Intraperitoneal perforations of the bladder in pediatric urological practice. Comparative evaluation of the effectiveness of various therapeutic and diagnostic approaches

BACKGROUND: Intraperitoneal damage to the bladder in the pediatric population is a rare phenomenon. Publications describe small series of observations, generalizing studies are isolated. There are no uniform diagnostic algorithms and tactics of patient management, a large number of diagnostic and tactical errors.

AIM: The aim of this study is to evaluate the possibilities of laparoscopy in the diagnosis and treatment of patients under 18 years of age with intraperitoneal bladder injuries.

MATERIALS AND METHODS: The work was based on the results of treatment of 16 patients with intraperitoneal perforations of the bladder under the age of 18, who were in the Regional Pediatric Clinical Hospital (Yaroslavl) and Vologda Regional Children’s Hospital No.2 (Cherepovets) for the period 2003–2023. In 10 cases, the perforations were traumatic in nature, in 6 — iatrogenic in nature.

RESULTS: Surgical treatment was performed with traditional access in 6 cases, laparoscopic — in 10. The groups of patients are similar in clinical parameters. Laparotomic surgical intervention was performed from the lower median access (n = 4) and Pfanenstiel access (n = 2); with laparoscopic intervention (n = 10), a trocar arrangement with umbilical access for the camera and two accesses in the iliac regions for instruments was used. Laparoscopic surgery was accompanied by less blood loss. The duration of bladder drainage with laparoscopic intervention is reduced by 1.7 days. Laparoscopic surgery in 1 case was accompanied by the installation of a cystostomy, in the rest drainage was carried out by catheterization of the bladder. Open surgery was mainly completed by performing a cystostomy or combined drainage with a cystostomy and a urethral catheter. The duration of hospitalization is significantly shorter after laparoscopic intervention. In the first 10 years (2002–2012) 5 open operations and 2 laparoscopic operations were performed, and in the second 10 years (2013–2023) — 8 laparoscopic and one open operations. The tactics regarding bladder drainage are changing: in the first analyzed period, drainage was carried out mainly by cystostomy (n = 5) and less often by urethral catheter (n = 2), subsequently — mainly by urethral catheter (n = 7), less often by cystostomy (n = 1) or by simultaneous drainage by stoma and catheter (n = 1).

CONCLUSIONS: Laparoscopic suturing is the method of choice in all cases of isolated intraperitoneal perforations of the bladder and in most combined injuries. Indications for open intervention are combined abdominal injuries, active intra-abdominal bleeding. The urethral catheter has advantages over cystostomy.