Urinary ascites: spontaneous bladder rupture presenting as acute oliguric renal failure

A marked elevation in serum creatinine/cystatin C ratio may indicate pseudo-acute kidney injury due to urinary ascites: a case report and literature review

BACKGROUND

Urinary ascites represents a scarcely observed pseudo-acute kidney injury in clinical settings. Protracted or missed diagnosis may hold grave ramifications for patient outcomes.

CASE PRESENTATION

We reported a case involving an elderly female patient experiencing pseudo-acute kidney injury accompanied by ascites, wherein her renal dysfunction persisted despite medical intervention and hemodialysis. Urinary ascites was identified via a methylene blue test and by contrasting creatinine levels in serum and ascites. This patient's kidney function was multiple typified by a marked elevation in serum creatinine/Cystatin C ratio (> 2 L/dL), potentially serving as a clue for the clinical diagnosis of pseudo-acute kidney injury engendered by urinary ascites.

CONCLUSIONS

This case suggested the potential diagnostic value of an asynchronous increase in serum creatinine and serum CysC (or an increased ratio of blood creatinine to blood CysC) in patients with pseudo-acute kidney injury.

Urinary Ascites: An Imitator of Portal Hypertension-Related Ascites

Urinary ascites is a rare and lesser-known etiology of ascites that may mimic portal hypertension (pHTN). We present an unusual case of urinary ascites in a patient with no apparent risk factors for bladder rupture. A 56-year-old woman with an uncomplicated, remote history of abdominal surgery presented with recurring episodes of ascites of unknown etiology. Of note, she has a history of functional, chronic urinary retention due to paruresis, a phobia of public urination. She had abdominal distension on the exam. Paracentesis revealed an elevated serum-ascites albumin gradient (SAAG), concerning portal hypertension. Additionally, the ascites creatinine to serum creatinine ratio was found to be extremely elevated at over 1, and a CT cystogram ultimately revealed bladder rupture, indicating a source of urinary leakage into the peritoneal space. This case report discusses the clinical recognition of urinary ascites as a mimic of apparent portal hypertension-related ascites and appropriate management.

Rupture of urinary bladder secondary to bladder carcinoma with extensive abdominal gangrene: A case report

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Spontaneous Urinary bladder rupture secondary to transitional cell carcinoma is a very rare entity.

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Abdominal gangrene is a severe necrotizing infection which is usually an extension of Fournier gangrene.

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Management of urinary bladder rupture with underlying transitional cell carcinoma of the bladder is not standardized.

Introduction and importance

Spontaneous rupture of the urinary bladder is rare but potentially severe. It is unusually related to bladder tumours. The morbidity and mortality rate are very high in these groups of patients.

Case presentation

We present a case of a 62-year-old man who was known to have a bladder tumour who presented with extensive gangrene of the anterior abdominal wall. Imaging showed an extraperitoneal urinoma extended to the anterior abdominal wall secondary to a bladder rupture with posterior bladder wall thickening suggesting a bladder tumour. After optimization of the patient’s condition, urinoma drainage and upper urinary tract drainage by bilateral nephrostomy, excision of all necrotic tissues and a biopsy of the bladder lesion was performed. At a multidisciplinary meeting, we opted for a transurethral resection of the bladder followed by palliative chemotherapy considering that the tumour was locally advanced and depending on the disease course and patient’s condition.

Clinical discussion

Gangrene secondary to urinary bladder rupture caused by transitional cell carcinomas is a very rare disease with poor oncological and infectious prognoses. For these reasons, treatment is often palliative.

Conclusion

Urinary bladder rupture secondary to bladder carcinoma could rarely be complicated with abdominal gangrene. No standardized treatment is recommended seeing the extreme rarity of this disease and management should be discussed on a case-by-case basis.

Giant vesicle calculi leading to spontaneous bladder rupture and acute renal failure: an unusual presentation

Spontaneous rupture of the urinary bladder is extremely rare. We report a case of a 70-year-old man with spontaneous bladder rupture secondary to neglected giant vesicle calculi who presented as acute renal failure. The patient was stabilised with per-urethral catheterisation and extravesical drain placement. About 700 mL pus mixed with urine was drained through the per-urethral catheter and approximately 2000 mL of pus was drained through the extravesical drain. Cystolithotomy showed two large calculi which were removed.

