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The purpose of this study was to evaluate a novel hernia repair glue fixation device (LiquibandFix8™) in laparoscopic IPOM repair for incisional hernias. All ventral incisional hernia patients requiring laparoscopic IPOM repair were included in the study. A retrospective review of the data was performed. 137 patients underwent 138 laparoscopic IPOM repairs for incisional hernias using n-butyl-2-cyanoacrylate (LiquibandFix8™) for mesh fixation over a 40-month period by a single experienced laparoscopic surgeon. There were 70 males and 67 females, median age 54 years (range 23–80 years). Defects were predominantly midline n = 123/138 (89%) and were closed by transfascial sutures in 126/138 (91%) prior to IPOM repair (IPOM plus). Mesh fixation was successful in all 138 repairs. Synthetic meshes (Symbotex™ [polyester/collagen composite, Medtronic] n = 80, and Dynamesh® [polypropylene/PVDF composite, FEG Textiltechnik mbH] n = 5) and biologic meshes (Surgimend® [bovine collagen dermal matrix, Integra] n = 53) were used. Median follow-up was 32 months (range 12–48 months). There were 16 adverse events in 12 patients (9%): conversion to open surgery (inadvertent enterotomy) 2 (1.5%), bladder perforation 1, intraperitoneal bleeding 2, port-site haematoma 2, port site wound infection 1, post-op ileus 2, chest infection 1, seroma 1 (1%), hernia recurrence 3 (2%) and chronic pain 2 (1.5%). This retrospective study shows that mesh fixation in laparoscopic IPOM using cyanoacrylate glue with the Liquiband Fix8™ device is feasible, safe, easy to learn, and is associated with a low risk of seroma, hernia recurrence and chronic pain with short-medium term follow-up.

Highlights • A patient underwent limb-sparing surgery for left proximal femoral chondrosarcoma. • Bladder perforation by staples occurred 26 years after limb-sparing surgery. • No reports describe staple migration into the bladder after limb-sparing surgery. • Bladder injury is possible in patients with urinary symptoms after pelvic surgery. • Implant complications may occur even after a long postoperative period., Introduction The need for implant use during orthopedic surgeries has been increasing. Accordingly, increased implant failures have been reported. However, bladder perforation remains a rare complication after orthopedic surgery. Although a few reports have described bladder perforation after total hip arthroplasty, no previous studies have reported the migration of staples into the bladder after limb-sparing surgery. Presentation of case A 65-year-old patient underwent limb-sparing surgery to remove a chondrosarcoma in the left proximal thigh. Twenty-six years after surgery, a staple that had been used to fix artificial ligaments to the pubis migrated to perforate the bladder, resulting in painful urination. The staple was removed, and her symptoms improved. Discussion In this case, bladder perforation by the staple resulted in painful urination. The bladder perforation was not detected until 26 years after the initial surgery. Conclusion Our observations emphasize that implant complications may occur even after a long postoperative period, and the possibility of delayed bladder perforation from previous pelvic surgeries should be considered in patients presenting with urinary tract symptoms.

Introduction The aim of the study was to identify predictors of surgical complications of transurethral resection of bladder tumour (TURBT). Material and methods We prospectively recruited 983 consecutive patients undergoing TURBT within 7 months in six academic institutions. All patients were followed up from the surgery up to 30 days postoperatively with at least one telephone contact at the end of the observation. The primary study endpoint was any intra- or postoperative surgical complication. For the identification of predictors of complications, univariate and multivariate logistic regression models were used. Trial registration: ClinicalTrials.gov (NCT03029663). Registered 24 January 2017. Results Surgical complications were noticed in 228 (23.2%) patients, including 83 (8.4%) patients with more than one complication and 33 cases of Clavien-Dindo grade 3 complications (3.3%). The most common in-hospital complications were bleeding (n = 139, 14.1%) and bladder perforation (n = 46, 4.7%). In a multivariate analysis, nicotine use, high ASA score, and the presence of high-grade tumour were the most significant predictors of high-grade complications. The stage of the disease was the strongest predictor of bleeding, while the presence of muscle in the specimen and resident surgeon were the strongest predictors for bladder perforation. Conclusions TURBT poses a significant risk of surgical complications, the majority of which are of low grade.

Post-traumatic injuries of the gall bladder are rare. We report through a clinical description of its physio-pathological and evolutionary aspects. A 14-year-old boy was received 48 hours after a stabbing attack. After initial haemorrhage, the patient presented clinical improvement; then a sudden deterioration with vague symptoms and disturbance of the hepatic balance. The abdominal CT scan revealed a perivesicular hematoma with a focus on hepatic contusion. Laparoscopy showed a penetrating sore of the liver, but the exploration was limited by an important inflammation of the digestive tract. The diagnosis of gall bladder perforation was made during the operation. We performed a cholecystectomy by laparotomy. Postoperative evolution was simple, removal of the slides at D + 4 and discharged at D + 7 postoperative after improvement. At the 6th month, he presented an acute intestinal obstruction on bridles, managed at emergency by open surgery. After one year of follow up, the patient has no symptoms. We note that the vague clinical presentation and the limit of imaging examinations made the early diagnosis of a vesicular perforation a real challenge for the clinician. Cholecystectomy remains the optimal treatment.

