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FIGURE 5.20. In an extraperitoneal perforation, extravasation of contrast is limited to the immediate area surrounding the bladder. a: On the anteroposterior (AP) views the leak is not obvious. b: On the lateral views an anterior leak is obvious. Note the two ureters posteriorly (the patient refluxes contrast up both ureters).
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FIGURE 5.20. Continued
Trainees are sometimes uncertain whether a perforation is extraperitoneal or intraperitoneal. Establishing this can sometimes be difficult, because both can cause marked distention of the lower abdomen—an intraperitoneal perforation by allowing escape of irrigating solution directly into the abdominal cavity, and an extraperitoneal perforation by expanding the retroperi-toneal space, with fluid then diffusing directly into the peritoneal cavity. The fact that a suspected intraperitoneal perforation was actually extraperitoneal becomes apparent only at laparotomy when no hole can be found in the bladder! However, in such cases where there is marked abdominal distention, whether the perforation is extraperitoneal or intraperitoneal is in many senses academic. The important thing is to explore the abdomen, principally to drain the large amount of fluid that can compromise respiration in an elderly patient by splinting the diaphragm, but also to
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FIGURE 5.21. In an intraperitoneal perforations, loops of bowel may be outlined by the contrast. There was an associated left ureteric injury managed by JJ stenting. a: On initial bladder filling no leak is seen. b: Small bowel loops are outlined by contrast as more contrast is instilled into the bladder.
S. TRAUMATIC UROLOGICAL EMERGENCIES I03
FIGURE 5.21. Continued
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check that loops of bowel adjacent to the site of perforation have not been injured at the same time. Failing to make the diagnosis of an intraperitoneal perforation, particularly if bowel has been injured, is a worse situation to be in than performing a laparo-tomy for a suspected intraperitoneal perforation, but then finding that the perforation was 'only' extraperitoneal.