Stesura Seveso 295Archivio Italiano di Urologia e Andrologia 2014; 86, 4 CASE REPORT Intestinal perforation after radical cystectomy due to drain: Case report Salih Budak 1, Hüseyin Aydemir 2, Hasan Salih Saglam 2, Oztuğ Adsan 2 1 Tepecik Training and Research Hospital, Urology Clinic, Izmir, Turkey; 2 Sakarya University Training and Research Hospital, Urology Clinic, Sakarya, Turkey The current standard treatment for non- metastatic invasive bladder cancer is radical cystectomy with urinary diversion. Radical cystec- tomy surgery carries a serious potential risk of complica- tions. In this case report, an intestinal perforation which was thought to be occurred due to a Foley catheter placed as a drain after the cystectomy is presented. KEY WORDS: Cystectomy; Intestinal perforation; Drainage. Submitted 28 July 2014; Accepted 30 September 2014 Summary No conflict of interest declared. approximately 5 cm in size on the anterior wall of the bladder, was performed. The histopathological evalua- tion report of the surgical material demonstrated a mus- cle invasive urethral carcinoma (T2G3). A radical cystec- tomy with urinary diversion by an ileal reservoir was proposed to the patient. Radical cystectomy, bilateral pelvic lymphadenectomy and ileal conduit diversion were performed. Urethra, uterus, cervix, ovaries and anterior wall of the vagina were removed with the bladder due to the involvement of the bladder neck. Bricker technique was applied for uretero-ileal anastomosis. As an abnormal finding during the surgery, there was a tumor extension from the blad- der anterior wall to the symphysis pubis. At the end of the operation, a silicon drain was placed into the abdomen and a Foley balloon catheter was placed into the urethrectomy region as drainage. The patient was mobilized in the postoperative 1st day and the nasogastric tube was removed. The oral feeding (regime 1) started in the postoperative third day, total parenteral nutrition was discontinued and the vaginal tampon was removed. Defecation occurred in the postoperative forth day and regime 2 was started, the abdominal drain was removed, but the Foley drain was left in place because it drained 300 cc. The deep vein thrombosis prophylaxis was ended in the postoperative fifth day and there was stool outflow. In the fifth postop- erative day nausea, abdominal pain and sensitivity occurred with increased white blood cell count. Oral nutrition was stopped and intravenous liquid replace- ment was started. A general surgery consultation was requested. The patient was followed with blood count evaluations, direct abdom- inal radiograph and findings of abdominal examinations. At the abdominal CT (with oral contrast) presence of free contrast between the intestinal loops was shown.. The patient was surgically explored in the postoperative fifth day. At surgical exploration at approximately 20 cm apart from the ileocecal junction, the 15 cm long ileum wall including the intestinal anastomosis line was thickened and there was a perforation of both the proximal and the distal ileum with respect to the anastomosis, although the anastomotic line was still intact (Figure 1). DOI: 10.4081/aiua.2014.4.295 INTRODUCTION The current standard treatment for the non-metastatic invasive bladder cancer is radical cystectomy with uri- nary diversion. Despite of the technical improvements, nowadays, radical cystectomy surgery carries a serious potential risk of complications. Although the improve- ments in the perioperative and postoperative care decrease the complication risks in years, the mortality rate of cystectomy is still 3% and the post-surgical mor- bidity rate is 30% (1). Cystectomy with urinary diversion is a serious surgical procedure for the physiological reserve. In this article, we presented a case of intestinal (ileum) perforation complicating the postoperative period of a patient who underwent radical cystectomy and urinary diversion. CASE REPORT A sixty-five year-old female patient presented with a recurrent macroscopic hematuria complaint. It was learned from her history that the patient was a smoker at a rate of 40 packets/year and that she did not have any other disease. At initial evaluation, there was no abnor- mal finding at physical examination and serum bio- chemical and hematological investigations were in the normal range. At ultrasonography of the urinary tract, both kidneys were normal but an approximately 4-5 cm large mass lesion was detected in the anterior wall of the bladder. A complete resection of the tumor formation, which was Budak2_Stesura Seveso 15/01/15 13:22 Pagina 295 Archivio Italiano di Urologia e Andrologia 2014; 86, 4 S. Budak, H. Aydemir, H. Salih Saglam, O. Adsan 296 !leum resection was performed in a way to include the two perforation areas and the anastomotic line (Figure 2). !leostomy was anastomosed to the skin. DISCUSSION In the cases of bladder tumors invasive to the muscle, cys- tectomy is the most effective treatment choice with a dis- ease-free survival rate of 87% (2). Postoperative close fol- low-up is important for the diagnosis and treatment of early complications. Since cystectomy and urinary diver- sion operations are serious operation for the physiological functions, the hospitalization periods of the patients might be approximately more than one week. Complications of the early period after radical cystectomy occurs approxi- mately at a rate of 6-30% and consist mostly in bleeding, intestinal obstruction, urinary extravasation, urinary reflux and infection (1). In our clinics, we restore oral nutrition and mobilization in the patients who underwent cystectomy in our clinics as soon as possible after the operation. The intestinal epithelium is quite sensitive to anoxia and necrosis and they can easily occur in the areas of the operation resulting in perforation. Intestinal perfo- ration may occur as a result of pressure or ischemic necro- sis (3). Although the early period of follow-up after the operation was in the normal course in our case, we think that the Foley drain that we placed into the urethrectomy region might have led to the necrosis of the ileum wall by making a physical pressure. As can be understood from Figure 3, erosion developed in the areas that had a contact with the foreign body. In conclusion, it should be taken into account that in the patients who had urinary diversion by using intestinal segments, the fragility of the intestinal structures increase. Thus, one should be careful in the placement of stents, drains and catheters. The early follow-up after the radical cystectomy should be carefully and drains and catheters should be removed as soon as possible. REFERENCES 1. Maffezzini M, Gerbi G, Campodonico F, Parodi D. Multimodal perioperative plan for radical cystectomy and intestinal urinary diversion. Effect on recovery of intestinal function and occurrence of complications. Urology. 2007; 69:1107-1111. 2. Stein JP, Leiskowsky G, Cote R, et al. Radical cystectomy in treat- ment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. 2002; 19: 666-675. 3. Kulaylat MN, Doerr RF. Small bowel obstruction. Holzhimer RG, Mannick JA (eds) Surgical Treatment: Evidence-Based and Problem- Oriented. 2001. Figure 1. White arrow: distal perforation, Green arrow: anastomotic line, Blue arrow: proximal perforation, Yellow arrow: ileal loop orifice. Figure 2. Exploration finding, two perforations in the ileum segment, White arrow: distal perforation, Green arrow: anastomose line, Blue arrow: proximal perforation. Figure 3. Blue arrow: proximal perforation, Green Arrow: urethrectomy region drain (Foley catheter). Correspondence Salih Budak,MD (Corresponding Author) salihbudak1977@gmail.com Tepecik Training and Research Hospital, Urology Clinic, Izmir, Turkey Hüseyin Aydemir, MD husaydemir@yahoo.com Hasan Salih Saglam, MD Associate. Prof. hasanss@hotmail.com Oztuiğ Adsan, MD Professor oztugadsan@yahoo.com Sakarya EAH, Uroloji Kliniği, Sakarya, Turkey Budak2_Stesura Seveso 15/01/15 13:22 Pagina 296