The Hartmann procedure is used for various colonic emergencies, including mainly colon obstruction and perforation. HP is technically reversible, and surgeons often consider the stoma associated with this procedure as being temporary until bowel continuity is restored by a second operation. Some of the patients who undergo HP, however, will not undergo stoma closure. In this case, a 52-year-old patient who underwent HP was admitted to the emergency department due to ileus, and he was hospitalized in our clinic to close the ostomy in the first postoperative year. During the operation bladder perforation developed. We aimed to present our case as a contribution to the medical literature. Bladder perforation during reversal of HP is evaluated.

Urinary bladder is the most common urologic organ exposed to iatrogenic injury. The bladder trauma is classified into extra-peritoneal, intra-peritoneal, or combined trauma. Intra-peritoneal bladder injury is conventionally being treated with open surgical repair, mainly to explore the abdominal viscera for possible associated injuries and to insert peritoneal drain. One rare form of the iatrogenic bladder injury is catheter-related bladder injury which is very uncommon and only few cases were reported. It is mainly related to other associated medical conditions like cancer and chronic catheterization which might be causing subsequent bladder wall weakness. Therefore, it is important to collect more data about this rare type of bladder injury, particularly urethral catheterization which is one of the most common medical procedures. We present a 74-year-old male patient who developed acute kidney injury and was treated by urethral catheterization in the emergency department. The patient developed immediately severe abdominal pain. Non-contrast CT showed intra-peritoneal bladder perforation by the urethral catheter. The patient developed peritonitis and failed a trial of conservative management. Consequently, laparoscopic abdominal exploration and bladder repair was performed successfully.

Background: Thulium laser resection of bladder tumors (TmLRBT) is recently considered as a common treatment option for non-muscle-invasive bladder cancers (NMIBC), but whether it is superior to Transurethral resection of bladder tumors (TURBT) are still undetermined.Materials and Methods: We retrospectively screened our institution database to identify patients who were treated by conventional TURBT or TmLRBT for NMIBC and followed by intravesical bacillus Calmette-Guérin (BCG) immunotherapy. The preoperative characteristics, perioperative outcomes, and recurrence-free survival were compared to assess the safety and efficacy of the two procedures.Results: Eventually, 90 patients who underwent TmLRBT (n = 37) or TURBT (n = 53) followed by intravesical BCG immunotherapy were included. Two groups were similar in baseline characteristics except for the smaller tumor size of the TmLRBT group(1.7 cm vs. 2.2 cm; P = 0.036). Obturator nerve reflex occurred in eight patients in the TURBT group and 3 of them suffered from bladder perforation while none happened in the TmLRBT group. The TmLRBT also had a shorter irrigation duration. In the multivariate Cox regression, the TmLRBT was related to less recurrence risk (HR: 0.268; 95% CI, 0.095–0.759; P = 0.013).Conclusion: Our results suggested that TmLRBT is safer than conventional TURBT with fewer perioperative complications, and it offers better cancer control, therefore might be a superior option for NMIBC patients with intermediate and high recurrence risk.

Retropubic midurethral sling (MUS) is safe and effective surgery used for the treatment of stress urinary incontinence in women. Bladder neck perforation is a rare intraoperative complication. If this complication missed in intraoperative cystoscopy may have serious morbidity. A 52-year-old woman underwent a retropubic MUS. She presented with early and unusual symptoms such as suprapubic and labial cellulitis and urine leakage through the suprapubic incision 1 week after surgery which was due to a missed bladder neck perforation during surgery. In cystoscopy after MUS revealed mesh traversing the bladder neck and it was removed. The missed bladder perforation may have early and unusual symptoms and cystoscopy must be done more carefully and obsessively in patients with risk factors.

Placenta percreta is the most severe form of placenta accreta and is characterized by placental invasion through the entirety of the myometrium and possibly into extrauterine tissues. It is associated with prior cesarean deliveries and placenta previa. Herein, we present the case of a patient who developed placenta percreta and experienced massive blood loss of 27 liters. She developed many complications over the next 11 months, including deep vein thrombosis, pulmonary embolism, preeclampsia after pregnancy, hematoma, blood clots in the bladder, lactation failure, ileus, vesicovaginal fistula, excessive scar tissue requiring surgery, loss of an ovary, and recurrent bladder perforation. We analyze the mechanisms of these complications and the most common complications associated with placenta percreta.

Vaginal pessaries are commonly used for uterine prolapse. Long forgotten pessaries get incarcerated in the vagina and may erode in the bladder and rectum. We present a unique case of a 60-year-old female patient who presented with dysuria and urge incontinence. In remote areas, bangles are still used as a pessary, which may present with atypical symptoms due to bladder perforation, encrustation, and Vesicovaginal fistula (VVF). VVF with a long curved tract can heal with prolonged catheterization. To our knowledge, this is the first case of glass bangle pessary being reported.

INTRODUCTION AND OBJECTIVE: To investigate whether spinal anaesthesia with an obturator nerve block (SA+ONB) can be effectively employed for transurethral resection of bladder tumours (TURBT) during the COVID-19 pandemic to improve patient outcomes whilst also avoiding aerosol-generating procedures. We aimed to compare outcomes of TURBT using spinal anaesthesia (SA) alone versus SA+ONB in terms of rates of obturator reflex, bladder perforation, incomplete tumour resection, tumour recurrence and local anaesthetic toxicity. METHODS: We conducted a comprehensive search of electronic databases (MEDLINE, PUBMED, EMBASE, CINAHL, CENTRAL, SCOPUS, Google Scholar and Web of Science), identifying studies comparing the outcomes of TURBT using spinal anaesthesia versus spinal with an obturator nerve block. The Cochrane risk-of-bias tool for RCTs and the Newcastle-Ottawa scale for observational studies were used to assess the included studies. Random effects modelling was used to calculate pooled outcome data. RESULTS: Searches of electronic databases resulted in 107 articles, from which four randomised control trials (RCTs) and three cohort studies met the eligibility criteria, enrolling a total of 448 patients. The use of spinal anaesthesia with an obturator nerve block was associated with a significantly reduced risk of obturator reflex (p

