The diagnosis of an intraperitoneal perforation is obvious if you can actually see loops of bowel as you are looking through the resectoscope. The telltale sign of the Ellik evacuator not sucking back can occur with both intraperitoneal and extraperi-toneal perforation, and this therefore tells you that something is wrong, rather than what is wrong.
When there is marked abdominal distention, or where it is obvious that the perforation has been made right through into the peritoneum or, as is often the case, the perforation is obscured and accompanied by haemorrhage, then it is necessary to explore the abdomen.
The bladder is approached through a Pfannenstiel incision or lower midline abdominal incision, opened between stay sutures, the clot evacuated, the bleeding controlled, and the hole sewn up. The peritoneum is opened if not already done so. This allows you to see if there is any blood-stained fluid inside. Adjacent loops of small and large bowel should be pulled out and diathermy damage looked for. A hole in the small bowel is closed in its transverse axis. A hole in the colon should be protected with a temporary loop-colostomy.
The Delayed Diagnosis of Iatrogenic Bladder Perforation
Bladder perforation during surgery (TURBT, TURP, open pelvic surgery, etc.) may not initially be recognised until after the patient has returned to the ward. All may initially appear to be well until the patient develops a fever and an ileus. After open abdominal or pelvic surgery, a drain may have been left and there may be persistent output of fluid (urine) from this. The creatinine level in this fluid will be greater than that in serum. Imaging studies may show a pelvic or abdominal fluid collection. In this situation, if the patient has undergone gynaecological or bowel surgery, imaging studies should be done to determine whether there is an associated ureteric injury as well as a bladder one (see below).
Bladder Perforation During TURP
This occurred in 0.25% of cases in a large audit of complications occurring after TURP (Neal 1997). In practice, danger only arises