We present the case of a 43-year-old male, with no known drug allergies or medical or surgical history of interest, with an abdominal gunshot wound (pistol with 9 mm parabellum projectile). The patient was admitted to the emergency department in haemodynamically stable condition, with severe abdominal pain. Physical examination revealed the bullet entry wound in the left iliac fossa and exit through the left buttock, with abdominal pain and signs of peritoneal irritation mainly in the hypogastrium and left iliac fossa. No involvement of the external genitalia or urethrorrhagia was observed. After urethro-vesical catheterisation, intense macroscopic haematuria was observed. The only notable finding in the admission analysis was anaemia (Hb: 9.2 g/dl), with the rest of the biochemical parameters, blood count and coagulation being normal.
Given the patient's haemodynamic stability, it was decided to complete the study by means of imaging tests prior to surgery. Given the theoretical trajectory of the projectile (once the entry and exit orifices were known), with the suspicion of bladder injury by firearm and given the possible involvement of other organs, it was decided to perform abdominal-pelvic CT and CT-cystography (by gravity bladder repletion with 300 cc of diluted contrast material).
- Abdominal-pelvic CT and cystographic CT: extraperitoneal, left lateral-postero-lateral bladder rupture, with extravasation of contrast after filling. Minimal dilatation of the left collecting system. Entry wound in the left iliac fossa with areas of haemorrhage in the mesosigm, left lateral vesical side, left seminal vesicle and left perirectal and ischiorectal areas.

With these findings, exploratory laparotomy was decided. With the patient in the supine decubitus position, a supra-infraumbilical midline laparotomy was performed. Initially, a small perforation in the mesosigm was repaired without affecting the sigmoid loop and a minimal lesion was repaired at the level of the left primitive iliac vein, subsequently verifying the indemnity of the rest of the iliac arterial and venous axis.
An anterior longitudinal median cystotomy was then performed and a double bladder perforation was observed, corresponding to the entrance (4 cm in the bottom of the bladder) and exit (1-2 cm, in the left retromeatic region) of the projectile. After exploring the indemnity of the left distal ureter with a 5F ureteral catheter, it was found that the intramural portion was completely disinserted and that the projectile had also severed the left vas deferens. It was decided to suture the double bladder perforation in two planes, after debridement of the devitalised edges, and to perform ureteral reimplantation with a transvesical technique and double J catheter (26 cm/6 F) in the posterior wall, after distal ureteral release and section of the damaged end. After closure, also in a double plane, of the anterior longitudinal cystotomy, a urethro-vesical catheter and double closed suction drainage were left: one intraperitoneal and the other extraperitoneal, separated from the bladder suture line.
Intravenous broad-spectrum antibiotherapy was prescribed: Ceftriaxone 2 grams every 24 hours and Metronidazole 1.5 grams every 24 hours, and the initial postoperative period was favourable. On the 5th day the patient presented deterioration of the general condition, hypotension, fever and leukocytosis with marked left deviation (31% of the keys). Empirical antibiotic therapy was replaced, pending the results of the blood cultures, with Imipenem 500 milligrams every 6 hours intravenously, and the patient improved significantly both clinically and analytically. In the blood cultures, an E. coli producing extended-spectrum b-lactamase, sensitive to Imipenem, grew. A new abdominal-pelvic CT scan was performed, which only showed post-surgical changes, ruling out the existence of liquid collections that could have caused the septic condition.
The rest of the postoperative period was uneventful, with initial removal of both drains and, on the 10th day, the urethro-vesical catheter. Finally, the patient was discharged after completing 10 days of intravenous antibiotherapy. It was replaced by Ciprofloxacin 250 milligrams every 12 hours orally, according to the previous antibiogram, until the JJ catheter was removed.
One month after the operation, the patient returned to our department for urethro-cystoscopy and removal of the JJ catheter. It was observed that the double bladder wound was completely healed, with the suture of the mucosal plane almost completely reabsorbed. The JJ catheter that was tutoring the ureteroneocystostomy is removed endoscopically without any problems. Currently, three months after the operation, the patient is urologically asymptomatic.