Pseudo-renal failure: bladder rupture with urinary ascites

We report a case of pseudo-renal failure caused by urinary ascites due to spontaneous bladder rupture following transurethral resection of a bladder tumour (TUR-BT). A 63-year-old man presented with 2 months of abdominal distension due to ascites. Laboratory findings showed elevated serum creatinine and hyperkalaemia. Peritoneal fluid urea, creatinine and potassium levels were greater than those in serum levels. CT scan showed partial wall thinning in the bladder wall, and cystography indicated fragility in the dome where the latest TUR-BT was performed. Pseudo-renal failure (laboratory abnormalities of acute kidney injury in the setting of normal kidney function) from urinary ascites and reverse intraperitoneal dialysis was diagnosed. Symptoms and laboratory abnormalities improved promptly with insertion of a urinary catheter. This report aims to increase recognition of urinary ascites when a patient with genitourinary surgical procedures or radiation therapy, or blunt abdominal trauma, presents with ascites and elevated creatinine simultaneously.

Pseudo-acute Renal Failure due to Intraperitoneal Urine Leakage

Ascites, oliguria and vomiting with an increasing serum creatinine level are often observed in patients with acute renal failure. However, these symptoms are also noted in individuals with intraperitoneal urinary leakage. Bladder rupture without a history of obvious trauma is sometimes mistaken for acute renal failure. We herein report a case of bladder perforation resembling acute renal failure in which the presentation was delayed until the patient began to experience symptoms of urinary ascites. The diagnostic dilemma associated with the rarity of this condition and possible aetiologies are discussed.

Pseudorenal failure secondary to reversed intraperitoneal autodialysis

A 16-year-old boy was admitted for anuria, ascites, and abdominal pain. The patient had undergone a laparoscopic appendectomy two days prior to admission. Initial laboratory analysis revealed a plasma creatinine level of 5,07 mg/dL and blood urea nitrogen level of 75 mg/dL. Computed tomography imaging revealed diffuse abdominal ascites with normal kidneys without signs of hydronephrosis. Laprascopic revision found a 3 mm bladder tear and yielded an aspirate of 1,8 litre abdominal fluid. The abdominal fluid exhibited a fluid : serum creatinine ratio exceeding 1, indicating uroperitoneum. This case underscores the importance of bladder ruptures causing uroperitoneum presenting with azotemia.

Diverse presentation of spontaneous rupture of urinary bladder: review of two cases and literature

The objective of the study was to highlight diagnostic dilemmas and suggest pointers toward early diagnosis of spontaneous rupture of urinary bladder based on case study of 2 patients diagnosed as a case of spontaneous rupture of urinary bladder. A 26-year-old man presented with painless progressive abdominal distension of 1-week duration. In absence of acute abdominal symptoms and signs, the diagnosis of chronic liver disease with ascites was entertained. Peritoneal fluid aspirate demonstrated high urea and creatinine levels. Computed tomographic (CT) scan of abdomen suggested urinary bladder rupture, which was further confirmed by CT cystogram. Another 34-year-old man presented with acute abdominal pain, hematuria, and features of peritonitis. There was no history of trauma. Foley catheterization revealed blood-stained urine. Ultrasonography abdomen suggested urinary bladder rupture, which was again confirmed by CT cystogram. Both patients made uneventful recovery after repair of bladder perforation. Spontaneous rupture of urinary bladder is extremely rare with only very few reports available in literature. High creatinine levels in the peritoneal fluid aspirate of the first patient and the blood-stained urine in the second patient were pointers toward possibility of urinary bladder rupture. Rupture of urinary bladder should always be considered in differential diagnosis of patients presenting with free fluid in abdomen/peritonitis, decreased urine output, hematuria and in whom increased level of urea/creatinine are detected in serum and/ or peitoneal fluid aspirate.

Pseudo-azotaemia due to intraperitoneal urine leakage: a report of two cases

Ascites, oliguria and increasing serum creatinine levels are often noted in patients with acute kidney injury. However, these presentations are also observed in patients with intraperitoneal urinary leakage. Bladder perforation without obvious trauma is sometimes mistaken for acute kidney injury. We report two cases of bladder perforation resembling acute kidney injury. The first case was a 37-year-old woman with delayed intraperitoneal urinary leakage following total abdominal hysterectomy, and the second was a 70-year-old woman with spontaneous bladder perforation. Although the initial diagnosis in both cases was acute kidney injury, rupture of the urinary bladder was later identified.

