BERKELEY, CA (UroToday.com) - Perforation is one of the frightening complications of transurethral resection of bladder tumors (TURBT) and is usually a consequence of an inadvertent full thickness bladder wall resection. Bladder perforation can occur more commonly in elderly patients with thin bladder walls or when an unexpected obturator reflex is induced. The incidence of this complication is reported to be 0.9% to 5%., but it is possible that many unnoticed perforations occur without post-operative sequelae and also some clinicians advocate deep tumor resection as part of aggressive local tumor control. Some authors have postulated that there is a potential for extravesical seeding of malignant cells after perforation which negatively impacts patient prognosis. There are other clinicians that do not believe that an adequately drained perforation will impact outcome.

A recent review from M. D. Balbay and colleagues from Ankara, Turkey attempted to evaluate the true incidence of bladder perorations after TURBT and looked at patient outcome and cancer control. The manuscript is published in the December 2005 issue of the Journal of Urology.

In the study, a total of 36 patients (33 male and 3 female) with a mean age of 65.6 years and a solid mass in the bladder suggested by ultrasound or CT scan underwent TURBT that was preceded and followed by a gravity cystogram in the operating room. The cystograms were performed with 400 cc of dilute contrast instilled by gravity at 60 cm above the patient. All resections were done using a 24 F resectoscope and two additional deep cold cup biopsies were obtained from the tumor base to aid in the pathologic assessment of depth of invasion. The mean size of the tumors was 2.03 cm. 31 patients had a single focus of disease and 5 patients had multifocal disease. Regular evaluations with cystoscopy and ultrasound or CT scans were done to detect possible tumor recurrence and perivesical seeding.

Review of the cystograms obtained post TURBT revealed that there was evidence of contrast extravasation in 21 of the 36 patients (58.3%). All perforations were extraperitoneal and were treated conservatively with catheter drainage for 24 to 48 hours. No patient had suspicious cystoscopic findings during the tumor resection to suggest a bladder perforation. There was no extravesical tumor seeding per CT during a mean follow-up of 21.9 months. The only factor which seemed to have any impact on the development of bladder perforation was total tumor size on multivariate analysis.

The authors conclude that the extravasation of urine (asymptomatic perforation) after transurethral bladder tumor resection may occur much more frequently than believed or reported. It also seemed that this extravasation did not impose a significant risk of extravesical tumor seeding.

J Urol. 2005 Dec;174(6):2260-63