Introduction: Gallstones are common in western countries. Usually in minimally invasive cholecystectomy, cystic artery and duct both are separately ligated using metallic clips and then divided. Harmonic scalpel is effectual, useful, and secure instrument regarding control of blood loss and dissection especially in laparoscopic procedure for cholecystectomy. Objective: To delineate outcome of totally clipless laparoscopic cholecystectomy with harmonic scalpels in gall stones disease.Materials and Method: This research (a retrospective case study) was done at surgical department, Lahore General Hospital, Lahore for 12 months. Total 195 patients fulfilling the above mentioned inclusion criteria were enrolled. Then patients underwent surgery under general anaesthesia. During surgery, operative time, gall bladder perforation and blood loss were noted. Patients were evaluated if conversion to open surgery was required. After surgery, patients were followed-up in OPD for 7 days for assessment of infection.Results: Mean age of patients was 45.75±14.98 years. Among patients 93(47.7%) were male and 102(52.3%) were female. Mean duration of gall bladder stone was 5.02±0.80 months. Mean time for operation was 50.27±12 minutes. Mean loss of blood was 73.11±20.46 ml respectively. There were 24(12.3%) cases who had perforation. Total 35(17.9%) patients suffered from infection post operatively. Conclusion: Total laparoscopic clipless cholecystectomy by harmonic scalpels is fully safe and useful technique in surgery for gall bladder stones.Key words: Total laparoscopic clipless cholecystectomy, harmonic scalpels (HS), gall bladder stones

Laparoscopic cholecystectomy is a routinely performed surgery nowadays. However, it is associated with certain complications. Gall bladder perforation during the procedure can result in spilled and lost gallstones. Lost gallstones most commonly cause intra-abdominal infection. However, very rarely, they can be associated with troublesome retroperitoneal abscess formation. We present a case where a lost gallstone caused a retroperitoneal abscess formation and was retrieved from a back abscess in the right paraspinal region.

BACKGROUND: Holmium lasers have been used to treat bladder stones and achieve good therapeutic effects, but its efficacy remains to be explored. METHODS: The PubMed, Embase, Medline, Ovid, Springer, and Web of Sciences databases were searched from their establishment to December 31, 2020. Studies of randomized control trials (RCTs) examining the treatment of vesical calculi by holmium laser lithotripsy were identified. The Cochrane Handbook for Systematic Reviews of Intervention 5.0.2 was used to assess risk bias, and Rev Man5.3 was used to conduct the meta-analysis. RESULTS: A total of 10 studies, comprising 1,642 subjects, were included. The meta-analysis results showed that the surgery time and the hospitalization time of patients treated with holmium laser lithotripsy decreased, and the calculus removal rate increased. The experimental group had a lower incidence of adverse reactions, such as postoperative urinary tract infection, mucosal damage, vesical perforation, residual calculi, hematuria, and abdominal pain than the control group; however, no notable difference was observed in relation to surgery time, hospital stay, the calculus removal rate, mucosal damage, bladder perforation, hematuria, and abdominal pain between the 2 groups. DISCUSSION: Holmium laser lithotripsy significantly reduced the hospitalization time of patients treated with holmium laser lithotripsy and elevated the removal rate.

Background: Bipolar and monopolar transurethral resections have a stable status for non-muscle invasive bladder cancer (NMIBC). We conducted a meta-analysis to analyze the outcomes and complications of bipolar vs. monopolar energy for transurethral resection of bladder tumors (TURB).Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses was followed. Based on the Population, Intervention, Comparator, Outcomes, and Study Designs (PICOS) strategy, randomized controlled trials were searched in MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. The reference lists of the associated articles were also retrieved. The data were calculated by Rev Man v5.3.0.Results: Eleven publications containing an amount of 2, 099 patients were involved in the study. Two groups did not show a significant difference in the mean age and the number of bladder tumors. The results showed that m-TURB had a greater decrease in postoperative hemoglobin level [mean difference (MD) −0.26, 95% confidence interval (CI) −0.48 to −0.04, P = 0.02] and sodium level (MD −0.36, 95% CI −0.62 to −0.10, P = 0.007) compared with b-TURB. B-TURB spent relatively little in hospitalization time (MD −0.52, 95% CI −0.88 to −0.15, P = 0.005) than m-TURB with the exception of operation time (P = 0.47) and catheterization time (P = 0.19). B-TURB did not show a significant difference in the incidence rate of obturator reflex (P = 0.10), bladder perforation (P = 0.32), postoperative blood transfusion (P = 0.28), and clot retention (P = 0.21) compared with the b-TURB group. Besides, there were no significant difference in terms of muscle tissue sampling (P = 0.43), recurrence-free survival at 6 months (P = 0.68) and 12 months (P = 0.78).Conclusions: B-TURB was more effective than m-TURB in minimizing intraoperative or postoperative bleeding with the smaller loss of hemoglobin and the shorter hospitalization time for patients with NMIBC.

