Cystoscopically Guided Repair of a Posterior Perforation of Augmented Bladder

Background: Augmentation cystoplasty for the management of neurogenic bladder is one of the mainstays of pediatric urology. This procedure has multiple well-known complications. The most dangerous of these complications is bladder perforation, which has a mortality rate of 23% to 25% in large part caused by delayed presentation and sepsis. This case report discusses a novel method for identifying the perforation using endourologic techniques to allow for easier repair. Case Presentation: A 24-year-old woman with a history of spina bifida s/p augmentation cystoplasty with appendicovesicostomy and rectus fascia bladder neck sling 5 years ago presented to the emergency department with a 2-day history of decreased oral intake, nausea, vomiting, fevers, diffuse abdominal pain, and distention. She was found on CT cystogram to have a contrast extravasation from the posterior-dependent portion of the bladder and a large retrovesical fluid collection. On exploratory laparotomy, a leak from the posterior portion of the bladder was confirmed. Owing to the conditions in the abdomen and the patient's obese body habitus, the perforation was very difficult to view. A 17F rigid cystoscope was utilized and the perforation was identified on the posterior inferior portion of the bladder at the anastomotic line. A wire was passed through the perforation into the abdomen where it was seen and an 18F council catheter was then placed in an antegrade manner from the abdomen. Placement of the catheter and inflation of the balloon did not cause any additional apparent damage to the bladder mucosa. With the catheter on traction, the dependent bladder could be pulled back into the operative field, allowing complete observation of the defect for water-tight two-layer closure. Conclusion: Bladder perforation after augmentation cystoplasty is a potentially life-threatening complication that can be difficult to repair. This article serves to present a novel way to identify and facilitate repair of the defect intraoperatively using endourologic principles for a posterior defect.