EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Peritoneal dialysis is a well-established renal repla-cement therapy for end-stage renal disease. Insertion of a peritoneal dialysis catheter has inherent complication risks. We present a case of a triple-cuff peritoneal dialysis catheter that traversed the urinary bladder on its way to its final destination and was discovered 3 months later during living donor kidney transplant. We observed a 22-year-old male patient on peritoneal dialysis who was admitted for living related kidney transplant. Intraoperatively, we discovered that the well-functioning peritoneal dialysis catheter was inserted through the urinary bladder. Diagnostic intraoperative cystogram and cystoscopy were conducted. Open removal of the peritoneal dialysis catheter and repair of entry and exit sites were performed. The postoperative course was uneventful, and the patient was discharged 11 days postoperatively with a functioning graft. Bladder catheterization before peritoneal dialysis catheter insertion, even in low-risk patients, is mandatory, to avoid bladder perforation. In addition to the case report, we reviewed the pertinent literature.

Key words : Bladder catheterization, Cystoscopy, Living donor kidney transplantation, Renal replacement

Peritoneal dialysis (PD) is an effective form of therapy for end-stage renal disease.^1,2 The PD catheter can be inserted by 3 techniques: open surgery, laparoscopy, or percutaneous approach.³ The frequency of complications ranges from 1% to 28% of cases, depending on the implant technique used and the type of complication that occurs.^1,4 Infection is the most common complication of PD.⁵

Noninfectious complications of PD catheters include intestinal and bladder perforation, bleeding, impaired flow per catheter leak, and catheter cuff extrusion.⁶ Bladder perforation by the catheter is rarely seen. Bladder catheterization effectively prevents this rare complication during catheter placement.^1,7 This is the first reported case of a well-functioning PD catheter traversing the urinary bladder before reaching its final destination. It was discovered unexpectedly 3 months later during a living donor kidney transplant.

A 22-year-old man developed end-stage renal disease due to hypertension and had been on PD for 3 months. The patient presented with oliguria and had a history of epilepsy and open appendectomy. He received a living related kidney transplant from his 26-year-old brother. The donor laparoscopic nephrectomy was uneventful, with 2 minutes of warm ischemia time. After basiliximab induction, the standard retroperitoneal technique was performed: the renal vein was anastomosed to the external iliac vein and the renal artery to the common iliac artery. On reperfusion, there was excellent perfusion and immediate graft function.

Ureteroneocystostomy over double J ureteric stent was performed. We noticed a small peritoneal tear caused by retraction. On testing the ureteric anastomosis, we noticed that significant fluid was flowing from the peritoneal tear opening. We added methylene blue dye to the testing fluid, and the colored fluid returned from the peritoneal hole. We suspected an intraperitoneal bladder injury during the Foley catheter insertion. An intraoperative cystogram revealed no contrast leak (Figure 1). Intraoperative cystoscopy revealed a double J stent, and it was apparent that the PD catheter had entered the bladder at the anteromedial wall with a visible cuff inside the bladder and exited through the posterolateral wall (Figure 2 and Figure 3).

We performed medial retraction of the rectus muscle and then carefully dissected the bladder wall. The PD catheter cuff site at the anteromedial aspect of the bladder was identified, and we proceeded with a 4-cm cystostomy over the cuff site, dissected the catheter cuff, and identified the exit site at the posterolateral aspect of the bladder. The PD catheter was removed, and we repaired the exit site perforation with 2-0 absorbable sutures (Vicryl), followed by 2-layer closure of the entry site with Vicryl 2-0 sutures. The bladder was tested, and the fascial opening was closed with Vicryl 3-0 sutures (Figures 4 and 5). The transplant wound was closed in layers over a closed suction drain. After we dressed the wound, we removed the subcutaneous PD catheter cuffs, and the exit site was closed with skin clips.

Postoperatively, we asked the patient about the detailed history of the PD catheter insertion. He mentioned that another hospital had inserted the PD catheter laparoscopically about 3 months previous. Immediately after the PD catheter insertion, he had experienced urine retention, and a Foley catheter was inserted for 2 days. The Foley catheter was removed, and the patient was discharged home asymptomatic with a functioning PD catheter. He denied any pain, bleeding, or fever.

The transplant course was uneventful. Follow-up ultrasonography revealed adequate perfusion with no collection. The Foley catheter was retained in place for 10 days and then removed after a pressure cystogram (Figure 6) on postoperative day 10. The closed suction drain was removed on postoperative day 11, and the patient was discharged home with normal serum renal function. The ureteric stent was removed after 6 weeks. Three months after transplant, the patient was asymptomatic with normal serum creatinine.

Perforation of bowel or bladder during catheter insertion is a rare complication, occurring in less than 1% of procedures.^4,8 The risk of bladder perforation increases in patients who cannot empty their bladder (eg, patients with chronic bladder outlet obstruction, detrusor underactivity, or neurogenic bladder) before PD catheter placement.⁹ Moreover, other causes of atonic bladder have been reported, including stroke and spinal trauma. A bladder scan or post-void catheterization should be performed for symptoms of urinary retention.^10,11 Our patient was a young adult without any risk factors, but his bladder may have been complete before the PD catheter insertion.

Riar and colleagues reported the need for prophylactic Foley catheterization for patients in high-risk groups, particularly in people with diabetes or older patients, while undergoing blind percu-taneous placement.^1,12

The diagnosis should be suspected in patients on PD who present during or shortly after PD catheter implant with urgency to void during catheter placement, sudden increase in urine volume, urinary incontinence with PD fills, bladder discomfort with PD filling or draining, or high urine glucose concentration consistent with urine/dialysate admixture.¹³

In patients with suspected bladder perforation, the diagnosis can be confirmed with cystoscopy, cystography, or abdominal computed tomography without contrast.⁷

Urinary retention following PD catheter insertion should be considered an urgent complication. our case, insertion of a Foley catheter without further workup to determine the cause of retention, parti-cularly in this low-risk patient, was questionable.

Management of bladder perforation varies according to the associated lesions. If no other lesion requires surgery, then conservative treatment by placement of a Foley catheter is proposed. Conversely, bladder repair remains the rule, which can be performed by laparoscopy or open surgery^.12,14,15

Bladder perforation by the PD catheter is a rare complication. Urethral catheterization before peri-toneal catheter insertion remains a means of pre-vention to minimize the occurrence in all patients. Urinary retention or urgency after PD catheter insertion requires further investigation.

Volume: 21 Issue: 12 December 2023

FULL TEXT