Enterocystoplasty is a commonly utilized technique within pediatric urology as a method of both increasing vesical storage capacity and decreasing pressure transmission to the upper urinary tracts in children with inadequate bladder volumes and abnormal bladder wall dynamics. The most frequent indications for augmentation include a poorly compliant, high-pressure, low-capacity bladder secondary to spina bifida (or other spinal cord anomaly or insult), posterior ure-thral valves (PUV), or bladder exstrophy. Augmentation is inherently associated with significant risks and therefore should only be recommended in select patients following an exhaustive trial of medical therapy. Only those with ongoing risk of renal deterioration or socially unacceptable urinary incontinence, despite maximal medical treatment and clean intermittent catheterization (CIC), should be considered for augmentation. Furthermore, vigilance and selection of patients and their families in whom compliance with CIC is assured, is important to reduce potentially catastrophic complications. Unfortunately, despite these precautions, a small number of patients present to the emergency department with an acute abdomen secondary to spontaneous bladder rupture postaugmentation. A high index of suspicion must be maintained in these patients, as this condition is frequently associated with a delay in diagnosis with potentially lethal results (Couillard et al. 1993).
Although the exact etiology of bladder perforation is unknown, traumatic catheterization, noncompliance with CIC leading to chronic bladder overdistension, and blunt trauma have all been implicated (Elder et al. 1988; Jayanthi et al. 1995; Rushton et al. 1988). The diagnosis must be suspected, and the condition ruled out, in any patient who presents with abdominal pain and a history of augmentation. The majority of children who
undergo augmentation are neurologically impaired; therefore, lower abdominal sensation is diminished and signs and symptoms may be nonspecific. Patients may complain of nausea, vomiting, fever, obstipation, gross hematuria, and oliguria; physical examination demonstrates a distended rigid abdomen with positive peritoneal signs.
If suspected, a CT cystogram must be performed immediately and is the most sensitive test to rule out perforation in these patients. The bladder must be filled to capacity with the retrograde instillation of contrast and both pre- and post-contrast images taken in order to accurately determine the diagnosis (Fig. 8.30). Complete blood work, including blood and urine cultures, should be taken and fluid resuscitation, catheter drainage, and parenteral broad-spectrum antibiotics initiated immediately. Stable patients without signs of sepsis and in whom a small perforation is suspected, may be managed nonoperatively. Serial blood work and physical examinations are paramount to this approach, as any sign of clinical deterioration mandates immediate operative intervention. The majority of patients with bladder rupture, however, will require immediate exploratory laparotomy, closure of the perforation and irrigation of the peritoneal cavity. Broad-spectrum par-enteral antibiotics are continued and patients are monitored closely for signs of postoperative intraperitoneal abscess formation during convalescence.
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