identifies a bladder tear by documenting intraperitoneal contrast leakage. patients presenting with IBP are more likely to present with significantly higher levels of creatinine and BUN compared with the patients with EBP. Biochemical alterations can be used to differentiate traumatic IBP and EBP with subtle physical examination and radiological findings.