Orthotopic neobladder perforation: an unusual presentation of small bowel obstruction
A 71-year-old male had undergone a radical cystectomy and orthotopic neobladder formation 5 years previously, and was self-catheterising. He presented to the emergency department with a 24-h history of abdominal pain and distension. There was associated nausea and a reported decrease in urine production. Examination revealed a distended abdomen with some lower abdominal tenderness but no evidence of peritonism. Bowel sounds were absent. Relevant blood analysis revealed creatinine 354 µmol/l, WCC 15.9 × 109/l and CRP > 380. An abdominal X-ray revealed dilated small bowel loops, and a CT showed moderate volume ascites and distal small bowel obstruction with the transition being a thickened small bowel loop lying next to the neobladder (Fig. ).\nConservative management was instituted (catheter, nasogastric tube) for presumed adhesional obstruction, and the patient was admitted under the care of the general surgical team. The urology team were contacted in light of the CT findings, and as the patient had not improved over a 24-h period, a decision was made to proceed with an exploratory laparotomy.\nAt surgery, there was a large amount of turbid urinary ascites, and the offending loop of small bowel seen on the CT was found to be stuck to a 5 mm perforation in the neobladder, at the junction of the afferent limb and the pouch. This was oversewn with an omental patch. The patient made a good recovery, creatinine normalized to 95 µmol/l, bowel function returned to normal and a cystogram at 10 days did not show any evidence of a leak.