BLADDER RUPTURE DURING VOIDING CYSTOURETHROGRAPHY
ABDOL M. KAJBAFZADEH, PARISA SAEEDI, ALI R. SINA, SEYEDMEHDI PAYABVASH, AMIRALI H. SALMASI
Pediatric Urology Research Center, Department of Urology, Children’s Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran
Bladder rupture is rare during infancy and most of reported cases had urethral obstruction or neurogenic bladder. We report two cases of infantile bladder rupture during voiding cystourethrography (VCUG). This report reinforces the criteria for proper VCUG imaging procedure. Consideration of expected bladder volume for body weight, and close monitoring of bladder pressure and injection speed could prevent such complications.
words: bladder; children; diagnostic imaging; rupture; iatrogenic
Voiding cystourethrography (VCUG) is widely applied for the radiological evaluation of the bladder and urethra in children. Bladder rupture during VCUG is exceedingly rare (1). We present two infants with iatrogenic bladder rupture during VCUG performed by radiology staffs in two district hospitals. These infants were referred to our center for further management.
#1 - A 10-day-old boy, weighing 3.2 kg, was referred to nephrologists
with history of prenatal hydronephrosis. On day 7 after birth, ultrasonographic
exam confirmed bilateral hydroureteronephrosis, which was severe on the
left side and mild on the right side. VCUG was requested to evaluate a
possible vesicoureteral reflux (VUR). A 6F feeding tube was inserted into
the urethra and contrast media was injected using a 50-mL syringe, under
fluoroscopic guide. During the first filling cycle, severe left side VUR
appeared following injection of 15 mL of contrast media (Figure-1) and
the right VUR appeared in volume of 35 mL. However, the radiographer continued
the instillation until the intraperitoneal bladder rupture occurred in
volume of 60 mL (Figure-1). The baby was referred to urologist and immediately
underwent abdominal exploration through a Pfannenstiel incision. The bladder
dome was the site of a 2 cm long rupture. The peritoneal cavity was washed
with saline and the bladder was closed in two layers using 4-0 polyglactin
suture. A Malecot catheter was inserted in the bladder as suprapubic tube.
A mini-vacuum closed drain was left in the perivesical space. The post-operative
course was complicated by prolonged urine leakage from the site of suprapubic
catheter extracted on the 14th postoperative day. The child
was referred to our institution for further management. A 6F Foley urethral
catheter was inserted. After 7 days, the leakage was stopped and the catheter
was removed on the 24th postoperative day. The patient was
discharged 3 days later with good condition and prescription of prophylactic
bladder rupture is rare (2) and only 17 cases have been reported between
1956 and 1985 (3). The main predisposing factors include posterior urethral
valves and neurogenic bladder followed by bladder outlet obstruction from
other etiologies and trauma (3). Few cases of iatrogenic bladder perforation
have been reported in children following diagnostic and therapeutic procedures
(3,4). To our knowledge this is the second report of infantile bladder
rupture during VCUG (2).
CONFLICT OF INTEREST
The authors of this manuscript present two cases of iatrogenic bladder rupture in infants undergoing voiding cystourethrograms. This radiographic study is one of the most common imaging studies ordered in children and needs to be performed safely and reliably. Those of us who work in dedicated children’s hospitals take this for granted. However, the cases reported in this series were performed by radiologists clearly unfamiliar with proper technique as nicely outlined by the authors. It is important to remember that the peritoneum drapes quite anteriorly in small children thus making a rupture very likely to be intraperitoneal, as in these two cases, and therefore surgical exploration is required.