B L A D D E R INJURY DURING HERNIORRHAPHY

Manifested by Aseites and Azotemia

A R N O L D H. COLODNY, M.D.

From the Departments of Surgery, Children's Hospital

Medical Center, and Harvard Medical School,
Boston, Massachusetts

A B S T R A C T - A case o f inadvertent injury to the bladder during repair o f an inguinal hernia in a

three-month-old male infant is reported. This injury was manifested by urinary ascites and severe
a~otemia. Awareness of the anatomic relation of the bladder to the internal inguinal ring in infants
will prevent this injury or allow recognition of it at surgery. Proper repair can then be undertaken
before serious complications ensue.

Inguinal protrusions of the urinary bladder
(bladder ears) are frequently seen on intravenous
pyelograms or voiding cystourethrograms in
infants (Fig. 1A). This demonstrates the close
anatomic relationship of the bladder to the in-
ternal inguinal ring in infants. Many of these are
~mlsitory, and only a small percentage are as-
sociated with clinically detectable hernias. 1
During inguinal herniorrhaphy in infants the
properitoneal fat is frequently seen at the base of
the sac. Unless the physician is aware of this
possibility it may b e mistaken for a peritoneal
redundancy and result in inadvertent injury to
• e bladder. 2 Occasionally, the bladder itself may
~e=:~ Sliding component in the hernia.
......~njury to the bladder during hernia repairs in
:ffifants is not common. At surgery we have reeog-
:~i~d 6 such eases. Proper management pre-
~ve~ed any sequellae. Shaw and Santulli 2 re-
pot'ted injury of the urinary bladder during
lierfiia repair in 2 infants, 1 had local urinary
~ a v a s a t i o n with a resulting w o u n d infection,
!a~ad the other had no significant complication.
This case report concerns an infant who sus-
tained a bladder injury during herniorrhaphy with
t ~ g l t a n t aseites and severe azotemia. This injury
almost was fatal since the condition was un-
~:rec0gnized for three days.
Case Report
;Three days prior to admission a three-month-
0ld male infant had surgical repair of an inear-
eerated hernia on the left side. Although it was
present for twenty-four hours, the intestine ap-
peared to be viable. Postoperatively, the patient
did well for twenty-four hours although he had
a temperature of 103°F. Antibiotic therapy was
started at this time. Twenty-four hours following
surgery the a b d o m e n b e c a m e more distended,
and an x-ray film revealed no evidence of in-
testinal obstruction. There was some free peri-
toneal fluid present. Leukocytosis d e v e l o p e d
with a shift to the left. The hematocrit gradually
fell from 40 to 27. Distention varied somewhat,
b u t the following day the patient's a b d o m e n be-
came markedly distended, and he vomited three
times. Roentgenograms again revealed no evi-
dence of intestinal obstruction, b u t aseites was
noted. Gastric suction and intravenous fluids
were started. The patient continued to void clear
urine (155 ec. in twenty-four hours), except on
one occasion w h e n 50 ee. of brownish urine were
voided. Urinalysis revealed microscopic hema-
turia. Blood urea nitrogen was 95 mg. and serum
ereatinine 2.15 mg. per 100 ml. Serum sodium
was 128 mEq., potassium 5 mEq., and chloride
100 mEq. per liter. Eight hours later, after ade-
quate hydration, blood urea nitrogen was 68 mg.
per 100 ml., and three hours later it was 74 rag.
per 100 ml. At this time the patient was trans-
ferred to Children's Hospital.
On arrival the patient was in acute distress. His
skin was gray and mottled, temperature was
102°F., and respirations were grunting. The

