Intraperitoneal Bladder Rupture after Abdominal Liposuction

Sir: A 42-year-old woman underwent an outpatient liposuction procedure at a community hospital. Using a flat suction cannula directed through bilateral stab incisions just above the hips, the surgeon removed over 5100 cc of fat from the abdomen, hips, and waist. The patient was discharged to home from the recovery room in stable condition. While at home, the patient noted progressive voiding difficulty. On postoperative day 3, she presented to her local emergency department in mild distress with urinary retention, diffuse abdominal discomfort, distention, nausea, and vomiting. She was tachycardic without hypotension or fever and demonstrated acute peritoneal signs. Her medical history included a remote cesarean section and an abdominal hysterectomy for benign disease. She denied any prior voiding difficulties. In the emergency department, a urinary catheter was easily placed and drained a low volume of bloody urine. Laboratory tests revealed a serum creatinine level of 6.0 mg/dl and a white blood cell count of 17,000 cells per microliter. An abdominal computed tomographic scan demonstrated an intraperitoneal position of the urinary catheter, gross ascites, and free air (Fig. 1). Because of the limited urologic resources of the referring hospital, the patient was transferred to our facility for definitive care.Fig. 1.: Computed tomographic scan of the abdomen/pelvis showing an intraperitoneal urinary catheter balloon with moderate ascites, consistent with an intraperitoneal bladder injury.Broad-spectrum antibiotics were initiated and the patient was brought to the operating room for an exploratory laparotomy through a low midline incision. After draining a large volume of cloudy ascitic fluid, the urinary catheter balloon was visualized exiting the bladder through a single 3-cm perforation in the posterior aspect of the dome. No other injuries were identified. There was notable chronic scarring of the prevesical space. Debridement and two-layer cystorrhaphy were performed, leaving a 20-French catheter for gravity drainage through the urethra. Postoperatively, the patient remained stable and her serum creatinine promptly reached its nadir at 0.6 mg/dl. Cultures were negative and antibiotics were discontinued. She was discharged to home on postoperative day 6 with a urinary catheter that was removed 1 week later. To our knowledge, this is the first published report of bladder injury related to abdominal liposuction. A nationwide survey of abdominal contour surgery in 497 patients reported no systemic complications, including specific questions about intraabdominal perforation. An earlier review of 487 cases of abdominoplasty combined with liposuction identified a single case of intraabdominal perforation; however, the bladder was uninjured.2 The cause of the bladder defect in our patient was most likely secondary to direct trauma from the liposuction cannula and was consistent with an American Association for the Surgery of Trauma grade IV injury.3,4 During abdominal liposuction, adipose tissue is directly suctioned and/or melted with 26- to 36-cm-long cannulae directed superficial to the plane of the abdominal fascia.5 If the cannula is directed at too steep of an angle, the fascia may be perforated, placing underlying intraperitoneal structures at risk. There may be a higher risk of injuries in patients with previous pelvic or abdominal surgery, where adhesions, scarring, or fixation may be present. In our patient’s case, a prior cesarean section and hysterectomy most likely caused the observed prevesical adhesions with anterior displacement and fixation of the bladder to the abdominal wall. Incomplete bladder emptying before surgery or progressive bladder distention caused by diuresis may have also played a role. Spontaneous bladder rupture secondary to overdistention or rupture secondary to perforation from the Foley catheter would be unlikely causes of the injury. The slowly progressive time course of the patient’s abdominal symptoms point toward an intraoperative timing of the initial injury. A previously unreported complication of abdominal liposuction is intraabdominal perforation with intraperitoneal bladder injury. Progressive azotemia, abdominal distention, and voiding difficulties warrant thorough radiographic and clinical evaluation to appropriately guide clinical management. Injuries of this nature require emergent exploration and repair. Prior pelvic surgery and bladder overdistention at the time of liposuction may have placed our patient at additional risk. In such patients, consideration should be made for urinary catheter decompression during the liposuction procedure to reduce the risk of such an injury. Stephen H. King, M.D. Jane Miller, M.D. James K. Kuan, M.D. Department of Urology University of Washington Seattle, Wash.