Objective To evaluate the feasibility and effectiveness of robotic/laparoscopic repair of cesarean scar defects or cesarean scar pregnancies with a uterine sound. Materials and methods All consecutive women with cesarean scar defects or cesarean scar pregnancies who underwent robotic/laparoscopic repair with a bent uterine sound guidance were reviewed. Subjective changes in symptoms and objective changes in the depth and width of cesarean scar defects after surgery were reviewed. Results A total of 20 women underwent robotic (n = 3) or conventional laparoscopic (n = 17) repair of cesarean scar defects, which included postmenstrual vaginal bleeding associated with cesarean scar defects (n = 15), cesarean scar pregnancies (n = 3), accumulated pus in the cesarean scar defect (n = 1) and an incomplete abortion incarcerated in the cesarean scar defect (n = 1). Bladder perforation occurred in one woman during robotic adhesiolysis. All women with cesarean scar defects (n = 15) reported an improvement in postmenstrual vaginal bleeding after surgery. Follow-up sonography showed a decrease in the depth and width of the cesarean scar defect and an increase in the residual myometrial thickness. Conclusion Robotic or laparoscopic repair with a uterine sound guidance seems to be a feasible and effective method in the treatment of cesarean scar defect or cesarean scar pregnancy.

Rectus sheath haematoma (RSH) is an uncommon cause of abdominal pain. Despite being previously viewed as a benign, self-limiting condition, there is increasing evidence suggesting significant local and systemic complications with RSH. We present a case of an 82-year-old female who developed a large RSH following prescription of therapeutic anticoagulation for her new onset atrial fibrillation. She subsequently developed significant haemodynamic collapse, which necessitated emergency radiological intervention. We describe a novel approach to prevent recurrence of bleeding by inserting a covered endovascular stent across the origin of inferior epigastric artery. We also describe a rare finding of bladder perforation, presumed secondary to pressure necrosis from the haematoma. Our report contributes to the growing evidence which suggests RSH, particularly secondary to anticoagulation in the elderly, can result in catastrophic complications. In addition, bladder perforation is a rare but possible complication that needs to be considered.

Acute bladder injuries are rare and usually occur following significant amount of trauma. It has also been reported to occur in patients with chronic conditions like carcinoma, prolonged indwelling catheters, chronic infections of the bladder among others. We present a case of an otherwise fit and healthy young woman who presented to our emergency department following an episode of binge drinking and urinary retention. She had a perforation of the bladder following a simple indwelling 18-Fr Foley’s catheter insertion. In our knowledge, this is probably the first case to be described for such an injury with such mechanism.

Background: Gallbaldder perforation is rare but life threatening complication following acute cholecystitis. Series of events occur that leads to gallbladder perforation. Hence; the present study was undertaken for assessing the surgical management of gallbladder perforation patients. Materials & methods: The present study was conducted in the department of general surgery with the aim of assessing the surgical management of gallbladder perforation patients. Complete demographic data of all the patients was obtained. Records of all patients diagnosed to have gall bladder perforation were analysed. Ultrasonography and Abdominal computerized tomography findings of all the patients were obtained. Details of surgical treatment followed was recorded and analysed. Results: Out of 10 patients with gallbladder perforation, four patients had type I perforation, four patients had type II perforation and remaining two patients had type III perforation. Diagnosis was acute cholecystitis in 7 patients while 3 patients had peritonitis. There were 3 females while 7 males. Biliary sphincterotomy with Open cholecystectomy was carried out in 1 patient. Open cholecystectomy was done in 1 patient with type I perforation. In one patient with diagnosis of peritonitis, laparoscopic cholecystectomy was done. ERCP, Biliary sphincterotomy and Open cholecystectomy was carried out in one patient. Open cholecystectomy along with segmental resection of transverse colon was carried in two patients (type III perforation). Laparoscopic cholecystectomy, Common bile duct exploration and Choledochoduodenstomy were done in another patient. Laparoscopic cholecystectomy converted to open cholecystectomy in two patients. Conclusion: Gall bladder perforation is life threatening condition. Early diagnosis and emergency surgical treatment of gallbladder perforation is of crucial importance. If the patient is stable, then intervention after optimizing has better outcome.

Uterine perforation is an uncommon complication of intrauterine device insertion, with an incidence of uterine perforation by IUCD ranged from 0.4 to 1.6 per 1000 insertions. Perforation may be complete, with the device totally in the abdominal cavity, or partial, with the device to varying degrees within the uterine wall. We hereby describe a case report of a 36-year-old lady who presented with abdominal pain and her imaging with an ultrasound revealed a perforation of the uterus and partially migrated to the urinary bladder lumen. The IUCD was easily removed by grasping the tip of the vertical arm with the forceps of the flexible hysterofibroscope and directly pulling it out appropriately. Most cases are due to traumatic perforation that occurs at the time of insertion. However, “secondary” perforation can also occur by gradual erosion. Most of the uterine perforations by IUCD are uncomplicated, with the device lying in a quiescent state in the abdomen. Keywords: Uterine perforation, Intrauterine device, Intrauterine system, Bladder perforation, Inflamatory procedure.

