Case and Research Letter
Intravesical fat-fluid level as a warning sign of contained bladder perforation: Correlation between cystoscopy and computed tomography findings
Nivel líquido-grasa intravesical como señal de alerta de perforación vesical contenida: correlación entre los hallazgos de la cistoscopia y la tomografía computarizada
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Nivel líquido-grasa antigravitatorio dentro de la vejiga (asterisco) y defecto en la pared lateral izquierda con herniación intravesical de grasa extraperitoneal (flecha en<span class="elsevierStyleHsp" style=""></span>B).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Montosa Ródenas, M. Gómez Huertas, M.A. Pérez Rosillo, A.J. Láinez Ramos-Bossini" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Montosa Ródenas" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Gómez Huertas" ] 2 => array:2 [ "nombre" => "M.A." "apellidos" => "Pérez Rosillo" ] 3 => array:2 [ "nombre" => "A.J." 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Single nucleotide polymorphisms (SNPs) of <span class="elsevierStyleItalic">LHCGR</span> (rs2293275) and <span class="elsevierStyleItalic">NR5A1</span> (rs1057517779) genes were investigated by Tetra-ARMS PCR method. Statistical analysis that frequency of C allele in <span class="elsevierStyleItalic">LHCGR</span> (rs2293275) polymorphism and frequency of A allele in <span class="elsevierStyleItalic">NR5A1</span> (rs1057517779) polymorphism in patients with male infertility were significantly more than healthy controls. These alleles may be risk factor for male infertility.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Behvarz, S.A. Rahmani, E. Siasi Torbati, S. Danaei Mehrabad, M. Bikhof Torbati" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Behvarz" ] 1 => array:2 [ "nombre" => "S.A." "apellidos" => "Rahmani" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Siasi Torbati" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Danaei Mehrabad" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Bikhof Torbati" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480623001286" "doi" => "10.1016/j.acuro.2023.08.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480623001286?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578623001129?idApp=UINPBA00004N" "url" => "/21735786/0000004800000003/v1_202404020631/S2173578623001129/v1_202404020631/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letter</span>" "titulo" => "Intravesical fat-fluid level as a warning sign of contained bladder perforation: Correlation between cystoscopy and computed tomography findings" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "254" "paginaFinal" => "256" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Montosa Ródenas, M. Gómez Huertas, M.Á. Pérez Rosillo, A.J. Láinez Ramos-Bossini" "autores" => array:4 [ 0 => array:3 [ "nombre" => "P." "apellidos" => "Montosa Ródenas" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Gómez Huertas" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M.Á." "apellidos" => "Pérez Rosillo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:4 [ "nombre" => "A.J." "apellidos" => "Láinez Ramos-Bossini" "email" => array:1 [ 0 => "ajbossini@ugr.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Radiología Abdominal y Urogenital, Hospital Universitario Virgen de las Nieves, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "ibs.GRANADA - Instituto de Investigación Biosanitaria, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nivel líquido-grasa intravesical como señal de alerta de perforación vesical contenida: correlación entre los hallazgos de la cistoscopia y la tomografía computarizada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 646 "Ancho" => 1674 "Tamanyo" => 107939 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Computed tomography cystography <span class="elsevierStyleBold">(A</span>, supine position; <span class="elsevierStyleBold">B</span>, prone position). Intravesical fat-fluid level in antigravitational position that mobilizes with the patient's movements (asterisks) and wall defect in the left lateral wall contained by herniation of perivesical fat, without evidence of urinary leakage (arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bladder perforation is a relatively frequent and potentially serious complication of transurethral resection of the bladder (TURB),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> with an estimated incidence ranging from 2.4% to 10%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The perforation site may allow adjacent fat to migrate into the bladder, resulting in an intraluminal fat-fluid level that can be detected by imaging examinations such as computed tomography (CT). This finding is uncommon and has a broad differential diagnosis that includes primary, infectious and traumatic causes. Therefore, it is important to use the most appropriate imaging protocol and to know the main imaging findings that allow a confident diagnosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of an asymptomatic patient with an intravesical fat-fluid level detected by CT due to an extraperitoneal perforation of the bladder contained by perivesical fat herniation following TURB.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 71 year-old male under follow-up by medical oncology for lung cancer was referred to our Urology department due to benign prostatic hyperplasia with obstructive voiding symptoms. As medical treatment proved ineffective, transurethral prostatic resection was performed. During the procedure, an excrescent lesion suggestive of neoplasm was detected on the left lateral wall of the bladder. Therefore, the patient was scheduled two months later and for lesion resection by TURB. The pathology report of the lesion was low-grade urothelial carcinoma (T1G3).