UROL_V3_No2_001_Editorial.qxd Case Report Intravesical Explosion during Endoscopic Transurethral Resection of prostate Mohammadali Mohammadzadeh Rezaee* Department of Urology, Ghaem Hospital, Mashhad, Iran KEY WORDS: benign prostatic hyperplasia, bladder explosion, intra-operative complications 109 Urology Journal UNRC/IUA Vol. 3, No. 2, 109-110 Spring 2006 Printed in IRAN Introduction Transurethral resection of prostate (TURP) and bladder tumors is one of the most common surgeries in urology.(1) This approach is frequently being performed in most medical centers in Iran. Several intra-operative and postoperative complications of these surgeries have been reported in literature; but, one of the most uncommon complications of this technique is intravesical explosion during the surgery. Few cases of this complication have been reported.(1-3) We report 3 cases of intravesical explosion during TURP in patients with benign prostatic hyperplasia (BPH) and discuss its mechanism and the possible preventive measures. Case Report During our 15-year surgery experience, we had 3 cases of intravesical explosion in 3 patients with BPH who underwent TUR. The type of anesthesia was spinal and the bladder washing liquid was sterile distilled water. The cautery device used for these operations was a Martin ME 400 surgical unit (Gebruder Martin, Tuttlingen, Germany) and the coagulation and cutting powers were 60 W and 70 W, respectively. The resectoscope sheet used was 24 F with intermittent irrigation. In all cases, the explosion occurred at the end of the operation while anterior lobe resection was being performed at 12 o'clock position. The noise of the explosion was heard and its vibration was sensed in the suprapubic area. In 2 patients, the explosion was not accompanied by any significant complications, but in 1, the bladder was ruptured in the dome region. After the explosion, the returned amount of washing liquid decreased. On cystoscopy, a rupture was noted in the bladder dome, from which the intestinal loops were seen. The patient was secured in a position suitable for achieving a median suprapubic incision. On laparotomy, we noticed a 3- to 4-cm rupture in the bladder dome. The remained liquid was immediately evacuated and the rupture was repaired in 2 layers. A urethral catheter was inserted, and after 1 week, the patient was discharged without any complications. Discussion Intravesical explosion is an extremely rare complication during endoscopic prostate and bladder surgeries. A case of pelvic explosion during endoscopic pelvic tumor resection has been reported in 1991.(4) Explosion is more prevalent during TURP than transurethral resection of pelvic and bladder tumors, because TURP is being preformed more frequently.(3) A mild explosion in the bladder generally does not cause complications; but, if it is severe, bladder rupture may occur, leading to severe complications especially when the surgeon does not notice the rupture and the treatment is delayed. The explosion is caused by the explosive gases, mainly oxygen and hydrogen, which are formed during the procedure. About 30% and 3% of the released gases in bladder are H2 and O2, respectively.(5) A flammable mixture of these Received September 2005 Accepted February 2006 *Corresponding author: Department of Urology, Ghaem Hospital, Mashhad, Iran. Tel: +98 915 111 6023, E-mail: m-rezaee@mums.ac.ir Intra-operative Intravesical Explosion gases and the air introduced into the bladder during TURP explode when resectoscope loop contacts the gases.(5) The accumulated hydrogen, itself, does not cause explosion, but when mixed with oxygen, becomes flammable.(4) These mechanisms have been demonstrated through in vitro studies.(2) Intracellular fluid electrolysis results in the release of the explosive gases during cutting and resection of the organs due to the high temperature of resectoscope. The more is the temperature of the resectoscope, the more is the gas accumulation.(5,6) All the 3 cases of intravesical explosion occurred during the first 4 years of our experience. Thereafter, we considered some technical points which were anticipated to reduce the risk of explosion and subsequently, did not encounter this complication. Thus, to prevent intravesical explosion, we recommend the following measures: avoiding a high-temperature cautery during TURP; decreasing the mean time of tissue resection; using continuous irrigation sheets (because with intermittent sheet, some air enters the bladder during its evacuation that causes explosion); and evacuating the air in the bladder using suprapubic catheter or suprapubic pressure during bladder dome tumor fulguration or during prostate anterior lobe resection (at 12 o'clock position). Gas enters the bladder, especially after tissue resection using an Ellik evacuator. References 1. Ning TC Jr, Atkins DM, Murphy RC. Bladder explosions during transurethral surgery. J Urol. 1975;114:536-9. 2. Hansen RI, Iversen P. Bladder explosion during uninterrupted transurethral resection of the prostate. A case report and an experimental model. Scand J Urol Nephrol. 1979;13:211-2. 3. Horger DC, Babanoury A. Intravesical explosion during transurethral resection of bladder tumors. J Urol. 2004;172:1813. 4. Andrews PE, Segura JW. Renal pelvic explosion during conservative management of upper tract urothelial cancer. J Urol. 1991;146:407-8. 5. Davis TR. The composition and origin of the gas produced during urological endoscopic resections. Br J Urol. 1983;55:294-7. 6. Blandy JP, Notley RJ. Transurethral resection. 4th ed. Oxford: Isis Medical Media; 1998. p. 148. 110