The objective was to discuss the evaluation and management of stress urinary incontinence (SUI) following traumatic pelvic injury by use of a video case. We present a patient with severe SUI following pelvic trauma and our surgical approach to her case. Her injuries included two sacral compression fractures and four un-united bilateral pubic rami fractures, with her right-upper pubic rami impinging on the bladder. Preoperative assessment included detailed review of her pelvic imaging, multichannel urodynamic testing, cystoscopy, and examination of periurethral and bony pelvis anatomy. We proceeded with a synthetic retropubic mid-urethral sling, which required medial deviation of the trocar passage owing to her distorted anatomy. Rigid cystoscopy provided an inadequate bladder survey following sling placement, thus flexible cystoscopy was used to confirm the absence of bladder perforation. Postoperatively, our patient experienced resolution of SUI. In patients who sustain pelvic fractures, imaging to evaluate bony trauma and genitourinary tract injury is essential. Urodynamic testing provides clarity of the nature and severity of incontinence symptoms. Rigid and/or flexible cystoscopy should be performed for diagnostic purposes pre-operatively and after operative intervention. Typical anti-incontinence procedures can be offered to these patients, but since bony anatomy can be unreliable, an individualized approach to their specific injury should be utilized.

Gall bladder perforation as a sequel of typhoid-induced acalculous cholecystitis is a rare clinical encounter, reported sparsely in literature. Here, we discuss a case wherein successful laparoscopic management of typhoid-induced gall bladder perforation was performed. A 24-year-old female presented with a history of 5 days of fever and acute pain in the abdomen for 2 days. Computed tomography scan suggested gall bladder perforation which was confirmed on diagnostic laparoscopy. Laparoscopic cholecystectomy with peritoneal lavage was performed. The patient did well postoperatively and was discharged on post-operative day 4 after drain removal. One should be aware about the possibility of gall bladder perforation as a sequel of acalculous cholecystitis in typhoid fever. Minimal access surgery techniques can be applied for confirming the diagnosis as well as the definitive treatment.

Complete transurethral resection of bladder tumor (TURBT) is the initial procedure of choice for non-muscle-invasive bladder cancer, but its quality is far from optimal in clinical practice. We evaluated the existing body of evidence substantiating current quality control indicators (QCIs) for TURBT. A literature search was performed using PubMed and Embase, and selected articles were reviewed according to their level of evidence. Disease recurrence and progression were used as the primary end points. No hard evidence supports complete resection as a QCI, but rationally, it is the most important indicator for TURBT. A repeat resection is an important QCI in high-risk disease patients, but evidence suggests that it may not be necessary when detrusor muscle is present in the initial resection specimen. The presence of detrusor muscle in the resection specimen is a validated QCI for TURBT. Adjuvant intravesical instillation is a scientifically proven QCI. Bladder perforation is a controversial QCI in the existing literature. No evidence indicates the ideal time frame for the initial TURBT; thus, initial therapy in the first 6 weeks after diagnosis is not a good QCI. Three of the 6 proposed QCIs for TURBT are supported by evidence. Our literature analysis indicated the use of complete resection, repeat resection, the presence of detrusor muscle, and intravesical instillation are QCIs to minimize recurrence and progression, and increase beneficial outcomes.

The objective is to study the possibility of using the obturator nerve block under the control of nerve stimulator to prevent the thigh adductor muscles spasm during transurethral resection of bladder tumor. Materials and methods . The prospective randomized study included data obtained during the surgical treatment of 50patients with lateral wall bladder tumor, which was subjected transurethral resection of the bladder. In the GA group (n = 25) was performed general anesthesia with use muscle relaxants, in the NS group (n = 25) spinal anesthesia was performed in combination with obturator nerve block by 10 ml of a 2 % solution of lidocaine under the control of nerve stimulation. Results. The thigh adductor muscles spasm was observed in 5 cases (25 %) in the GA group and in 3 cases (12 %) in the NS group (p = 0.702), this was the cause of bladder perforation in 1 (4 %) patient in the NS group. The incidence of arterial hypotension in the NS group was lower than in the GA group (0 % versus 32 %; p = 0.004), as well as the incidence of sinus bradycardia (12 % versus 48 %; p = 0.012). The time of being in operating room in the NS group was 45 minutes (40; 53) versus 60 minutes (50; 85) in the GA group (p = 0.006). Conclusion . The spinal anesthesia in combination with obturator nerve block under the control of nerve stimulation, as well as the general anesthesia with use muscle relaxants did not guarantee the absence of adductor muscles spasm during transurethral resection of the lateral wall bladder. The obturator nerve block under the control of nerve stimulation only can not be recommended to prevent perforation of the bladder wall in these interventions.

Objectives: To assess the safety and the effectiveness of bipolar energy in the transurethral resection of primary large bladder tumours (TURBT) and compare it to conventional monopolar energy. Patients and methods: From November 2015 to June 2017, 80 patients underwent endoscopic resection primarily for large bladder cancer tumours of >3 cm. They were randomly assigned into two groups: 40 patients underwent a TURBT with conventional monopolar current (M-TURBT) and 40 were treated with bipolar current (B-TURBT). Results: There were no statistically significant differences between the two groups for the patients’ demographic and tumour characteristics. There was a significant difference between M-TURBT and B-TURBT for resection time, obturator reflex, hospital stay, and catheterisation time, which were all higher in the M-TURBT group; the mean (SD) resection time was 26.45 (5.73) vs 22.85 (7.52) min (P = 0.048), the obturator reflex was 25% vs 5% (P = 0.025), the median hospital stay and catheterisation times were 2 vs 1 day (P = 0.012 and P = 0.023, respectively). No statistically significant difference was found between the groups for bladder perforation, TUR syndrome, drop in haemoglobin level, and blood transfusion rate. However, there was statically significant difference in the postoperative haematuria rate, which was higher in the M-TURBT group, at 24 patients vs eight in the B-TURBT group (60% vs 20%; P = 0.01). After 1-year follow-up, there was no significant difference in the recurrence rate between the groups. Conclusion: B-TURBT is a safe and effective alternative procedure to M-TURBT for the management of primary large bladder tumours of >3 cm. Abbreviations: CONSORT: consolidated standards of reporting Trials; Hb: haemoglobin; NMIBC: non-muscle-invasive bladder cancer; TUR: transurethral resection; (B-)(M-)TURBT: (bipolar) (monopolar) transurethral resection of bladder tumour

