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|Year : 1982 | Volume
| Issue : 3 | Page : 176-78
Bilateral internal iliac artery ligation for massive recurrent haemorrhage following urethral dilatation--(a case report).
Shah LK, Rao MS, Bapna BC, Vaidyanathan SS, Kapoor VK, Joshi VK, Sachdev NK
|How to cite this article:|
Shah L K, Rao M S, Bapna B C, Vaidyanathan S S, Kapoor V K, Joshi V K, Sachdev N K. Bilateral internal iliac artery ligation for massive recurrent haemorrhage following urethral dilatation--(a case report). J Postgrad Med 1982;28:176
|How to cite this URL:|
Shah L K, Rao M S, Bapna B C, Vaidyanathan S S, Kapoor V K, Joshi V K, Sachdev N K. Bilateral internal iliac artery ligation for massive recurrent haemorrhage following urethral dilatation--(a case report). J Postgrad Med [serial online] 1982 [cited 2020 Jan 26];28:176. Available from: http://www.jpgmonline.com/text.asp?1982/28/3/176/5566
A 23 year old male sustained fracture of pubic rami and bladder injury 2 months back due to fall from a running tractor-trolley. Bladder rent was repaired and suprapubic Malecot's and a urethral Foley's catheter drainage was provided. Both catheters were removed, in a period of 30 days. Suprapubic wound had healed and the patient was voiding when he was discharged. However, he complained of gradual thinning of the urinary stream. The first urethral dilatation was uneventful. During the second dilatation, profuse bleeding resulted which could not be controlled by conservative management. Emergency abdominal exploration was done. At operation, large amount of clots were removed from the bladder. No active bleeding point was seen. The bladder was closed with drainage provided by a suprapubic Malecot's and urethral Foley's catheter. Vital signs stabilised and urine became temporarily clear. The patient had recurrent episodes of massive bleeding on the second, fourth and fifth day after urethral dilatation. These were managed by blood transfusions and saline irrigation of bladder through these catheters. He received nine unit; of blood transfusion in 5 days. At this juncture, he was referred to the P.G.I. Urology Emergency Service.
At the time of admission, the patient was in haemorrhagic shock. Catheters were draining sanguinous effluent with bladder irrigation on. There was, in addition, profuse pericatheter bleeding. Suprapubic wound was infected and gaping with urine leak and bleeding. A soft abdomen with bowel sounds and without any organomegaly was observed. His haemoglobin was 7 g%; PCV 19%; blood urea: 21 mg% and serum creatinine: 1.7 mg%. Coagulogram was normal. The patient was administered blood transfusions. Monitoring of vital signs, analgesics, antibiotics, catheter and wound care, and continuous cross-irrigation of the bladder through catheters constituted his initial treatment. Vital signs stabilised and the urine became spontaneously clear. Revision cystostomy was planned. However, within 3 days of admission he developed two more episodes of massive haemorrhage. At the second bleed, he went pale with tachycardia of 190 per minute and fall of blood pressure to 80/50 mm Hg. In view of his precarious status requiring immediate intervention, angiographic studies were not done. The patient had received 19 units of blood transfusion thus far. Emergency bilateral internal iliac artery ligation was performed. The bladder was full of clots. Postoperative period was uneventful. Retrograde urethrogram showed normal urethra and a big false passage in the prostate [ Fig. 1] and[Fig. 2 ]. No recurrent bleeding occurred after the bilateral internal iliac artery ligation. Upon calibration three months later, the urethra accepted 22 Fr. catheter easily.
Urethral dilatation is the most commonly practised urological minor procedure. Eight hundred and sixty three urethral dilatations were performed during 1981 which formed 40.84% of the urological minor procedures in our hospital. Bleeding during urethral dilatation occurs due to creation of a false-passage, but it is usually controlled by conservative methods. In this case, bleeding was massive and recurrent as false passage was made in the prostate. Although profuse bleeding from urethral dilatation producing even clot retention is known, we were unable to find any previous report in the literature of bleeding being so massive and recurrent as to require bilateral internal iliac artery ligation for ultimate control.,  The other therapeutic alternative with less morbidity which is promising under these circumstances is pelvic angiography followed by arterial embolisation. This requires skilled radiologic techniques for tertiary vessel catheterisation, which are not yet available in many hospitals, where such cases present themselves as emergencies. So there is still a place for internal iliac artery ligation in such a situation even today.
Internal iliac artery ligation offers a safe, rapid and effective life saving method of control of pelvic haemorrhage. Various indications in urological, obstetrics and gynaecologic practice include spontaneous haemorrhage from advanced pelvic cancer, control of post-operative pelvic haemorrhage, intra-operative control of haemorrhage, and prophylactic ligation prior to extensive pelvic surgery.,  In urological practice, the commonest indication is the control of post-prostatectomy bleeding. Recurrent masive bleeding after prostatectomy could occur due to arteriovenous fistula, but as angiography was not done it was not possible to ascertain the presence or otherwise of prostatic arterio-venous fistula in this patient.
During the last 10 years, internal iliac artery ligation was performed by the Urology Service, P.G.I., Chandigarh, India in 9 cases, the indications being: intra-operative control of bleeding during prostatectomy (4 cases) ; control of postprostatectomy bleeding (3 cases); control of bleeding from bladder tumour (one case) ; and control of post urethral dilatation haemorrhage (present case).
With the advent of optical internal urethrotome, urethral dilatation may no longer be the commonest urological minor procedure. However, awareness of such a complication and its management would help the clinician to deal- with it effectively.
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