5. TRAUMATIC UROLOGICAL EMERGENCIES 105
from perforations where large prostatic veins are opened and a large volume of fluid escapes into the circulation; it is rare for escape of fluid into the retropubic space to cause any trouble. However, occasionally fluid introduced with the Ellik evacuator does not suck back, or a change in the character of the respiration and a coldness and swelling of the suprapubic tissues may suggest that there has been a massive loss of fluid.
Stop the resection. If there is significant abdominal disten-tion make the decision to proceed with open drainage of the retropubic space. Make a Pfannenstiel incision. Expose the bladder, open it between stay sutures, and evacuate the clot. Complete the prostatectomy (if it is not already complete) by enucleating the remaining adenoma with the finger. Get exact haemostasis by sutures, and if you can see the hole in the capsule, close it with a stitch. Only when all the bleeding is controlled should you close the wound with a suprapubic and urethral catheter and a drain to the retropubic space.
Bladder Perforation Following Pelvic Fractures
This has been discussed previously. If the bladder injury is extraperitoneal and there are no other associated injuries to the urethra, kidneys, or intraabdominal viscera, then bladder drainage with a urethral catheter for approximately 2 weeks is all that is necessary. A cystogram can be done 10 to 14 days later to confirm that the perforation has healed. If it has not, it is reasonable to wait for another week or so, and in most cases a further cystogram will demonstrate no further leak. Occasionally there will be persistent leakage of contrast and this can be an indication that a piece of bone is poking into the bladder. Exploration and repair should be carried out.
There are situations in which an extraperitoneal bladder perforation should undergo suture repair:
■ If you have opened the bladder to place a catheter, because, for example, there is an associated urethral injury, there seems little point in not repairing an extraperitoneal rupture if one is found.