Spontaneous rupture of urinary bladder associated with massive fecal impaction (fecaloma)

We report a case of sudden death due to a catastrophic spontaneous rupture of a urinary bladder associated with megacolon due to a fecal impaction (fecaloma). The massively distended rectum and sigmoid colon filled the pelvic cavity and pressed up against the posterior aspects of the uterus, vagina, and urinary bladder. This produced bladder outlet obstruction, followed by massive dilatation and rupture of the urinary bladder, bilateral hydronephrosis, and a 3.5 liter collection of urinary fluid within the abdominal cavity. Complications of chronic constipation, fecalomas, and rupture of the urinary bladder are reviewed.

Incidence and management of anastomotic leakage following laparoscopic prostatectomy with implementation of a new anastomotic technique incorporating posterior bladder neck tailoring

In laparoscopic prostatectomies, vesicourethral anastomotic leaks may result in significant morbidity because of the chemical and metabolic derangements created by urine within the peritoneal cavity. To date, minimal data are available on this problem. Herein we present our experience with urine leaks after RALP. Over a period of 24 months, 135 men underwent RALP. Any drainage creatinine greater than two times the serum creatinine was considered as an anastomotic leak. According to our criteria, 20% of the first 110 patients developed an anastomotic leak. The patients were analyzed in two groups, those with and without leaks. In the two groups, there was no statistically significant difference in age, height, weight, prostate volume and pre-op hemoglobin. The patients with leaks did have higher rate of prior abdominal surgery (50 vs. 36%), higher average pre-operative PSA values (7.6 vs. 6.1), higher rates of multiple biopsies (27 vs. 17%) and a higher average BMI (29.6 vs. 27.8). Intraoperative differences included an average of 30 min longer operative time and 66 cm³ higher average EBL in patients with leaks. The transfusion rate was higher in the leak group at 18 vs. 1% in the no leak group. Recovery tended to be longer in patients with leaks, with hospital stays of an average of 3.6 days longer. The most common indication for prolonged hospitalization was ileus, which 55% of patients with leaks developed. Management included placing the catheter on mild traction, continuous antibiotics and taking the drain-off suction with caution to monitor the signs of a worsening ileus. In the last 25 patients, we revised our anastomotic technique. We now include posterior tailoring of the bladder neck prior to the vesicourethral anastomosis when the bladder neck is enlarged. This facilitates a water-tight anastomosis. Using this technique, we have yet to see the anastomotic leak. In RALPs, anastomotic leaks can lead to ileus formation and longer hospital stays. These leaks are associated with a higher average blood loss and transfusion rate. Management should focus on prevention. Since we have incorporated posterior bladder neck tailoring with the anastomosis, the problem has been markedly reduced.

Spontaneous bladder rupture caused by a giant vesical calculus

Spontaneous rupture of the urinary bladder is an uncommon occurrence. A 36-year-old man had complaints of pain and progressive distension of abdomen and anuria for 2 days. His abdomen was tense, tender and distended with free fluid. Blood urea was 340 mg% and ascitic fluid urea was 337 mg%. An USG showed massive ascitis, a large vesical calculus and a left renal calculus. The urinary bladder could not be catheterized. Patient underwent hemodialysis and placement of abdominal drains. About 2 l of yellow turbid fluid was drained. Cystolithotomy showed a 6 cm size impacted calculus with a rent in the dome of the bladder, which was repaired. Subsequently patient underwent percutaneous nephrolithotrypsy for left staghorn renal calculus and nephrectomy for right non-functioning kidney.

Spontaneous rupture of the urinary bladder presenting as oliguric acute renal failure

A 64-year-old female was admitted to hospital for acute abdominal pain with ascites. The patient had received postoperative pelvic irradiation for carcinoma of the uterine cervix 7 years previously. Serum creatinine (Scr) was elevated to 2.70 mg/dl, and urinary output was reduced to below 200 ml/day. Cystoscopy revealed a small perforation from the bladder diverticulum. Following transurethral catheterization, urinary output was promptly increased, and Scr was returned to 0.65 mg/dl 4 days later. This rare case suggested that spontaneous rupture of the urinary bladder following postoperative radiotherapy could occur very late with laboratory features of oliguric acute renal failure.

Pseudo-renal failure following the delayed diagnosis of bladder perforation after diagnostic laparoscopy

We present a case of bladder injury as a complication of gynaecological laparoscopic surgery. A young female presented with peritonitis, an acute systemic inflammatory response and biochemical features of acute renal failure secondary to urinary peritonitis. Laparotomy with drainage of urine from the peritoneal cavity and repair of the bladder perforation resulted in rapid resolution of the biochemical abnormalities.