Nonoperative Management of a Spontaneous Perforation of Neobladder Secondary to Blackout From Solitary Binge Drinking: A Case Report and Current Literature Review.

Abstract

The orthotopic ileal neobladder is becoming a popular technique of urinary diversion after radical cystectomy (RC) for localized muscle-invasive bladder cancer (MIBC), allowing patient continence, with a more desirable body image and good quality of life. Minimally invasive robot-assisted RC and neobladder have the potential to minimize physical and psychological trauma and are increasingly being adopted for patients with MIBC worldwide. Spontaneous perforation of orthotopic neobladder is uncommon;however, it represents serious complications. Solitary binge drinking can be dangerous in a patient with a neobladder because of reduced level of consciousness and overdistension of the neobladder. We report a case of spontaneous ileal neobladder perforations one year post-robotic RC secondary to blackouts from binge drinking. We also describe nonoperative active management and review the literature. A 66-year-old gentleman was brought by ambulance to our emergency department with a reduced level of consciousness, vomiting, and abdominal pain in the early hours of the morning. Collateral history revealed that he had drunk alcohol alone the night before at his home where he lives alone. Initial examination revealed tachycardia and hypotension. Immediate resuscitation using the sepsis six protocol included intravenous normal saline, blood culture, broad-spectrum antibiotic, lactate measurement, and insertion of a urethral catheter to monitor urine output. Following contrast-enhanced computed tomography (CECT) of the abdomen and pelvis, the patient was referred to a urologist. A diagnosis of spontaneous perforation of the neobladder was made. A nonoperative or 'conservative' management approach was adopted with careful active monitoring at the intensive care unit (ICU) involving a multidisciplinary team. Follow-up CT was performed to assess radiological recovery. The patient recovered successfully and was discharged home five weeks post-admission with an indwelling urethral catheter. The catheter was removed 10 weeks post-admission following a cystogram confirming the integrity of the neobladder. The patient has preserved neobladder function and continence and is doing well until the last follow-up at six months post-discharge. Patients with neobladder should be rigorously counseled about the importance of timed voiding, intermittent self-catheter, serious consequences of solitary binge drinking, and urinary retention.