Introduction: Many techniques are available for inserting peritoneal dialysis (PD) or continuous ambulatory peritoneal dialysis (CAPD) catheters, with varying possible complications. We report a case of bladder perforation that was managed with catheter salvage. Case report: A 48-year-old man with end-stage renal disease (ESRD) underwent CAPD catheter placement percutaneously, with tip in the pelvis. On the 3rd day after placement, the patient complained of increase in urinary volume with PD flushing. Urine analysis showed 3(+) glucose and absent creatinine. Cystogram showed the catheter abutting the bladder wall. CT of the abdomen showed the catheter piercing the bladder and exiting through the posterior wall. The PD catheter was repositioned under fluoroscopy. Discussion: The complications surrounding insertion of CAPD catheter can be either mechanical or infectious. Peritoneo-vesical fistula or placement of the PD catheter into the urinary bladder is a very rare complication. The possibility of catheter salvage should be entertained while discussing management options.

Intravesical chemotherapeutical agents after transurethral resection have shown to be effective in reducing the risk of recurrence and progression during the follow up. Specifically, an early single chemotherapeutical instillation (SI) might play an important role but the efficacy of this treatment has been questioned. For these reasons, we sought to review and summarize the current evidence with a non-systematic Medline/PubMed literature search. Level 1a evidence strongly supports the utility of SI in reducing recurrence in low-intermediate risk non-muscle invasive bladder cancer (NMIBC) patients, with about 35% of relative reduction rates in patients with single

To present our clinical experience with gall bladder perforation with exploring etiology, diagnosis and treatment of it. Fifty-six patients were taken in the study, which had presented in Safdarjung hospital between Jan. 2012 and Jan. 2018. The parameters including age, sex, site of perforation, type of perforation, symptoms, etiology, diagnosis, management and mortality were evaluated. Twenty-one patients had type 1, 25 patients had type 2 and ten patients had type 3 gall bladder perforation according to Niemeier’s classification. Perforation was more common in female (M:F, 25:31) and having co morbid condition. Most common site of perforation was fundus (66%). Type 1 gall bladder perforation mostly diagnosed intraoperatively, type 2 diagnosed preoperatively by CECT abdomen and type 3 were diagnosed during laparoscopic cholecystectomy. Most patients of type 1 gall bladder perforation had been operated in emergency after proper resuscitation and exploratory laprotomy was done. Type 2 and type 3 gall bladder perforation were treated conservatively initially and planned for lap cholecystectomy. Histopathological report was acute cholecystitis (n = 32), chronic cholecystitis (n = 23) and one carcinoma gall bladder. Most of the patients had gall bladder calculus. Eight patients had died due to sepsis and multiple organ failure. Mortality was mostly in type 1 gall bladder perforation. Early diagnosis and treatment is very important aspect in gall bladder perforation. Contrast enhanced CT [CECT] scan of abdomen may play an important role in diagnosis. Patient with gall bladder calculus with co morbid condition needs more attention for management. Mortality can be reduced by early diagnosis and management.

Background and aim Even though laparoscopic cholecystectomy LC became the gold standard for the treatment of gallstones, bile duct injuries, (BDI), are still more frequent than that recorded in the open cholecystectomy OC era. The aim of the study is to describe the experience with this modified technique through a retrospective case series. Materials and methods This record-based study was carried out at Dawadmi General Hospital in Riyadh, Kingdom of Saudi Arabia. The data were collected from hospital records from January 2008 to September 2017. It included all the patients undergoing Laparoscopic Cholecystectomy (LC) performed by the author using a modified infundibulum first technique with cystic artery identification. The number of eligible records was 502. Results The majority of patients were women (81.7%), having symptomatic cholelithiasis and chronic cholecystitis (83.7%). The median operative time was 43.1 minutes. Nine (1.79%) patients experienced intra-operative incidents, the most common being iatrogenic gall bladder perforation (4 patients). None of the patients had bile duct injury (BDI), while 3 required conversion to open cholecystectomy (OC). Overall, 8 (1.59%) patients had early post-operative complications. The overall morbidity rate was 2.99% (95% CI: 1.75–4.77). Conclusion and recommendations The modified LC approach based on identification of the cystic artery is associated with lower rates of intra- and post-operative complications, with low conversion rate. A multi-center randomized clinical trial is recommended to provide more evidence of the utility of this technique.

An H-section steel bar that had been set against the wall fell and hit the abdomen and then both legs of a 33-year-old Chinese man. As his vital signs were stable and his chief complaint was leg pain, he was transferred to a local medical facility. After the confirmation of gross hematuria by an indwelling a bladder catheter there, he was transported to our hospital. On arrival, his vital signs were stable. His main complaint was foot pain. He had a scabbing injury at the scrotum and bilateral foot joint deformity. Whole-body computed tomography (CT) from head to toe revealed trabecular formation in the bladder and slight fluid collection in the rectovesical pouch, as well as bilateral fracture-dislocations at the ankles. The urinary tract injury and the fluid collection in the rectovesical pouch were managed conservatively, and the lower limbs were treated tentatively. Follow-up CT on day 3 revealed multiple free air pockets in the intra-abdominal cavity, which was considered to indicate perforation of the duodenal ulcer and treated conservatively. However, he showed abdominal pain on day 7, and repeated CT revealed increased fluid in the intra-abdominal cavity. Urgent laparoscopy showed intact bowels and perforation of the bladder that was closed by suturing. He ultimately obtained a survival outcome. This is the first case of transient trabecular formation in the bladder and delayed free air due to traumatic intraperitoneal bladder rupture. This unique case adds another radiological finding to the list of documented etiologies of traumatic bladder perforation.

