Examkin

Question

Difficulty: Very hardUrologic Surgery

A 68-year-old man is evaluated in the emergency department for a 2-day history of escalating lower abdominal pain, nausea, and fever. Seven days ago, he underwent a transurethral resection of the prostate (TURP) and cystolitholapaxy for severe benign prostatic hyperplasia and concurrent bladder stones. His urethral catheter was removed on postoperative day 2 prior to an uncomplicated discharge. Today, his temperature is 38.9°C (102.0°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Physical examination reveals marked suprapubic tenderness with voluntary guarding. Laboratory studies show a leukocyte count of 18,500/mm³. A CT scan of the abdomen and pelvis with intravenous contrast reveals a 5-cm rim-enhancing fluid collection in the prevesical space (space of Retzius) with adjacent fat stranding. The intraperitoneal cavity has no free fluid. Which of the following is the most appropriate next step in management?

  1. Percutaneous fluid drainage and urethral catheterizationAnswer
  2. B
    Urethral catheterization and intravenous antibiotics
  3. C
    Immediate exploratory laparotomy with primary bladder repair
  4. D
    Intravenous broad-spectrum antibiotics and continued observation
  5. E
    Lower extremity venous duplex ultrasonography

Answer

The most appropriate management is percutaneous fluid drainage and urethral catheterization to achieve source control and bladder decompression.
The correct answer addresses both the localized infection and the underlying anatomical defect. The patient has an infected prevesical fluid collection (abscess) likely due to an unrecognized extraperitoneal bladder perforation sustained during his recent cystolitholapaxy and TURP. The anterior bladder wall is extraperitoneal; therefore, injuries here leak fluid into the space of Retzius rather than the peritoneal cavity. While uncomplicated extraperitoneal perforations can be managed non-operatively with catheter drainage alone, the presence of a macroscopic abscess requires source control via percutaneous drainage, combined with bladder decompression (urethral catheterization) to allow the urothelium to heal.

Step-by-Step Solution

1
Analyze the patient's surgical history and current presentation.
The patient recently underwent TURP and cystolitholapaxy, procedures that carry a risk of bladder injury. He now presents with systemic inflammatory signs and an acute abdomen.
Establishing the temporal relationship between the procedure and the onset of sepsis symptoms directs the diagnostic focus to procedural complications.
2
Interpret the imaging findings in the context of pelvic anatomy.
The CT scan shows a 5-cm rim-enhancing fluid collection in the space of Retzius (extraperitoneal) with no intraperitoneal free fluid.
Differentiating between extraperitoneal and intraperitoneal pathology is critical, as it fundamentally alters the surgical management algorithm.
3
Determine the optimal intervention based on the anatomical compartment and presence of infection.
The extraperitoneal abscess requires percutaneous drainage for source control, alongside Foley catheter placement to divert urine and allow the bladder defect to heal.
Uncomplicated extraperitoneal leaks are managed with Foley alone, but infected collections (abscesses) mandate active fluid drainage.

Key Concept

Extraperitoneal bladder perforations (often manifesting in the prevesical space of Retzius) complicated by abscess formation require a combination of percutaneous fluid drainage and prolonged bladder decompression via urethral catheterization.
Estimated Time:1m 30s
Rate this question

Topics

Urologic Surgery

More questions from this topic