Urinary bladder rupture is mostly associated with trauma, chronic bladder disease, or bladder outflow obstruction. Nontraumatic, spontaneous intraperitoneal bladder rupture, which is associated with pelvic radiation therapy, is rare in cervical cancer patients. The diagnosis of urinary bladder rupture may be difficult due to unreliable history and variable presentation. Spontaneous intraperitoneal bladder rupture is commonly initially misdiagnosed, and sometimes can be a life-threatening event.

Case presentation

A 52-year-old woman presented to the hospital(Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China)with abdominal distension, oliguria, and ascites for the first time in January 2010. She denied any history of trauma. She was diagnosed with cervical cancer in 2003.She underwent radical hysterectomy and pelvic lymph node dissection on March 24, 2003, and was diagnosed with squamous carcinoma of the cervix (stage IIb).She received postoperative pelvic concurrent chemoradiotherapy, including pelvic radiation (Dt 4600 cGy/23 F) and brachytherapy (Dt 1700 cGy/3 F), then regular follow-up. After a 5-year follow-up period, there was no significant recurrence, the patient was asymptomatic,and regular follow-up was discontinued.

In January 2010, the patient was admitted to the hospital (Tongji Hospital, Tongji Medical College,Huazhong University of Science and Technology,Wuhan, China) because of abdominal distension and pain, decreased urine output, and a large amount of ascites. On examination, her temperature, blood pressure,and heart rate were normal. Chest auscultation showed a regular heart beat without murmur and clear breath sounds without crackles. The abdomen was grossly distended with free fluid, and she had hypoactive bowel sounds. There were no features suggestive of peritonitis,no palpable liver or spleen, and no percussion pain in the kidney area. No abnormalities were found on gynecologic examination. The diagnosis at admission was suspected ascites of unknown cause and cervical cancer. Blood urea nitrogen and serum creatinine were slightly increased.The complete blood cell count, liver function, and coagulation tests were normal, and tumor marker levels,including carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCCA), CA 153, CA 125, and CA 19-9 were also normal. Ultrasound examination showed a rough bladder wall and a large amount of abdominal and pelvic effusion. Computed tomography (CT)showed a large amount of ascites without evidence of malignancy or any obstruction. No obvious abnormalities were found on cystoscopy, other than pale bladder mucosa. Positron emission tomography PET/CT showed abnormally elevated fluorodeoxyglucose uptake in both the abdominal and pelvic cavities, with strong suspicion of metastatic lesions. Routine biochemical tests and pathological examination of the ascites fluid revealed the presence of red blood cells, lymphocytes, and mesothelial cells, but no cancer cells. The patient was diagnosed with incomplete malignant bowel obstruction, and was discharged after improvement with symptomatic and supportive treatment. From 2010 to 2015, the patient had recurrent abdominal pain and distension, with different amounts of ascites. No obvious abnormalities were found on CT and cystoscopy. The symptoms were relieved with ascites drainage and supportive treatment.

In July 2015, the patient was readmitted with the same symptoms, including abdominal pain, lower abdominal distension, and oliguria. PET/CT examination showed no specific abnormalities. A multidisciplinary team (MDT) consisting of an oncologist, gynecologist,gastroenterologist, and radiologist, decided to perform laparoscopic exploration, but no obvious abnormality was found. In 2015 and 2016, the patient experienced intermittent abdominal pain and a large amount of ascites.Symptoms usually occurred without apparent cause. The nonspecific treatment included ascites drainage and symptomatic and supportive treatment, since the cause of the ascites had not been identified. In November 2016,the patient presented with the same symptoms, and underwent exploratory laparotomy for the second time.The bladder wall was found to be extremely thin, and a very tiny fissure was found on the wall. After repair of the ruptured bladder, the patient recovered, and has not experienced ascites since then.

Discussion

Our case highlights three interconnected phenomena:radiation cystitis, recurrent ascites, and spontaneous bladder rupture.

Spontaneous intraperitoneal bladder rupture is a rare cause of ascites, but when a patient presents with ascites and oliguria of unknown cause, especially with a history of radiation therapy to the pelvis, the possibility of spontaneous intraperitoneal bladder rupture should be considered in the differential diagnosis. To avoid the risk of death, prompt and precise diagnosis are mandatory.After proper surgical treatment, patients must be educated regarding bladder emptying, to prevent overdistension.We hope our case report heightens awareness of spontaneous intraperitoneal bladder rupture, so that these patients can be diagnosed promptly and treated appropriately to obtain the best possible outcomes.

2.3 疗效判定 治疗前，两组患者视力水平无显著性差异，经过3周临床连续性静脉注射前列地尔治疗后，治疗组有效率显著高于对照组(P＜0.05）(见表 3）。

载氧体量过少不利于生物质热解和气化，需外加热量为燃料反应器提供能量；当载氧体过量时，生物质将完全氧化，碳转化为CO2，氢转化为H2O，这对高H2/CO比合成气制备极为不利。因此，需合理选择载氧体量[29]。本研究中生物质化学式可简化为CH1.70N0.72O0.76，如生物质在载氧体Fe2O3上气化，并分别转化为CO、H2和FeO，则理论Fe2O3/C比为0.244；如生物质完全氧化为CO2和H2O，则Fe2O3/C比为2.0。因此考察了Fe2O3/C比在0 ～ 2.4范围内的影响，TFR设为825℃，无水蒸气添加。为强化对CO2的捕集，将CaO/C比设定为1.0，结果如图4所示。

