Korean J Anesthesiol 2009 May; 56(5): 597-600□ Case Report □

DOI: 10.4097/kjae.2009.56.5.597

597

Received: November 19, 2008.

Accepted: January 5, 2009.

Corresponding author: Young Kug Kim, M.D., Department of Anesthesiology

and Pain Medicine, Asan Medical Center, University of Ulsan College of

Medicine, 388-1, Pungnap-2 dong, Songpa-gu, Seoul 138-736, Korea.

Tel: 82-2-3010-3868, Fax: 82-2-470-1363, E-mail: kyk@amc.seoul.kr

Copyright ⓒ Korean Society of Anesthesiologists, 2009

Pneumomediastinum due to inadvertent bladder perforation during transurethral resection of the prostate

− A case report−Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Sung Hoon Kim, Won Jung Shin, Jun Young Park, Young Kug Kim, Gyu Sam Hwang, and Jai Hyun Hwang

Transurethral resection of the prostate (TURP) is a common procedure for managing benign prostatic hyperplasia (BPH), and

this procedure is associated with low complication rates. Bladder perforation is an unusual complication of TURP, and it may

create an air leak into the retroperitoneal space. Here we describe a case of pneumomediastinum, pneumoretroperitoneum and

subcutaneous emphysema that were all due to a bladder perforation that occurred during performing TURP in a 74-year-old male

patient with BPH. (Korean J Anesthesiol 2009; 56: 597～600)

Key Words: Bladder perforation, Pneumomediastinum, Pneumoretroperitoneum, Subcutaneous emphysema, Transurethral resection of

the prostate.

Transurethral resection of the prostate (TURP) is a common

procedure for benign prostatic hyperplasia (BPH), and consid-

ered as the best surgical management [1]. Pneumomediastinum,

pneumoretroperitoneum or subcutaneous emphysema are usually

complicated in colon or rectal surgery [2-4], but rarely asso-

ciated with TURP. We present a case of pneumomediastinum,

pneumoretroperitoneum, and subcutaneous emphysema due to

bladder perforation during TURP. The associated pathophysiol-

ogy, diagnosis, treatment and the anesthetic implications are

discussed.

CASE REPORT

A 74-year-old man was scheduled for TURP to treat BPH.

He had acute obstructive symptoms of the lower urinary tract

and gross hematuria. Medical history included hypertension and

regular calcium channel blocker medication. Preoperative labo-

ratory findings and chest X-ray findings were within normal

ranges. Preoperative electrocardiography showed a normal sinus

rhythm, and echocardiography showed normal left ventricular

function except for mild aortic insufficiency.

Upon arrival at the operating room, his blood pressure (BP)

was 155/95 mmHg, a heart rate (HR) was 95 bpm, and oxy-

gen saturation was 97%. Routine monitoring was performed in-

cluding non-invasive blood pressure measurement, electrocardio-

gram, pulse oxymetry, end tidal CO2 and body temperature.

Anesthesia was induced using sodium thiopental, vecuronium,

fentanyl, and sevoflurane, and was maintained using sevo-

flurane 2−3 vol%, N2O 1 L/min and oxygen 1 L/min, with

supplemental fentanyl and vecuronium.

Following massive bladder irrigation with normal saline, ap-

proximately 200 ml of blood clot was evacuated by an Ellik

evacuator. Bladder distension was relieved immediately. TURP

was then started using a 3.3% mixed solution of mannitol and

sorbitol for bladder irrigation. Approximately 60 minutes after

the beginning of the surgery, peak inspiratory pressure abruptly

increased from 14 to 30 cmH2O, and physical examination re-

vealed a tense and distended abdomen. Then his BP suddenly

decreased from 135/85 to 90/50 mmHg and electrocardiographs

showed frequent premature atrial contractions. Physical exami-

nation revealed a crackling feeling around the chest wall and

neck. Arterial blood gas analysis in 50% oxygen showed a pH

7.25, PaCO2 40 mmHg, PaO2 98 mmHg, HCO3− 17.5 mEq/L,

Vol. 56, No. 5, May 2009 Korean J Anesthesiol

598

Fig. 2. (A) Chest computed tomog-

raphy showing a pneumomediastinum

(black arrowheads), subcutaneous em-

physema (white arrow). (B) Abdominal

computed tomography showing intra-

mural gas in the anterior bladder

wall (white arrow) and a pneumo-

retroperitoneum (asterisks).

Fig. 1. Chest X-ray revealing extensive subcutaneous emphysema

around the chest wall and neck (white arrows).

Base Excess −9.1, Na＋ 129 mEq/L, K＋ 3.1 mEq/L, and he-

matocrit 35%. Up to that time, 650 ml lactated Ringer’s sol-

ution and 150 ml colloid (VoluvenⓇ, Fresenius Kabi,

Germany) had been infused.

