Surgical Treatment of Gangrene of the Urine Bladder, Review of Three Cases

Gangrene of the urine bladder is a very rare life threatening acute urology disease that requires extremely fast diagnoses followed by urgent and radical surgical treatment. Fronstein once noticed that gangrene of the urine bladder is so rare that it should be described each appearance as a separate case. The first such case was described in 1650 by Willis (Carson, 1925). Two etiology factors have so far been described mostly for the occurrence of the vesical gangrene. The first is the gangrenous cystitis that occurs in untreated acute cystitis in patients with reduced immunity or in female who developed gangrenous cystitis post-partum (Prabhat et al., 2019), and the second factor is described as a complication after embolization of the hypogastric artery or complication during pelvic thrombophlebitis (Sieber, 1994). In majority of cases described, surgical treatment consisted of partial or total cystectomy and temporary urinary derivation (Stirling and Hopkins, 1934). The aims of the study was to analyze the diagnostic methods, operative and post-operative treatment and follow-up of the patients with gangrene of the urine bladder treated at our urology department. The results obtained was compared with the existing data in the world literature and relevant scientific papers and determine the justification for second surgical intervention in order perform definitive urinary derivation with ileal conduit. Three consecutive cases of vesical gangrene have been treated in the past 18 months at the Urology Department at the General City Hospital “8^th September” – Skopje, R of North Macedonia. All three were admitted as acute abdomen with septic condition and treated at the Emergency Center. Two of them were treated due to complete vesical gangrene and the third was treated first as acute abdomen caused by fibrotic obstruction of the sygma as a complication after radiation therapy received for cervical cancer. The third case was treated for vesical gangrene developed eight months after the first surgery as a complication due to persistent recto-vesico-vaginal fistula. The intraoperative finding revealed acute phlegmonoso-gangrenous peritonitis caused by complete gangrene and perforation of the urine bladder in two cases, and partial vesical gangrene with vesico-recto-vaginal fistula developed eight months after partial resection and colostomy in the third case. Emergency surgery with radical cystectomy and ureterocutaneostomy was performed on the patients with complete gangrene and perforation of the urine bladder. The third patient was treated as complication of persistent urinary infection due to recto-vesico-vaginal fistula and performed radical cystectomy with ileal conduit as permanent urinary derivation. Six months after the emergency surgery urinary diversion with ileal conduit was performed in one of the patients due to complete stenosis of the ureterocutaneostomy and acute obstructive renal failure with metabolic acidosis. The two years’ post operative follow up showed good health with normal function of the ileostoma in both patients and normal function of the ureterocutaneostoma in one patient with normal values of the electrolytes and blood degradation products. Urine bladder gangrene is rare but extremely urgent life threatening condition which requires radical surgical treatment during the first 24 hours from its appearance. Acute occlusion of one of the hypogastric arteries with thromb embolus, as a complication of pelvic phlebothrombosis, according to our experience is the most common cause for its appearance. Long presence of vesico-rectal or vesico-vagino-rectal fistula could also result with partial necrosis of the urine bladder wall. But unlike the acute occlusion of the hypogastric artery, it has chronic symptoms and signs. Urgent radical cystectomy with bilateral ureterocutaneostomy in the first stage and urinary diversion with ileal conduit in second stage is so far the most convenient surgical solution for these acute urinary conditions