基于2016年该病种次均费用、次均耗材费、直接可控成本占比等大幅上升，医院数据中心分析发现，该病种直接可控成本中高值耗材同比增长77.17%，远高于药品、试剂、设备等只有个位数的增长率。进一步深入分析，原来一款单价为2.8万元的椎体扩张球囊导管在2016年的使用量比2015年增加88个，其大量使用直接导致该病种各项费用的上升。

Conflicts of interest

This case shows that when a cervical cancer patient experiences ascites after radiotherapy, we should think of the possibility of rupture of the bladder [28]. For patients with recurrent ascites, cytology should be performed and urea and creatinine levels in the ascites fluid should be tested. Spontaneous intraperitoneal bladder rupture should always be considered in the differential diagnosis of patients who present with abdominal distension, oliguria,ascites, and increased levels of urea and creatinine in serum and/or peritoneal fluid aspirate [29]. The prognosis is good when diagnosis and treatment are prompt.

Spontaneous intraperitoneal bladder rupture is rare in cervical cancer patients who undergo radiation therapy,but can be life-threatening [8]. The most common causes of bladder rupture are blunt trauma, chronic bladder disease, or bladder outflow obstruction; other possible reasons include surgical procedures and irradiation to the pelvis [9–12]. Accurate diagnosis of spontaneous intraperitoneal bladder rupture is difficult before surgery and is often delayed in the absence of history of trauma or preexisting chronic bladder disease. Symptoms and signs of spontaneous intraperitoneal bladder rupture can be nonspecific and misleading [13–15]. Patients usually present with an acute abdomen, abdominal distension,oliguria/dysuria, and hematuria [12–13]. Symptoms may be insidious in onset, presenting only as ascites or acute renal failure[14, 16–18]. Ultrasonography and CT may miss most intraperitoneal bladder ruptures. CT cystography may help to diagnose bladder rupture, but it is difficult to identify tiny fissures [19]. The gold standard for the diagnosis of intraperitoneal bladder rupture is exploratory laparotomy. However, this operation is invasive for a patient without serious complications. Measuring urea and creatinine levels in ascites and serum is a simple and noninvasive diagnostic test, and an ascites-to-serum creatinine ratio ＞ 1.0 usually supports the diagnosis of spontaneous intraperitoneal bladder rupture [20–21]. The conservative treatment of spontaneous intraperitoneal bladder rupture consists of antibiotics and percutaneous peritoneal drainage for patients with a history of pelvic irradiation [22–23]. For recurrent cases, or patients with severe symptoms after ineffective conservative therapy,immediate surgery, with repair of the urinary bladder in 2 layers, is strongly recommended [24–25]. After repair of the bladder, prolonged drainage is required, and patients must be educated to avoid bladder overdistension, because of increased risk of reperforation [26].

Seven years after surgery and radiotherapy, our patient began to experience intermittent abdominal pain and a large amount of ascites. During the next 6 years, although she had undergone cystoscopy, PET/CT, and even laparotomy, there were no positive findings to explain all the symptoms. We did not perform a peritoneal fluid analysis of urea and creatinine levels because we did not initially consider the possibility of spontaneous intraperitoneal bladder rupture. It was not until the second exploratory laparotomy that the bladder wall was found to be significantly thin, with a tiny localized fissure. After the bladder was repaired in 2 layers, the patient recovered and has not experienced abdominal pain and ascites again.

Conclusion

Radiation cystitis is a common complication of cervical cancer after pelvic radiotherapy [1]. According to the time of occurrence and severity, radiation cystitis may be divided into three types: acute radiation cystitis,chronic radiation cystitis, and radiation-induced bladder fistula [2–3]. Acute radiation cystitis occurs during or soon after radiation treatment, usually within 6 months. It is mostly characterized by increased urinary frequency and urgency, with gross or microscopic hematuria [4], and is usually self-limited and generally managed conservatively[5]. Chronic radiation cystitis accounts for 80% of cases of radiation cystitis [6], and can develop 6 months to 20 years after radiation therapy. The main presenting symptom is hematuria, which may vary from mild to severe, lifethreatening hemorrhage [5, 7]. Radiation-induced bladder fistula is often associated with the radiation dose, and can occur in some severe cases.

数学抽象能让学生将复杂问题简单化，更好地去理解和学习知识内容.养成学生的逻辑推理能力，学生不但掌握其形式，更要掌握其思想方式，并且更有助于学生理解数学知识间存在的联系，从而构建起知识体系.所以，学生在实际学习中能关联所学习到的知识内容，深化记忆，切实发挥已知条件的作用，将复杂问题简单化，更容易进行解决.

This case is rare. The patient was admitted to the hospital repeatedly over 6 years with recurrent ascites,but no peritonitis or acute renal failure. This patient was a dancer, and often delayed bladder emptying due to occupational reasons. Overdistension is hazardous for a bladder that has undergone radiation therapy and will aggravate the occurrence of all complications. Since the rupture site was extremely small and pelvic adhesions developed after surgery and radiotherapy, the fissure was not detected on cystoscopy and initial laparoscopic exploration.

As described by Addar et al in 1996 [27], treatment of spontaneous bladder rupture must be individualized but should be based upon 6 principles as follows: (1)the defect must be identified and confirmed; (2) the peritoneal cavity should be thoroughly lavaged; (3) the defect should be widely excised; (4) reconstitution of the intact bladder should be performed using tissue with an intact blood supply, especially in radiated areas;(5) adequate healing with prolonged bladder drainage and prophylactic antibiotics should be promoted; and(6) primary or recurrent malignant disease should be excluded.

The authors indicated no potential conflicts of interest.

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