A 33-year-old gravida 2, para 0-1-0-0 pregnant woman was referred to our fetal center at 23 weeks and 6 days of gestation with concern for fetal hydrops. Her obstetrical history was significant for a previous emergency cesarean section at 24 weeks’ gestation because of a placental abruption, with the infant’s death occurring at 6 months of age. The current infant had no genetic abnormalities or structural anomalies. Upon referral, fetal ultrasonography showed large ascites with skin edema and bilateral pleural effusions (Fig 1A), which was consistent with hydrops, and an amniotic fluid index (AFI) of 8 (Figs 1A and 1B). In addition, the bladder wall was observed to have thickened (Fig 1C), which suggested a lower urinary tract obstruction (LUTO). A multidisciplinary team that included the fetal intervention team, neonatology, nephrology, and urology evaluated the woman for possible intrauterine intervention. Fetal echocardiography showed no structural abnormalities, mild tricuspid regurgitation, trivial pulmonary regurgitation, and normal chamber anatomy/systolic function. Fetal magnetic resonance imaging (MRI) revealed bladder outlet obstruction with in utero bladder diverticulum formation and bladder perforation (Fig 2A), explaining the cause of the massive fetal urinary ascites (Fig 2B). In addition, MRI revealed possible pulmonary hypoplasia, duplex morphology of the left kidney with normal renal appearance, with an observed/expected total lung volume of 32%. Figure 1A. Fetal ultrasound scan at 23 weeks and 5 days of gestation showing fetal ascites (yellow arrow). Pleural effusions are visualized by the red arrow. Figure 1B. Fetal ultrasound scan at 23 weeks and 5 days of gestation showing fetal ascites (green arrow). Figure 1C. Fetal ultrasound scan at 23 weeks and 5 days of gestation showing a thickened bladder wall. Figure 2A. Fetal magnetic resonance imaging scan at 24 weeks' gestation showing the suspected bladder perforation (blue arrow). Figure 2B. Fetal magnetic resonance imaging scan performed at 24 weeks' gestation showing 1) fetal urinary ascites, …

Gall bladder perforation (GBP) is a rare and life-threatening complication of acute cholecystitis that requires immediate intervention. The diagnosis itself poses a diagnostic challenge, if the patient presents after the perforation of the gall bladder, especially if the initial imaging techniques such as ultrasonogram (US), computed tomography (CT) scan, hepatobiliary iminodiacetic acid (HIDA) scan and magnetic resonance cholangiopancreatography (MRCP) are inconclusive. Subtle clues such as free fluid around gall bladder and contracted gall bladder should warrant the clinician as these might be the only clues suggestive of gall bladder perforation. Here we describe a case of GBP successfully diagnosed by peritoneal drainage and analysis and subsequently managed by endoscopic retrograde cholangiopancreatography (ERCP) and open cholecystectomy.

Gall bladder related disease is now one of the commonest indications for elective and emergency surgery and laparoscopic cholecystectomy is the mainstay treatment in patients with gall bladder stones, however some patient delay their surgical intervention for some period of time which might lead to life threatening complications in later stages such as GBP which is rarest but when it occurs along with other predisposing risk factors (hypoalbuminemia and SIRS) might increase the morbidity and mortality rate. Here we report a case of pre-operative Type-I GBP with generalized biliary peritonitis with sepsis with hypoalbuminemia in younger age group. Acute cholecystitis patient of younger age group without any comorbid illness, needs prompt surgical intervention (cholecystectomy)., Highlights • Acute cholecystitis patient of younger age group without any co-morbid illness, also needs prompt surgical intervention (cholecystectomy). • GBP should be considered with acute cholecystitis, when the clinical condition is deteriorating rapidly. • GBP associated with pre-operative risk factors (such as hypoalbuminemia and SIRS) needs prompt surgical intervention, as these factors might increase the morbidity and mortality in this rarest life threatening complication of acute cholecystitis.

A 24-year-old man presented with anal bleeding after accidentally falling on a table leg. Computed tomography showed free air in the bladder and around the rectum with a high-density area without intraperitoneal free air. The patient was suspected of having extraperitoneal bladder perforation with rectal impalement, and he underwent transanal rectal repair, colostomy, and urethral catheter placement after intraperitoneal bladder perforation was excluded by exploratory laparoscopy. Postoperative course was uneventful, and the urethral catheter was removed 19 days after surgery. Three months after the operation, colostomy reversal was performed, and the patient did not experience any complications.