We considered the possibility of inadvertent perforation of

the bladder and notified that the surgeon had to cease the pro-

cedure immediately. To relieve acute abdominal distension, an

angiocatheter was percutaneously inserted at the counter-McBurney

point by the surgeon. About 1,000 ml pinkish-colored fluid

was drained. The hematocrit decreased to 27%, and BP was

90−95/50−55 mmHg. A chest X-ray taken in the operating

room showed extensive subcutaneous emphysema in the chest

wall (Fig. 1). We stopped the administration of sevoflurane

and N2O, and awaked the patient from anesthesia. An urgent

computerized tomography (CT) scan of the chest, abdomen and

pelvis was performed without tracheal extubation. The CT

showed a perforation of the anterior aspect of the bladder, ret-

roperitoneal air and fluid collection, an extensive pneumo-

retroperitoneum, pneumomediastinum and subcutaneous emphy-

sema (Fig. 2). As the CT did not show fluid or air in the in-

traperitoneal cavity anymore, the surgeons decided upon a con-

servative treatment for the bladder perforation.

The patient was transferred to the intensive care unit (ICU)

and closely monitored. One hour after arrival at ICU, careful

extubation was done. BP was 110/65 mmHg, HR was 105

bpm and oxygen saturation was 98%. Postoperative serum so-

dium levels returned to normal by the first postoperative day

(Na＋ 138 mEq/L, K＋ 3.8 mEq/L) and the pneumomediastinum

and subcutaneous emphysema disappeared gradually. The pa-

tient recovered uneventfully and discharged on postoperative

day 8. A cystogram on postoperative day 15 revealed an intact

bladder.

DISCUSSION

TURP is a common procedure for BPH management.

TURP-associated morbidity and mortality was decreased sub-

stantially due to advances in anesthesia and surgical techniques

for TURP. Nevertheless, TURP can result in complications

such as bleeding, transurethral resection syndrome, extravasation

of irrigation fluids, bladder perforation, and injury of orifices

or external sphincter [1].

Bladder perforation is an uncommon complication of TURP

(incidence of approximately 0.7%) that may mostly result in

abdominal pain, respiratory insufficiency, and electrolyte im-

balance but open drainage is not often required [5,6]. Further-

Kim et al：TURP and pneumomediastinum

599

more, infiltration of air into the body cavity and soft tissue as

a complication of TURP is thought to be extremely rare. As

far as we can tell, this is the first report to describe a case of

pneumoretroperitoneum, pneumomediastinum and subcutaneous

emphysema caused by bladder perforation during TURP.

Possible causes of bladder perforation during transurethral re-

section are repeated trials of tumor resection, sudden twitch

caused by stimulation of the obturator nerve, extensive perfo-

ration of the prostate capsule and overdistension of the bladder

using the Ellik evacuator [7]. In our case, we suggest an addi-

tional possible perforation mechanism whereby the depth of the

cutting loop inadvertently exceeded the thickness of the bladder

wall. The present patient suffered long-standing recurrent lower

urinary tract obstruction which may have resulted in stretching

and thinning of the bladder wall.

Bladder perforation can be classified as extraperitoneal or in-

traperitoneal from a urological point of view. Intraperitoneal

bladder perforation is more serious, and can be complicated by

systemic absorption of irrigating fluid and result in hypo-

volemia, hypotension, oliguria, acute renal impairment, and

metabolic acidosis [6,8]. Extraperitoneal perforation is more

common than intraperitoneal perforation, but is usually asso-

ciated with less severe clinical manifestations [9]. Although our

patient had both intraperitoneal and extraperitoneal perforations,

we decided upon a conservative treatment for the bladder per-

foration rather than surgical repair because the CT scan re-

vealed no apparent intraperitoneal lesion after percutaneous

drainage.

Previous reports associated pneumoretroperitoneum, pneumo-

mediastinum and subcutaneous emphysema complications with

colon perforation or diverticulitis [2-4], and urological surgery

[10,11]. In our case, massive pneumoretroperitoneum, pneumo-

mediastinum and subcutaneous emphysema were caused by air

originating from the perforated bladder. Air can be introduced

into the bladder via cystoscope or/and irrigation tube through

leakage. Undue instrument manipulation or neglected massive

air irrigation via the Ellik evacuator may result in an overt

pneumoretroperitoneum. The likely passage of air is from the

retroperitoneal pelvic compartment through the kidney and

great vessels, through behind the crus, aortic hiatus and caval

foramen of the diaphragm, and then into the mediastinum.

Also, air can travel from the mediastinum and the retroperitoneum

to the subcutaneous soft tissues because these areas are con-

nected by fascial planes [12].