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Three months later, in a follow-up cystoscopy, a fibrin-covered area was identified at the resection site (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Six months later, a new control cystoscopy was performed in which the lesion was still visualized, without significant changes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). However, a contiguous grayish lesion was also identified in an antigravitational position, rounded and slightly elevated, with soft and depressible consistency after liquid entry through the cystoscope (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). These lesions were described as non-specific in the cystoscopy reports.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Concomitantly to this process, the patient underwent routine oncologic body CT follow-ups for lung cancer. Incidentally, in the control CT performed one month after TURB, an intravesical fat-fluid level and a wall bladder defect anterior to the left ureteral meatus with perivesical extraperitoneal fat invagination was identified. No inflammatory changes or surrounding liquid was observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). These findings were not present in previous imaging studies and raised the radiological suspicion of extraperitoneal bladder perforation contained by perivesical fat.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">To rule out urinary leakage, non-contrast CT and CT cystography in supine and prone position were subsequently performed, revealing that the intravesical fatty component adopted an antigravitational position and outside the bladder wall (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The study was complemented with ultrasound, which showed a lobulated hypoechogenic structure in the left lateral wall of the bladder and a hyperechogenic anti-gravitational level consistent with a fat, in correspondence with the CT findings.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The presence of intravesical fat is an infrequent finding that must be differentiated from an air-fluid level on CT by means of a correct measurement of Hounsfield Units (approximate range of −40 to −100) and from bladder wall lipomas. In the latter case, CT in supine and prone position can be useful, since true bladder wall lipomas do not change their location with patient’s position.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The etiology of intravesical fat includes traumatic, post-surgical and medical conditions.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Regarding post-surgical causes, isolated cases secondary to partial nephrectomy, radiofrequency ablation of renal tumors or hemicolectomy have been reported.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> To our knowledge, this is the first intravesical fat-fluid level secondary to TURB reported in the literature.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The most common hypotheses to explain the presence of intravesical fat secondary to urological invasive procedures are related to damage of the lymphatic system (chyluria)<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> or rupture of the bladder wall, in which small perivesical fat droplets would pass through the bladder parietal defect and move towards the lumen.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">While previous reports have documented intravesical fat-fluid levels resulting from various urological procedures, our case stands out as the sole instance reported in the literature where an asymptomatic patient presented with concomitant intravesical fluid-fat level following TURB, with the bladder perforation contained by herniation of perivesical fat.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, this case highlights the unique occurrence of an intravesical fat-fluid level resulting from an extraperitoneal bladder perforation contained by perivesical fat. This uncommon finding underscores the importance of considering bladder perforation as a potential complication and utilizing appropriate imaging protocols to achieve an accurate diagnosis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 516 "Ancho" => 1674 "Tamanyo" => 83719 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cystoscopy <span class="elsevierStyleBold">(A,</span> first follow-up after transurethral resection of bladder; <span class="elsevierStyleBold">B</span> and <span class="elsevierStyleBold">C</span>, second follow-up). Intravesical herniation of extraperitoneal fat (arrows) and fat-fluid level in antigravitational position within the bladder (asterisk).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 724 "Ancho" => 1674 "Tamanyo" => 118626 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Axial non-contrast computed tomography images. Antigravitational fat-fluid level within the bladder (asterisk) and wall defect in the left lateral wall with intravesical herniation of extraperitoneal fat (arrow in B).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 646 "Ancho" => 1674 "Tamanyo" => 107939 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Computed tomography cystography <span class="elsevierStyleBold">(A</span>, supine position; <span class="elsevierStyleBold">B</span>, prone position). Intravesical fat-fluid level in antigravitational position that mobilizes with the patient's movements (asterisks) and wall defect in the left lateral wall contained by herniation of perivesical fat, without evidence of urinary leakage (arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "En-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer: A meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y. Di" 1 => "H. Li" 2 => "C. He" 3 => "H. 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