Highlights • Spontaneous urinary bladder rupture is a rare complication of urosepsis. • Co-occurrence of pneumoperitoneum with a bladder perforation is very rare. • Surgical intervention is mandatory in most cases of bladder perforations., Introduction and importance Spontaneous urinary bladder rupture is a rare complication of urosepsis. Its co-occurrence with pneumoperitoneum is even more unusual. Case presentation A 73-year-old patient presented with acute retention with mild lower abdominal pain and difficulty with urinary voiding and cystitis. He was treated with bladder catheter and antibiotics. After one month, he suddenly developed peritonitis and shock. Pneumoperitoneum was observed on a chest x-ray. An emergent laparotomy was performed and a perforation of the bladder secondary to necrosis of part of the wall was found and resected. The patient recovered satisfactorily after the surgical intervention. Clinical discussion Spontaneous bladder rupture is a life-threatening condition that could be missed. Surgical intervention is mandatory to rule out other more probable causes of peritonitis and to manage the bladder perforation itself. Conclusion Pneumoperitoneum is rarely secondary to a bladder perforation. Immediate surgical intervention is required in order to avoid delays in treating any intra-abdominal condition including a bladder wall perforation.

In the management of bladder tumors bipolarenergy has been used as a common alternative to the conventional monopolar transurethral resection of the bladder (M-TURB).This study aims to examine the clinical efficacy and safety of bipolar versus monopolar TURB tumors (TURBTs).We conducted a systematic literature search in the PubMed, Cochrane Library, and Embase databases for the identification of prospective randomized controlled trials (RCTs) that compared the outcomes between the two procedures.Meta-analysis was performed using the software Review Manager 5.3.We identified nine RCTs involving 1193 patients. In terms of the surgical outcomes, there was no significant difference between the bipolar and monopolar TURBT. However, there was significantly reduced bladder perforation (risk ratio [RR] = 0.48; 95% confidence interval [CI] = 0.30-0.77; P = 0.002) and shorter hospital stay (mean difference = 0.43; 95% CI = 0.83-0.03, P = 0.01) in the bipolar TURBT group. There was also a lower incidence of thermal damage, which causes histopathological artifacts for patients treated via bipolar TURBT relative to those treated via monopolar TURBT (RR = 0.66; 95% CI = 0.55-0.78; P0.00001). P0.05 was considered to be statistically significant. However, after bipolar and monopolar TURBT, we had no sufficient evidence regarding the recurrence rate.This meta-analysis suggests that the use of bipolar technology, which is associated with less bladder perforation and lower thermal artifacts in TURBT is safer and more effective.

Introduction: We investigated the efficacy of a urethral catheter alone for intraperitoneal perforation during transurethral resection of bladder tumor (TURBT). Patients and Methods: We retrospectively evaluated the medical records of 4,543 patients who underwent TURBT from January 2000 to December 2017 using the Clinical Data Warehouse system. The clinicopathologic characteristics, recurrence-free survival, and progression-free survival were compared between the patient groups with intraperitoneal perforation treated with the Foley catheter alone, extraperitoneal perforation, and matched control TURBT. Results: Intraperitoneal perforation and extraperitoneal perforation were observed in 16 (35.6%) and 29 (64.4%) patients, respectively. In the intraperitoneal perforation group, 11 (68.8%), 2 (12.5%), and 3 (18.8%) patients were treated with the Foley catheter alone, additional percutaneous drainage, and delayed open surgery, respectively. The use of the Foley catheter alone in patients with intraperitoneal perforation of smaller size than the cystoscope or no pelvic radiotherapy history showed improved efficacy without sequelae or therapeutic delay. One of the 2 patients with the size of the intraperitoneal perforation larger than the cystoscope was successfully treated with the Foley catheter alone, whereas the other patient underwent delayed surgical repair. There was no difference in recurrence-free survival and progression-free survival of the intraperitoneal perforation treated with the Foley catheter alone compared to those of the matched control TURBT (p = 0.909, p = 0.518) and the extraperitoneal perforation (p = 0.458, p = 0.699). Conclusions: Intraperitoneal perforation rarely occurred during TURBT. In the case of intraperitoneal perforation of size smaller than cystoscopy or without pelvic radiotherapy history, treatment with the Foley alone showed successful improvement and safe oncological results. Therefore, treatment with the urethral catheter alone can be carefully considered when an intraperitoneal perforation smaller than the cystoscope size or without pelvic radiotherapy history occurs.

Background Transurethral resection of bladder tumour (TURB) is the initial and crucial step in the management of non-muscle invasive bladder cancer (NMIBC), having both diagnostic and therapeutic role. For many years, the gold standard for TURB was monopolar TURB (mTURB), however, it is associated with several complications related to its technical details. To overcome limitations of mTURB, TURB using bipolar technology (bTURB) has been developed. So far, making unequivocal statement about definitive advantage of bTURB over mTURB was difficult. The aim of this study was to systematically evaluate and compare the efficacy and safety of bTURB with mTURB. Methods A systematic search was conducted independently by two authors on the 4 electronic databases, including PubMed, Scopus, Embase and Cochrane Library, according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Nine comparative prospective studies with randomization (8 RCTs and 1 post-hoc analysis of RCT) were eligible to be included in this meta-analysis. Results After extraction, data were pooled to conduct the meta-analysis. The following outcomes were analysed: operation time, catheterization time, length of hospital stay, decrease in postoperative haemoglobin level, obturator nerve reflex rate, bladder perforation rate, transfusion rate, TUR syndrome rate, one year recurrence rate, failures of detrusor muscle detection. bTURB was associated with decreased operation and hospitalization time. There were no statistically significant differences between bTURB and mTURB in terms of catheterization time, decrease in haemoglobin level, postoperative complications rates, recurrence rates and pathologic outcomes. Conclusions This meta-analysis corroborates that bTURB shows significant advantage over mTURB in terms of operation and hospitalization time while other outcomes are comparable.