a 75-year - old male patient was emergently admitted to the hospital with gross hematuria , generalized abdominal pain , and oliguria of about 3 days ' duration .
he had undergone multimodal treatment for muscle - invasive bladder cancer ( stage t2 , urothelial cancer with sarcomatous differentiation ) with transurethral resection ( tur ) of the bladder tumor and 6 adjuvant cycles of cisplatin - based cytotoxic chemotherapy ( gemcitabine+cisplatin ) ( fig .
1 ) , because he desired bladder preservation and had a strong fear of urinary diversion .
one year after tur , a follow - up ct scan showed bladder tumor recurrence with a focal irregular margin of the bladder wall , suggestive of perivesical invasion .
so he underwent tur of the bladder cancer ( stage t2 , urothelial cancer with squamous differentiation ) ( fig .
2 ) with adjuvant chemotherapy ( methotrexate , vinblastine , adriamycin , and cisplatin ) . at 10 months after the operation , he presented with acute illness with vague abdominal pain .
he was febrile at 39. he did not have a history of recent pelvic trauma , instrumentation , pelvic radiation , infravesical obstruction due to benign prostatic hyperplasia , or episodes of acute urinary retention .
on the physical exam , the abdomen was markedly distended with muscular guarding and rebound tenderness .
the serum creatinine ( cr ) level was elevated to 5.8 mg / dl with biochemical features of acute renal failure [ k 5.7
mmol / l , na 126 mmol / l , serum blood urea nitrogen ( bun ) 53 mg / dl , bun / cr ratio 9:1 ] .
the spiral ct showed a large bladder tumor extending into the perivesical space with a focal bladder wall disruption .
the bladder tumor was nearly in contact with the anterior rectal wall without clear demarcation .
we therefore first suspected an invasive bladder tumor with a rectovesical fistula and performed sigmoidoscopy and plain film cystography with retrograde contrast media injection through an indwelling urethral catheter .
sigmoidoscopy showed no signs of fistula opening within the site of 70 cm from the anal verge except for a mild segmental mucosal edema .
plain film cystography showed a refractory bowel pattern to paralytic ileus and left lateral wall irregularity with a suggestive sinus tract , but no evidence of intra- or extraperitoneal contrast media extravasation ( fig .
, it was difficult for us to identify the cause of the acute peritonitis and biochemical features of acute renal failure .
so we finally performed ct cystography with the patient in the prone position with 50 ml megluatmine iothalamate mixed in 500 ml of normal saline .
the ct cystography showed the highly attenuated fluid in the peritoneum via a disrupted left lateral bladder wall and small bowel loop pooling with contrast media ( fig .
considering the patient 's age , poor general condition , and performance status , we decided to manage him conservatively with broad - spectrum antibiotics and indwelling catheters .
a 8.5 fr pigtail drain catheter was inserted into the right pelvic area under the guidance of fluoroscopy in addition to percutaneous nephrostomy catheters for adequate urine drainage .
after the insertion of the intraperitoneal drain catheter , 150 ml of turbid , yellowish urine with pus was drained .
after intervention , the patient 's serum creatine level and white blood cell count returned to normal values in 4 days .
the patient was discharged home with successful peritonitis resolution on hospital day 28th but died 3 months later as the result of acute renal failure .
spontaneous intraperitoneal bladder perforation is a very rare clinical event and is associated with high mortality .
most spontaneous bladder ruptures occur as the result of long - term indwelling catheters , radiation , chronic cystitis , bladder distention due to infravesical obstruction , or neurogenic bladder dysfunction .
however , bladder perforation associated with bladder cancer is an extremely rare cause of spontaneous rupture .
such rupture is a surgical emergency that may be rapidly fatal if its diagnosis and treatment is delayed or missed .
patients usually present with symptoms such as sudden onset of lower abdominal pain , high spiking fever , hematuria , abdominal distention with signs of peritoneal irritation , and anuria with biochemical features of acute renal failure due to auto - dialysis of urinary ascites across the peritoneum .
plain film cystography is accepted as the most accurate radiological technique for diagnosing bladder rupture .
but with the widespread use of ct cystography , this imaging technique is increasingly being performed as an alternate method of diagnosing bladder rupture and has been shown to be as accurate as conventional cystography .
ct cystography can also distinguish the specific type of bladder rupture between extraperitoneal or intraperitoneal .
ct cystography has several advantages over plain film cystography : ( 1 ) it is rapid and is easily performed at the same time as other ct studies , ( 2 ) it is less affected by overlying bone fragments , and ( 3 ) it is more sensitive to the detection of small amounts of intraperitoneal or extraperitoneal fluid . in the present case , even though an abdominal helical ct scan was performed with adequate bladder distention of intravenous contrast media injection , there was no evidence of intraperitoneal perforation even on the 10 minute delay scan .
so we checked ct cystography with retrograde contrast media injection in the prone position and finally diagnosed that the intraperitoneal perforation was associated with invasive bladder cancer .
urothelial carcinomas are known to demonstrate a wide range of divergent histologic differentiations into the entire spectrum of histologic variants , including squamous , glandular , micropapillary , sarcomatoid , small cell , clear cell , lymphoepithelial , and plasmacytoid components .
wasco et al found that any type or amount of divergent histologic differentiation present with urothelial carcinoma was strongly associated with unfavorable prognostic features .
such cancer with mixed histologic features was nearly uniformly high grade and highly invasive and was also an independent predictor of extravesical diseases . in our case , 2 tur specimens showed urothelial carcinoma with sarcomatoid differentiation and squamous differentiation , respectively .
highly aggressive characteristics of urothelial cancer with divergent differentiation may explain the spontaneous bladder perforation and following early death . in summary , we encountered a case of spontaneous intraperitoneal bladder perforation associated with highly aggressive urothelial cancer with divergent differentiation . at first , the findings of conventional helical ct and plain film cystography made it difficult for us to diagnose the intraperitoneal perforation properly .
although intraperitoneal bladder rupture is a serious condition due to increased urine leakage and subsequent systemic absorption , and prompt surgical repair is key for patient management , we managed the patient conservatively rather than by open surgical repair in consideration of his poor general condition and suboptimal prognosis .
we successfully treated the patient conservatively with adequate urinary diversion , intraperitoneal drainage , and broad - spectrum antibiotics .
 spontaneous bladder perforation is a very rare event . 
 prompt diagnosis of this injury is very important , particularly with intraperitoneal perforation , because mortality increases if surgical repair is delayed . 
 previous studies have reported that plain cystography is the primary modality of imaging study rather than relatively insensitive computed tomography ( ct ) when bladder perforation is suspected . 
 we report here a rare case of spontaneous intraperitoneal perforation of the bladder associated with urothelial carcinoma with divergent histologic differentiation , as diagnosed with ct cystography . 
CASE REPORT
DISCUSSION