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Bladder rupture post renal biopsy

Case contributed by Dayu Gai
Diagnosis almost certain

Presentation

Biopsy performed for investigation of glomerulonephritis. Three days after the biopsy, she described persistent hematuria. Post-biopsy trauma was suspected and a non contrast CT scan was performed.

Patient Data

Age: 60 years
Gender: Female

The findings suggest intra-peritoneal bladder rupture:

  • there is pneumoperitoneum. In addition, hyperdense material is seen in the right iliac fossa within an intraperitoneal location, suggesting hemoperitoneum. There is further free fluid within the peritoneal and retroperitoneal compartments
  • hyperdense material is present within the bladder, which is decompressed. Metallic coils are seen in the lower left kidney with an adjacent wedge shaped hypodensity suggesting decreased perfusion
  • a small amount of hematoma seen adjacent to the inferior pole of the left kidney
  • There is a left femoral arterial line in situ

Case Discussion

Bladder rupture can be categorized as either intra-peritoneal or extra-peritoneal1. Extra-peritoneal bladder rupture is more common, and is often associated with pelvic fractures. Intra-peritoneal bladder rupture is more uncommon and arises due to trauma when the bladder is already maximally distended. The patient demonstrated intra-peritoneal bladder rupture.

Intraperitoneal rupture of the bladder usually occurs at the dome. This is because the bladder dome  is the least supported of the bladder walls. Patients with intraperitoneal rupture may present with pseudo-renal failure3. This is due to the peritoneum absorbing creatinine and urea from the extravasated urine, causing serum tests to resemble that of renal failure.

Definitive management if bladder rupture is with operative bladder repair. This can either be open or laparoscopic. In one study, conservative management of a patient with bladder rupture failed, and ended up requiring extended open surgical repair of the defect2.

To our knowledge, there has only been one documented case of intra-peritoneal bladder rupture post renal biopsy. This was a 64 year old female who developed bladder rupture on Day 20 after a renal biopsy for possible lupus nephritis2. The authors suggested that the mechanism of rupture was due to formation and retention of bladder clot due from the renal biopsy, leading to increased intravesical pressures culminating in bladder rupture.

Case contributed by A/Prof. Pramit Phal.

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