2026 FSA Podium and Poster Abstracts

Introduction: Urinary leaks during surgery, whether iatrogenic or incidental, can result in significant metabolic and laboratory derangements. These abnormalities initially may go unrecognized intraoperatively, leading to delayed diagnosis and increased postoperative morbidity. Understanding the spectrum of lab changes, from electrolyte disturbances to altered renal function, is critical in guiding intraoperative management and postoperative care. We present a case where undetected urinary leak intraoperatively led to delayed extubation and prolonged ICU stay in an 84-year-old male who underwent a robotic cystectomy with ureteroileal conduit. 

Case Description: Our patient had a medical history of prior myocardial infarction over one year ago, coronary artery bypass graft surgery over ten years ago, prior prostate surgery and radiation in 2010, and acute gross hematuria leading to blood loss anemia, secondary to hemorrhagic cystitis. Approximately two hours into the case, patient was screened with a point-of-care arterial blood gas (ABG) sample, which revealed a pH of 7.33 with base deficit of -5.5; no adjustments were made other than administering a unit of PRBC as hemoglobin was found to be 8.7 and further blood loss was expected. Follow up ABGs were obtained hourly and showed a gradual decline of the pH from 7.29 to 7.24 to 7.15 with base deficit increasing from -8.5 to -10.6. PCO2 ranged from 36-38 during these same samples. Potassium levels rose from 3.3 to 4.3, though sodium levels remained stable at 140. Patient's hemodynamic instability intraoperatively was treated with a phenylephrine drip, two units of PRBC, 5% Albumin, calcium gluconate, and sodium bicarbonate. Due to worsening metabolic acidosis despite stable respiratory setting on ventilator, decision was made to bring patient to the ICU for further work up and medical optimization prior to extubation.

Discussion: Intraoperatively, common causes of urinary leaks include bladder injury from gynecological, colorectal, and/or urologic surgeries, ureteral injury from pelvic or vascular procedures, and renal pelvis trauma due to partial nephrectomies and percutaneous procedure. Upon bladder rupture or injury, urine accumulates within the peritoneal cavity forming a urinoma. Then, urine is absorbed back into the bloodstream through the peritoneal cavity by a process called reverse autolysis. Toxic metabolites get reabsorbed into the bloodstream causing azotemia, metabolic acidosis, and volume overload. From an anesthetic perspective, signs of metabolic acidosis and hyperkalemia might appear as increased respiratory drive and elevated T waves on electrocardiogram, respectively. In our case, point of care electrolyte values that were obtained intraoperatively did not provide enough support for an immediate diagnosis of a urinary leak. Urinary leaks during surgery and postoperatively pose a significant threat to patient safety due to their potential to cause profound metabolic and laboratory abnormalities. These derangements, such as hyperkalemia, hyponatremia, and elevated serum renal markers may mimic other pathologies if not properly identified. As demonstrated by previous case reports, timely diagnosis through advanced imaging and awareness of high clinical suspicion is crucial. More literature and case reports of intra operative urinary leaks will help provide better perioperative preparedness and to ultimately reduce post operative morbidity.