Intravesical Instillation of Mitomycin C: A Cause of Delayed Bladder Perforation?

We present a case of bladder perforation secondary to intravesical instillation of mitomycin C following transurethral resection of bladder tumour (TURBT) and the role of early detection leading to successful conservative management. We also review the key relevant literature. 1. Introduction The European Association of Urology and American Urological Association guidelines recommend immediate postoperative instillation of intravesical chemotherapy in cases of nonmuscle invasive bladder tumour (NMIBT). There is strong evidence showing immediate postoperative instillation of chemotherapy reduces the risk of recurrence by 39% [1]. Mitomycin C (MMC) instillation is routinely administered and generally safe. However, several papers have reported an association between postoperative intravesical MMC instillation and bladder perforation leading to severe morbidity including death. We present a case of bladder perforation suspected mostly to be secondary to MMC instillation post-TURBT and a review of the current literature. 2. Case Report A 77-year-old Caucasian gentleman underwent TURBT for a 1？cm recurrent superficial papillary tumour located high on the posterior wall, at its junction with the dome of the bladder. The primary tumour was initially resected 17 years previously showing a G1 pTa transitional cell carcinoma (TCC) but no subsequent surveillance had been organised as the patient was lost for follow up. The patient was an ex-smoker, stopping 20 years ago with a 20 pack year history. His past medical history had open bilateral inguinal hernia repair but no significant family or drug history. The lesion was completely resected and deep muscle biopsy taken separately using cold cup biopsy forceps and the biopsy site diathermised. Intraoperatively, there was no endoscopic evidence of bladder wall perforation; hence mitomycin C, 40？mg in 40？cc of water for injection, was instilled into the bladder postoperatively. Histology revealed a 30？mm Grade 1/2 (low grade) pTa papillary TCC. Following removal of catheter, delayed to the second postoperative day due to haematuria, the patient failed to void for the first eight hours. He subsequently developed excruciating pain in the lower abdomen on attempts at voiding, leading to a vasovagal syncopal attack. On examination there was evidence of peritonism localized to the suprapubic region. He was found to be in urinary retention and thus re-catheterised. Computed tomography (CT) with retrograde cystography demonstrated localised extraperitoneal extravasation in continuity with the anterior bladder wall (Figure