Continuous ambulatory peritoneal dialysis (CAPD) is a recognized and well-accepted modality of maintenance dialysis. This modality is used for sections of end-stage renal disease (ESRD) patients who reside far from hemodialysis units or have exhausted all possible hemodialysis access. Although “Peritoneal dialysis (PD) first” as renal replacement therapy for ESRD patients has been discussed for long, it has really not found foothold in India. The main reason for this is apprehension of peritonitis; others being cost, lack of a suitable caregiver, and lack of promotion by nephrologists. At our institution, being a 100% government-funded health-care facility, the main reason for not accepting CAPD is apprehension of infection. A few patients after initial acceptance, however, discontinue CAPD because of mechanical complications associated with the procedure.
The mechanical or noninfectious complications associated with PD catheter are outflow failure, pericatheter and pleuroperitoneal leaks, cuff extrusion, visceral perforation and bleeding, abdominal wall herniation, gastroesophageal reflux disease, pain in the back and abdomen, and pleural effusion. Visceral perforation during catheter placement is an uncommon complication. Bowel perforation is estimated to be <1%. Perforation of urinary bladder is extremely rare. We present a case of inadvertent urinary bladder perforation during percutaneous insertion of PD catheter, its management, and discussion.
A 70-year-old lady with type 2 diabetes mellitus, coronary artery disease-postcoronary artery bypass graft surgery and chronic kidney disease on regular follow-up at our institute was initiated on maintenance hemodialysis. She had a residual urine output of about 1000 ml. She was counseled for CAPD and was slotted for percutaneous PD catheter insertion under fluoroscopic guidance after due consent. Enema on morning of procedure and injection vancomycin 1 g IV were given as per center protocol. She had been asked to empty her bladder before reporting for procedure at interventional radiology center. PD catheter was inserted by percutaneous Seldinger technique through a 4–5 cm infraumblical horizontal incision after giving local anesthesia. Pelvic position of tip of PD catheter was confirmed on fluoroscopic imaging. CAPD fluid outflow was good. The patient was discharged after 2 days and training was initiated after a break-in period of 2 weeks, given for wound healing. She did not report any symptoms during this period.
On initiation of CAPD inflow during training, she complained of urinary urgency. There was no pain/dysuria or hematuria. Urine glucose was found to be 882 mg/dl. The suspicion of bladder perforation was made. Ultrasonography revealed the tip of PD catheter to be in urinary bladder. Her bladder was catheterized with a Foley’s catheter and noncontrast computerized tomography abdomen was done, which confirmed the finding of ultrasonography [Figures 1 and 2]. The case was discussed with the urologist, and the patient was taken up for laparoscopic withdrawal of tip of PD catheter with the aim of salvaging it and bladder vault repair. However, PD catheter was explanted intraoperatively and bladder was repaired. Foley’s catheter was retained for a period of 2 weeks to allow bladder to remain collapsed to aid healing. The patient recovered uneventfully and was unwilling for another attempt at PD catheter insertion. She continued on maintenance hemodialysis.
Open surgical dissection and laparoscopic placements of PD catheters by surgeons have the advantage of precise catheter placement and minimizing any possibility of viscus perforation. However, there is disadvantage of longer recovery time, requirement of general anesthesia, long waiting periods for surgery, and its greater cost. In many centers like ours, only few catheters that too in some complicated cases are put by surgeons, rest are done by nephrologists using the percutaneous Seldinger technique. In the absence of fluoroscopy guidance, it carries a greater risk of mechanical complications such as perforation of the bowel/bladder and improper placement as intraperitoneal structures are not well visualized. Injury to bowel and peritoneal vascular structures are more common. Urinary bladder perforation during percutaneous PD catheter insertion is extremely rare.
A literature search revealed 20 cases (13 cases till 2006, 14th by Ekart et al., 1 each by Eser et al., Nasir et al., Ounissi et al., Elgaali et al., Riar et al., and Gülcan et al.) of intravesical placement of PD catheter. Of these, the case described by Ounissi et al. was due to a postperitonitis peritoneal-vesical fistula formation. The other cases were perprocedure complications.
The factors responsible for perforation are previous peritonitis or abdominal surgery causing adhesions rendering the bowel and bladder relatively immobile, neurogenic bladder with voiding problem commonly associated with diabetes mellitus, and failure to empty an otherwise normal bladder. The complication is avoidable by ensuring an empty bladder before commencing procedure, either by voluntary voiding or catheterization of bladder. Catheterization of bladder before procedure is now the protocol at our center.
The patients usually present with abdominal pain, hematuria, and urinary urgency. Patients with bladder perforation usually present with a sudden sensation of distension when the inflow of PD solution begins. Our patient however, was completely asymptomatic till instillation of fluid was started, which was delayed till after the break-in period. Confirmation of diagnosis can be done by urine glucose assay, contrast instillation through PD catheter, imaging and direct cystoscopic visualization of catheter tip in bladder. Computed tomography is the imaging modality of choice as it accurately delineates the position of PD catheter. If the location of the catheter is not shown radiologically, a diagnosis can be delayed.
A variety of management methods have been described. Gülcan et al. could salvage the PD catheter by retracting it under ultrasonographic guidance. In most other cases, the PD catheter was removed and bladder rent repaired, either laparoscopically or by open laparotomy. In our case, also we initially tried to salvage the catheter by just pulling it laparoscopically but it was difficult to get the bladder repaired, and therefore finally, we had to explant it. Foley’s catheter should be placed to ensure a collapsed bladder to aid in healing. In most cases, PD catheter re-insertion can be done after few weeks. Urinary bladder perforation can be prevented by inserting a urinary catheter before the procedure in selected cases, such as those with symptoms of lower urinary tract obstruction or a neurogenic bladder. The risk can be further mitigated if performed under fluoroscopy guidance though in our case it happened in spite of confirmation of catheter position under fluoroscopy.
Inadvertent placement of PD catheter in urinary bladder is a rare complication. Although this is easily avoidable by ensuring empty bladder, most of these cases are attributable to neurogenic bladder due to diabetes mellitus, distended bladder due to failure to void or catheterize and peritoneal adhesions. These cases can be managed by removal of PD catheter and repair of bladder rent. PD catheter re-insertion can usually be done.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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