Complications and salvage options after laser lithotripsy for a vesical calculus in a tetraplegic patient: a case report

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• 作者：Subramanian Vaidyanathan (1)
  Gurpreet Singh (2)
  Fahed Selmi (1)
  Peter L Hughes (3)
  Bakul M Soni (1)
  Tun Oo (1)
  
  1. Regional Spinal Injuries Centre ; Southport and Formby District General Hospital ; Town Lane ; Southport ; PR8 6PN ; UK
  2. Department of Urology ; Southport and Formby District General Hospital ; Town Lane ; Southport ; PR8 6PN ; UK
  3. Department of Radiology ; Southport and Formby District General Hospital ; Town Lane ; Southport ; PR8 6PN ; UK
  
• 关键词：Spinal cord injury ; Tetraplegia ; Neuropathic urinary bladder ; Vesical calculus ; Laser lithotripsy ; Complications ; Bladder perforation
• 刊名：Patient Safety in Surgery
• 出版年：2015
• 出版时间：December 2015
• 年：2015
• 卷：9
• 期：1
• 全文大小：1,584 KB
• 参考文献：1. Althunayan AM, Elkoushy MA, Elhilali MM, Andonian S. Adverse events resulting from lasers used in urology. J Endourol. 2014;28(2):256鈥?0. CrossRef
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  9. Vaidyanathan S, Soni B, Selmi F, Singh G, Esanu C, Hughes P, et al. Are urological procedures in tetraplegic patients safely performed without anesthesia? A report of three cases. Patient Safety in Surgery. 2012; 6:3. 20 February 2012. CrossRef
  
• 刊物主题：Surgery;
• 出版者：BioMed Central
• ISSN：1754-9493

文摘

Background Laser lithotripsy of vesical calculi in tetraplegic subjects with long-term urinary catheters is fraught with complications because of bladder wall oedema, infection, fragile urothelium, bladder spasms, and autonomic dysreflexia. Severe haematuria should be anticipated; failure to institute measures to minimise bleeding and prevent clot retention can be catastrophic. We present an illustrative case. Case presentation A tetraplegic patient underwent laser lithotripsy of vesical stone under general anaesthesia. During lithotripsy, severe bladder spasms and consequent rise in blood pressure occurred. Bleeding continued post-operatively resulting in clot retention. CT revealed clots within distended but intact bladder. Clots were sucked out and continuous bladder irrigation was commenced. Bleeding persisted; patient developed repeated clot retention. Cystoscopy was performed to remove clots. Patient developed abdominal distension. Bladder rupture was suspected; bed-side ultrasound scan revealed diffuse small bowel dilatation with mild peritoneal effusion; under-filled bladder containing small clot. Patient developed massive abdominal distension and ileus. Two days later, CT with oral positive contrast revealed intra-peritoneal haematoma at the dome of bladder with perforation at the site of haematoma. Free fluid was noted within the peritoneal cavity. This patient was managed by gastric drainage and intravenous fluids. Patient's condition improved gradually with urethral catheter drainage. Follow-up CT revealed resolution of bladder rupture, perivesical haematoma, and intra-peritoneal free fluid. Conclusion If bleeding occurs, bladder irrigation should be commenced immediately after surgery to prevent clot retention. When bladder rupture is suspected, CT of abdomen should be done instead of ultrasound scan, which may not reveal bladder perforation. It is debatable whether laparotomy and repair of bladder rupture is preferable to nonoperative management in tetraplegics. Anti-muscarinic drugs should be prescribed prior to lithotripsy to control bladder spasms; aspirin and ibuprofen should be omitted. If significant bleeding occurs during lithotripsy, procedure should be stopped and rescheduled. Percutaneous cystolithotripsy using a wide channel could be quicker to clear stones, as larger fragments could be retrieved; lesser stimulant for triggering autonomic dysreflexia, as it avoids urethral manipulation. But in patients with small, contracted bladder, and protuberant abdomen, percutaneous access to urinary bladder may be difficult and can result in injury to bowels.