We report the case of a 43-year-old man, without known drug allergies or medical or surgical history of interest, with abdominal gunshot wound (push with 9 mm parabellum projectile).
The patient was hemodynamically stable in the emergency department with severe abdominal pain.
Physical examination revealed the entrance orifice of the projectile in the left iliac fossa with exit through the left glue, with abdominal pain and signs of peritoneal irritation mainly in the hypogastrium and iliac fossa.
There was no involvement of external genitalia or urethrorrhagia.
After urethrovesical catheterization, intense macroscopic hematuria was observed.
At admission, only anemia (Hb: 9.2 g/dl) was detected, and the rest of the biochemical parameters, blood count and coagulation were normal.
Given the hemodynamic stability of the patient, it was decided to complete the study by imaging tests prior to surgery.
Given the theoretical trajectory of the projectile (as soon as the entrance and exit orifices are known), with the suspicion of bladder injury by firearm and given the possible involvement of other organs, it was decided to perform abdominal CT with contrast).
- abdominal-pelvic CT and CT-cystography: extraperitoneal left posterolateral bladder rupture with contrast extravasation after filling.
Minimal dilation of the left collecting system.
Entry wound in the left iliac fossa with areas of hemorrhage in: mesosigma, left lateral bladder, left seminal vesicle and left perirectal and ischiorectal areas.
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With these findings, exploratory laparotomy was decided.
With the patient in the supine position, a supra-infraumbilical midline laparotomy was performed.
Initially, a small mesosigma perforation without sigmoid loop was repaired and a minimal iliac vein lesion affecting the left iliac vein was repaired, showing the rest of the iliac axis posteriorly.
Anterior mid-longitudinal cystotomy was then performed and a double bladder perforation was observed, corresponding to the entrance orifices (4 cm in bladder bottom) and exit orifice (1-2 cm in left retromectile region).
Left ventricular ejection fraction in the left distal ureter with 5F ureteral catheter was found to be completely deinserted in its intramural portion and the projectile in its course was also found
It was decided to suture the double bladder perforation in two planes, after debridement of devitalized edges and perform ureteral reimplantation with transvesical technique and double J catheter (26 cm/6 F) distal end of the ureteral wall.
After closure, also in double plane, of the anterior longitudinal cystotomy, an urethrovesical tube and double closed drainage of aspiration type were left: one at the intraperitoneal level and the other extraperitoneal bladder suture, separated from the line.
Intravenous broad-spectrum antibiotics were prescribed: ceftriaxone 2 grams every 24 hours and Metronidazole 1.5 grams every 24 hours, with favorable initial postoperative course.
On the 5 day the patient presented deterioration of general condition, hypotension, fever and leukocytosis with marked left shift (31% fallen).
Antibiotic therapy is replaced empirically, waiting for the result of the hemocultives by Imipenem 500 milligrams every 6 hours intravenous, significantly improving the patient both clinically and analytically.
An E. coli extended spectrum, sensitive to Imipenem, grows in hemocultives.
A new abdominal-pelvic CT scan is performed, which only shows post-surgical changes, showing the existence of dusty liquids causing the septic picture.
The rest of the postoperative period was uneventful, and both drainages were initially removed and the urethrovesical catheter was removed on the 10th day.
Finally, the patient was discharged after completing 10 days of intravenous antibiotic therapy.
It is replaced by ciprofloxacin 250 milligrams every 12 hours orally, according to the previous antibiogram, until the JJ catheter is removed.
One month after the operation, the patient returned to our service for urethrocystoscopy and removal of JJ catheter.
It is observed that the double bladder wound is completely healed, with the suture of the resorbed mucosal plane almost completely.
The tutoring JJ catheter removed endoscopically without problems.
Currently, three months after surgery, the patient is asymptomatic from the urological point of view.