In our opinion, the present patient may have had an anatom-

ical variation such as an abnormal hiatus or opening defect

which allowed air to spread widely throughout the body within

an hour. In addition, nitrous oxide administration was not dis-

continued until taking chest X-ray because pneumomediastinum

and subcutaneous emphysema were not detected. Therefore the

air cavity in the retroperitoneum may be expanded and the air

traveled to the mediastinum and subcutaneous tissues. In gen-

eral, nitrous oxide should be stopped immediately when air

within the body cavity is clinically suspected.

The most important step in the anesthetic management of

these patients is early recognition of bladder perforation using

physical examination and clinical signs. Such indications should

cause anesthesiologists to notify the surgeon to cease the pro-

cedure immediately, and nitrous oxide should be discontinued

because of expansion of air spaces during general anesthesia.

Pneumomediastinum and subcutaneous emphysema does not

usually pose a lethal threat and may require nothing more than

bed rest, medication to control pain and supplemental oxygen

[13]. However, since they can progress to a life-threatening

condition in rare cases, vigilant observation is required. If

there is extensive fluid collection and concerns about infecting

perivesical tissue, percutaneous drainage should be instituted [14].

Morbidity and mortality can also be reduced by surgical drain-

age of the retroperitoneal fluid, but this treatment seems only

to be necessary when there is massive intravascular absorption [6].

The administration of hypertonic saline is indicated when the

adverse effects of hyponatremia are observed or if the serum

sodium concentration falls below 120 mEq/L. Diuretic therapy

may be required when pulmonary edema occurs [15].

The present report describes a pneumoretroperitoneum, pneu-

momediastinum, and subcutaneous emphysema associated with

bladder perforation during TURP. While bladder perforation is

a relatively uncommon complication during TURP, anesthesiol-

ogist should be aware of the possibility of this complication,

especially in elderly patients with overdistended and thinned

bladder walls. To prevent a massive pneumomediastinum, it is

important to vigilantly monitor clinical signs.

REFERENCES

1. Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of

transurethral resection of the prostate (TURP) - incidence, manage-

ment, and prevention. Eur Urol 2006; 50: 969-79.

2. Webb T. Pneumothorax and pneumomediastinum during colonoscopy.

Anaesth Intensive Care 1998; 26: 302-4.

Vol. 56, No. 5, May 2009 Korean J Anesthesiol

600

3. Ota H, Fujita S, Nakamura T, Tanaka S, Tono T, Murata Y, et

al. Pneumoretroperitoneum, pneumomediastinum, pneumopericar-

dium, and subcutaneous emphysema complicating sigmoidoscopy:

report of a case. Surg Today 2003; 33: 305-8.

4. Besic N, Zgajnar J, Kocijancic I. Pneumomediastinum, pneumo-

pericardium, and pneumoperitoneum caused by peridiverticulitis of

the colon: report of a case. Dis Colon Rectum 2004; 47: 766-8.

5. Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral

prostatectomy: immediate and postoperative complications. A co-

operative study of 13 participating institutions evaluating 3,885

patients. J Urol 1989; 141: 243-7.

6. Hahn RG. Transurethral resection syndrome from extravascular ab-

sorption of irrigating fluid. Scand J Urol Nephrol 1993; 27:

387-94.

7. Montesinos BA, Banus JM, Palou RJ, Nogueron CM, Macias GN.

Physiopathology and surgical treatment of extravasated peritoneal

fluid after transurethral resection. Eur Urol 1984; 10: 183-6.

8. Hahn RG. Transurethral resection syndrome after transurethral re-

section of bladder tumours. Can J Anaesth 1995; 42: 69-72.

9. Balbay MD, Cimentepe E, Unsal A, Bayrak O, Koc A, Akbulut

Z. The actual incidence of bladder perforation following transure-

thral bladder surgery. J Urol 2005; 174: 2260-2.

10. Yang MK, Hong JS, Lee BD, Shin BH. Subcutaneous emphysema

and pneumomediastinum during laparoscopic Burch operation.

Korean J Anesthesiol 1997; 32: 467-72.

11. So EH, Kim IJ, Kim TW, Kyoun IS. Pneumomediastinum, sub-

cutaneous emphysema, pneumoperitoneum and pneumoretroperi-

toneum after nephrectomy. Koeran J Anesthesiol 1996; 31: 811-6.

12. Feldman MG, Lustberg H. Pneumomediastinum: retroperitoneal

pathway. Conn Med 1999; 63: 579-82.

13. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and media-

stinal emphysema. Pathophysiology, diagnosis, and management.

Arch Intern Med 1984; 144: 1447-53.

14. Manikandan R, Lynch N, Grills RJ. Percutaneous peritoneal drain-

age for intraperitoneal bladder perforations during transurethral re-

section of bladder tumors. J Endourol 2003; 17: 945-7.

15. Dorotta I, Basali A, Ritchey M, O'Hara JF Jr, Sprung J.

Transurethral resection syndrome after bladder perforation. Anesth

Analg 2003; 97: 1536-8.