Bladder Necrosis

 Written by: Medical Device Accident Expert Witness No. 3571

A patient underwent a trans-urethral resection of the prostate. The bladder was distended with sterile water hung about 1 meter above the patient and run through a fluid warming device. The surgery went as planned, but the patient later presented with pain and trouble urinating. Cystoscopy revealed what appeared to the surgeon to be a thermally burned lining of the bladder that was sloughing off. The bladder later necrosed and was surgically removed.

Pathology of the bladder found the bladder lining to have necrosed and sloughed, but the prostate, which was also removed, was pink and healing. No mention of any burn to the urethra was made.

If the bladder had been thermally burned during the surgery, the distending water would have to have been above 60°C, the temperature at which tissue proteins denature. If this was the case, then the prostate would also have been burned because it was opened to the water in the bladder. As this water flowed out through the metal resectoscope, the urethra would likely to have been burned as well. However, the surgeon and surgical technician had noted that the effluent water was warm but not hot. Additionally, the fluid warmer could not warm the water above 43°C. So something other than heat caused the bladder to necrose.

The 1950’s and 1960’s cystitis was sometimes treated by distending the bladder for up to 30 minutes. There are reports of bladder necrosis due to this treatment. Cystoscope and resectoscope instruction manuals warn against leaving the outflow stopped for long periods as this could cause necrosis of the bladder.

The bladder has a blood supply separate from the prostate, and is a thin walled structure like a balloon. When the bladder is distended, the blood vessels are forced shut by the tension in the bladder wall. If the blood flow is stopped for sufficient time, the tissue begins to die. Because the prostate has a separate blood supply, a more massive shape, and was being removed, it was not necrosed by the pressure.

We concluded that the bladder pressure had to have been maintained for sufficient time to cause bladder necrosis and that the fluid warmer did not overheat.

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