Transurethral resection of bladder tumour complicated by perforation requiring open surgical repair – clinical characteristics and oncological outcomes

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Evidence suggests that open repair of a bladder perforation during TURBT may increase the risk of pelvic or distant disease recurrence. The study demonstrates that while bladder violation during TURBT may carry a potential for considerable morbidity, it does not seem to substantially increase the risk of extravesical tumour seeding and disease recurrence. OBJECTIVE • To examine the clinical characteristics and long-term outcomes of patients with bladder perforation requiring open surgical repair as a complication of transurethral resection of bladder tumour (TURBT). PATIENT AND METHODS • A search of our institutional database yielded 4144 patients who underwent TURBT from 1996 to 2008, of whom 15 (0.36%) required open surgical intervention to repair a large bladder perforation. • In all cases, a filling cystogram was performed before laparotomy. Clinical, pathological and follow-up data were reviewed, and the incidence and time of extravesical tumour recurrence were recorded. RESULTS • Median patient age was 77 years. Intraperitoneal perforation was diagnosed in 12 patients, generally involving the posterior wall. Concomitant bowel injury was identified in two patients and managed by primary repair. Two patients in whom the diagnosis and intervention were delayed died within 1 week of surgery. • Metastatic progression was observed in two patients shortly after the perforation (median interval, 4.8 months), and local pelvic recurrence was noted in one of them. • None of the patients with stage Ta tumours had evidence of extravesical progression. Actuarial estimates of disease-free survival at 1, 3 and 5 years after the perforation were 83%, 71% and 41%, respectively. CONCLUSIONS • A significant bladder perforation during TURBT requiring open surgical repair is more likely to occur in elderly patients with large posterior wall tumours and heavily pretreated bladders. • Despite its potential for considerable morbidity, this adverse event does not seem to substantially increase the risk of extravesical tumour seeding. Prompt diagnosis, immediate intervention and meticulous bladder and bowel inspection during laparotomy are imperative.