Thermal Bladder Injury after Inadvertent Irrigation with Overheated Saline during a Bipolar Prostate 
Resection

PICTORIAL

Ioannis Efthimiou,* Zacharias Chousianitis, Kostadinos Skrepetis

CASE REPORT

A 75-year-old man with a medical history of type 2 diabetes mellitus (T2DM) and hypertension underwent a transurethral prostatectomy with the Olympus bipolar TURis system. Unfortunately, inadvertent bladder 
instillation with overheated saline at the onset of the procedure complicated the surgery.
Shortly after the onset of the operation, the bladder was contracted and could not be distended by the fluid. At 
the same time, the fluid contacted the surgeon’s hand, making him realize that it was overheated. Irrigation was 

Department of Urology, General Hospital of Messinia, Kalamata, Greece.
*Correspondence: Megalou Alexandrou 130, TK 24132, Kalamata, Greece.
Tel: +302 721 046990. Fax: +302 721 033666. E-mail: efthimiou_ioannis@hotmail.com.
Received November 2015 & Accepted February 2016

Keywords: urinary bladder/injuries; prostatectomy; benign prostatic hyperplasia/surgery; adverse effects.

Figure 1. Inflammation of bladder with patchy areas of necrosis.

Figure 3. Area of extensive necrosis covered by snow-like dead tissue. Figure 4. Resection of the lesion in Figure 3 shows necrosis and fibrosis 
of the detrusor muscle.

Figure 2. Worm-like necrotizing lesions arising from the bladder wall. 

Pictorial    2733



immediately abandoned, and only after the fluid came 
to the right temperature (41°C) did the surgery continue 
to completion. Although the contact time of the bladder 
mucosa with the overheated saline was short, it caused 
major injuries in the patient’s lower urinary tract. To 
alleviate the consequences of the injury, the patient was 
managed postoperatively with intravenous antibiotics 
and supportive treatment with high doses of intravenous 
and urethral corticosteroids and an indwelling urethral 
catheter. The patient underwent a cystoscopy under spi-
nal anesthesia 3 weeks later, which revealed the extent 
of the thermal injury. A heavily inflamed reddish muco-
sa with alternate pale and white areas was noticed (Fig-
ure 1). White worm-like necrotizing lesions (Figures 
2–4) arising from the posterior wall and the dome of 
the bladder due to the direct contact of these areas with 
the excessively hot saline were also noticed. Fortunate-
ly, both orifices (Figure 1) were spared major thermal 
injury. In the follow-up period, the patient experienced 
severe frequency voiding and nocturia; both were man-
aged conservatively.

DISCUSSION
During transurethral operations, surgeons should be 
aware of rare complications that can be caused to the 
bladder by the use of various kinds of thermal energy.(1) 
Bladder irrigation using fluids warmed to near boiling 
point is a rare complication caused by human error. It 
has been described in the literature and it can be fatal 
for some patients.(2) Animal studies have shown that 
bladder irrigation using fluids at temperatures below 
44°C was well tolerated but temperatures above this 
level caused decreased bladder capacity, azotemia, and 
death.(3)  

CONFLICT OF INTEREST
None declared.

REFERENCES
 1.  Mohammadzadeh Rezaee M. Intravesical 

explosion during endoscopic transurethral 
resection of prostate. Urol J. 2006;3:109-10. 

 2.  Kirby R, Dasgupta P, Beacock C. The case of 
the boiled bladder--or, how to avoid medical 
errors. BJU Int. 2010;106:299-300.

 3.  Haveman J, Smals OA, Rodermond HM. 
Effects of hyperthermia on the rat bladder: 
a pre-clinical study on thermometry and 
functional damage after treatment. Int J 
Hyperthermia. 2003;19:45-57.

Thermal Bladder Injury with Overheated Saline-Efthimiou et al.

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