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Perforation of the augmented bladder
S B Bauer1, W H Hendren, H Kozakewich
1Department of Surgery, Children's Hospital, Boston, Massachusetts.
Insights
Enterocystoplasty, a bladder augmentation technique, can lead to spontaneous perforations in children, particularly those with myelodysplasia. Detubularization methods may contribute to ischemia, increasing perforation risk when the augmented bladder is overdistended.
Area of Science:
- Pediatric Surgery
- Urology
- Gastrointestinal Surgery
Background:
- Enterocystoplasty is a surgical procedure used for bladder augmentation.
- Complications such as spontaneous perforation can occur following enterocystoplasty.
Purpose of the Study:
- To investigate the incidence and potential causes of spontaneous perforations in children following enterocystoplasty.
Main Methods:
- Retrospective review of 264 children treated with enterocystoplasty.
- Analysis of patient demographics, surgical techniques, clinical presentation, diagnostic findings, and histological results.
Main Results:
- 12 of 264 children experienced 15 spontaneous perforations; 9 of these children had myelodysplasia.
- Common presenting signs included abdominal pain, septic shock, and shoulder pain.
- Cystography confirmed leaks in most cases, and histological analysis suggested ischemia and suture granulomas as contributing factors.
Conclusions:
- Spontaneous enterocystoplasty perforation is a serious complication, especially in myelodysplastic children.
- Both overdistention and detubularization techniques potentially causing ischemia may contribute to perforation.
Abstract:
In 12 of 264 children treated with enterocystoplasty 15 spontaneous perforations occurred. Of the 12 children 9 had myelodysplasia. All segments of the gastrointestinal tract were used for the augmentation and most were detubularized. Surgery to increase bladder outlet resistance was done in 8 cases. At the time of each perforation 9 children had sterile cultures, however, 3 died of overwhelming sepsis. Presenting signs included abdominal pain in 8 cases, septic shock in 4 cases and shoulder pain in 4 older myelodysplastic children with diaphragmatic irritation from escaping urine. Cystography demonstrated a leak in 10 of 11 cases. Urodynamic studies revealed good compliance with low maximum filling pressure in 8 of 10 children. Hyperreflexia was noted in only 5 cases and outlet resistance greater than 85 cm. water was demonstrated in 5. Histological analysis showed changes in the bowel wall consistent with ischemia but suture granulomas were present in areas adjacent to the perforation site or thinned areas in biopsy or autopsy specimens. In addition to the theory that overdistention may cause enterocystoplasty perforation, current detubularization techniques may produce areas of relative ischemia, which become accentuated when the augmented bladder is distended beyond a reasonable volume.