:UROLOGY I JANUARY 1974 / VOLUME III, NUMBER 1 89

 FIGURE 1. (A) Inguinal protrusions of bladder, "'bladder ears," common in infancy, do not necessarily repre-
sent true herniations. (B) Roentgenogram taken on admission showing centrally floating intestines and bulging
flanks, intestinal loops abnormally separated, and strange mottled gas shadow in pelvis due to interstitial
emphysema of bladder and perivesical tissue. (C) Preoperative cystogram demonstrating interstitial and intra-
mural emphysema and extravasation of contrast material; note air in perivesical tissue planes.

abdomen was markedly distended and tense. It
was tympanitie to pereussion centrally and dull
to pereussion in the flanks. A urinary catheter
was passed and 40 ee. of clear urine obtained.
The white count was 18,000 per eu. mm., hema-
toerit 27, blood urea nitrogen 58 mg. per 100 ml.,
serum sodium 19.7 mEq., potassium 4 mEq., and
chlorides 101 mEq. per liter.
A roentgenogram revealed significant aseites
(Fig. 1B). There was no evidence of intestinal
obstruction, but there was an unexplained
mottled shadow- in the pelvis. Cystogram re-
vealed interstitial and perivesieal e m p h y s e m a
and extravasation of contrast m e d i u m (Fig. 1C).
The patient was treated with intravenous fluids
and antibiotics, and received 75 co. of blood.
At surgery air was released under tension
when the retropubic prevesieal spaee was
entered. Perforation of the urinary bladder on the
left side was seen. There was a purse-string ad-
jacent to this perforation. E d e m a and necrotic
tissue was noted around the bladder. The peri-
toneum was bulging with fluid and released 285
ee. of clear aseitie fluid on incision. Culture of
this fluid revealed no growth. The peritoneal
opening was closed, a suprapubic eystotomy per-
formed, and drainage of the prevesieal space
carried out. The patient made an uneventful
postoperative recovery. Serum electrolytes,
blood urea nitrogen, and serum creatinine rapidly
returned to normal, and prior to discharge an
intravenous pyelogram and voiding eystogram
revealed no abnormality. The patient has re-
mained well for three years.
Comment
Inadvertent injury to the urinary bladder dur-
ing hernia repair should not cause serious prob-
lems if it is recognized at the time of surgery and
repaired appropriately. If the injury is not recog-
nized, it may create a local problem of urinary
extravasation and infection. If the bladder is in-
jured by inclusion with closure of the peritoneal
hernia sac, as in this patient, urinary ascites may
result with severe azotemia and potential fatality,
There were several clues to the diagnosis in the
ease reported here. A logical differential diag,
nosis would have included intestinal obstrue,
tion with infarcted nonviable bowel due to the
incarceration. However, the hematocrit would
have b e e n expected to rise rather than fall, as it
did in this patient. The appearance of the roent-
genograms (lid not suggest intestinal obstruetion~
which would have b e e n anticipated if the peri-
toneal fluid was secondary to gangrenous in,
testine. In addition, distention was intermittent,
Apparently, when the peritoneu m was tensely'
bulging with urinary aseites, it tamponaded the
perforation in the bladder until some of the urine
was absorbed via the peritoneum. Hematuria and
azotemia were also present. A eystogram may be
misleading since the leak from the bladder or the
peritoneal ~"ommunieation may not always be
demonstrated if the peritoneum is distended;
Delayed ffxas may show opaeification of th~
ascitie fluid confirming the peritoneal eommuni~
cation. In this case although there was almos.~
300 co. of urinary aseites, no direct peritone~
communication was seen on eystogram.
300 Longwood Avenue~
Boston, Massachusetts 02 lt~d
References
l. ALLEN, R. P.~ and CONDON~ V.R.: Transitory extrape!~
toneal hernia of the bladder in infants (bladder earth
Radiology 77:979 (1961).
2. SHAW, A., and SANTULLI, T.V.: Management of slidi~$
hernias ,of the urinary bladder in infants, Surg. GyneC0~:
Obstet. ]IS': 1314 (1967).

90 UROI 0(:3 JANUARY1974 / VOLUME ItI, NUMBI~'¢