Intravesical explosion during transurethral electrosurgery

Introduction

Edwin Beer (1910) was the first to use electrosurgery to cauterize what appeared to him as bladder ‘warts’. This revolutionised the treatment of bladder tumours and enlarged prostate thereafter. Nowadays these two transurethral resections (TURs) have subsequently become the most common operations performed in urology inpatient clinics worldwide.

Common complications associated with TUR, of either bladder tumours or enlarged prostate, are widely described and include: TUR syndrome, bleeding, infection, and perforation of the bladder. This is a case report of an intravesical explosion which is an extremely rare but preventable complication of TUR operations.

Case presentation

A 79-year-old male had been admitted for transurethral resection of bladder tumour (TUR-BT) for biopsy and treatment of a bulky papilomatous tumour located behind the bladder neck at 11 o’clock position, under spinal anaesthesia. A 24 chr resectoscope (Olympus/Erbe, Hamburg,Germany) was used with an Olympus type of loop. Sterile H₂O was used for continuous flow irrigation. The cautery device was an ICC 300 Erbe (Erbe Elekromedizin GmbH). Coagulation and cutting powers had been set to 250 W and 120 W, respectively.

The tumour initially looked superficial but bulky macroscopically. Because of the size of the tumour, several attempts were made to take the loop diathermy out to clear it intraoperatively whereas Ellik evacuator was used to reduce the excessive amount of tissue blocks.

At the end of the surgery (as it is surprisingly reported in bibliography in other cases) ¹ a blunt sound was heard and the patient reported experiencing ‘a blast in his abdomen’. As soon as clear images could be obtainable through the scope, intestinal loops and omentum were noted and a rupture of the bladder was suspected. The patient underwent an urgent laparotomy under general anaesthesia. A 14 chr catheter was introduced intraoperatively as a guide. For the stitching of the bladder, the dome of which was split into three in a Y shape down to the posterior wall, 3-0 absorbable sutures (Polysorb Covidien) were used. No other organs were affected. A suprapubic catheter was introduced intraoperatively to guarantee bladder drainage postoperatively. After the operation, the patient was admitted for 24 h in the high-dependency unit. One week post operatively, the suprapubic catheter was removed and the patient was discharged. Twenty days post operatively, the patient had a successful trial of void. Histopathology examination reported an infiltrating lymphoepithelial carcinoma (T₂N₀Mx).

Three months after the patient was discharged, he did not complain of any lower urinary tract symptoms or incontinence and follow-up CTs did not show any signs of leakage or spillage. Further management was then discussed at a multi-disciplinary team (MDT) meeting and subsequent three monthly follow-up CT and cystoscopies were organised for the following year.

Conclusion

Only few reports about bladder explosions can be found in international literature.^1–4 This has to do with the fact that explosions although widely recognised, are rather rare complications. They are more often related to transurethral resection of prostates (TURPs) than TURBTs. ⁵ This is due to the fact that TURPs are more commonly performed operations than TURBTs.

There have been several attempts to provide a reasonable explanation of why such events might happen. In vivo and in vitro experiments have shown that there is formation of explosive gases such as hydrogen and explosive hydrocarbons due to both hydrolysis of the water (either used for irrigation or intracellular) and pyrolysis of the tissues.^6,7 Nevertheless, the amount of oxygen produced is not sufficient enough to generate ignition. It is therefore assumed that in fact oxygen from the atmosphere enters the bladder, mixing with the highly explosive gases produced intra-operatively, causing ignition under the mediation of the electrode loop.^7,8

Several preventive methods have been suggested and most of them are applied in our department as well. The generation of explosive gases in the bladder is associated with the power of the current used for cutting or coagulation, since the higher the temperature of the electrodes the bigger the amount of gases produced. ⁷ Therefore, the use of lower power could be safer while probably achieving the same results. Other ways of preventing atmospheric air from entering into the bladder include: avoiding unnecessary use of Ellik evacuator, ensuring that irrigation fluid bottles and tubes are devoid of any air before use and being highly aware of presence of air when changing fluid bottles. Two approaches can be used to remove explosive gases produced intra-operatively: one is the angling of the beak of the resectoscope along with application of suprapubic pressure to aspirate the air accumulated in the dome of the bladder. ⁹ ; the other is positioning the patient in Trendelenburg or anti-Trendelenburg positions to keep the gas bubble away from the field of work. ¹⁰

In conclusion, bladder explosion is a rare but well described and possibly catastrophic complication of TUR procedures. Certain precautions need to be taken to avoid such events.