a 79-year - old male patient was scheduled for holmium laser enucleation and morcellation of the prostate to treat bph . preoperative electrocardiography showed a normal sinus rhythm , and echocardiography showed normal left ventricular function . the volume of the prostate gland , measured preoperatively using endorectal ultrasonography , was 98 ml , including 75 ml for the transitional zone of the prostate . upon arrival at the operating room , his systolic / diastolic blood pressure was 120/90 mmhg , heart rate was 70 bpm , and peripheral oxygen saturation was 99% . routine monitoring was conducted such as electrocardiography , peripheral oxygen saturation , non - invasive blood pressure , end - tidal carbon dioxide , and body temperature . anesthesia was induced with 250 mg of sodium thiopental , 50 mg of rocuronium , and sevoflurane , and was maintained with sevoflurane ( 23 vol% ) , n2o ( 1 l / min ) , and oxygen ( 1 l / min ) , with supplemental rocuronium . continuous arterial blood pressure was monitored via the left radial artery using a 20 g catheter . initial arterial blood gas analysis in 50% oxygen showed values of ph 7.42 , arterial partial pressure of carbon dioxide ( paco2 ) 44 mmhg , arterial partial pressure of oxygen ( pao2 ) 245 mmhg , bicarbonate ( hco3 ) 28.5 meq / l , base excess 3.4 , na 141 meq / l , k 3.7 meq / l , and hematocrit 40% . following repeated massive bladder irrigation with saline , ~150 ml of blood clots were evacuated using an ellik evacuator and the bladder distension was relieved immediately . next , holmium laser enucleation and morcellation of the prostate was initiated using an isotonic saline solution for bladder irrigation . at this moment , his vital signs showed a systolic / diastolic blood pressure of approximately 130/80 mmhg , heart rate of 85 bpm , and oxygen saturation at 100% . one hour after the beginning of the procedure , the peak airway pressure increased to 23 cmh2o . on auscultation , no significant hemodynamic changes developed during the surgical procedure , and estimated blood loss was less than 100 ml . after completion of the procedure , 2 mg of neostigmine and 0.4 mg of glycopyrrolate for neuromuscular blockade reversal were administered intravenously . the patient was extubated after recovery from neuromuscular blockade , which was confirmed by hand grip and head lift . immediately after tracheal extubation , he experienced severe respiratory difficulty with low spo2 ( ~90% ) and complained of severe abdominal pain . physical examination revealed a tense and distended abdomen . the patient 's systolic / diastolic blood pressure was 110/85 mmhg with heart rate of 95 bpm . after applying a 100% o2 mask , arterial blood gas analysis indicated values of ph 7.15 , paco2 56 mmhg , pao2 72 mmhg , hco3 20 meq / l , base excess -9.7 , na 144 meq / l , k 3.8 meq / l , and hematocrit 38% . he was re - intubated using 5 mg of midazolam and 30 mg of rocuronium , and his peak airway pressure was 25 cmh2o at this time . chest x - ray showed acute pulmonary venous congestion and subsegmental atelectasis in both lower lobes . 1 ) . an urgent computed tomography ( ct ) scan of the abdomen and pelvis was performed without tracheal extubation . the ct scan showed massive fluid collection in the abdominal pelvic cavity suggesting bladder wall injury but with no demonstrable discontinuity of the bladder wall ( fig . the patient was transferred to the intensive care unit ( icu ) and was closely monitored . his systolic / diastolic blood pressure remained stable , around at 110/60 mmhg , with heart rate of 70 bpm . urinary output was maintained at 80100 ml / h after icu admission without renal impairment . laser enucleation and morcellation of the prostate has several advantages over standard transurethral resection of the prostate ( turp ) including no upper limit in size for prostate removal , less bleeding risk than turp , and short length of hospital stay . with many advantages , compared to other transurethral surgeries , significantly more tissue is extirpated , the surgical duration is longer , and the incidence of bladder injury is higher with enucleation and morcellation of the prostate . the pooled result of a large case series revealed that enucleation and morcellation of the prostate can result in several complications including bladder neck false passage , capsular perforation , ureteral orifice injury , and bladder mucosal morcellation injury . classically , bladder perforation has been classified into intraperitoneal or extraperitoneal perforation from a urological perspective . extraperitoneal perforation is more common than intraperitoneal perforation but is usually associated with a less severe clinical manifestation . it can be relieved by conservative treatment , without surgical repair . however , intraperitoneal perforation is more serious and may be complicated by systemic absorption of irrigating solution . intraperitoneal perforation may also result in a significant increase in intraabdominal fluid with a subsequent increase in abdominal pressure . the resulting abdominal compartment syndrome causes several problems , including deterioration of ventilation , renal dysfunction , and reduction of perfusion to the abdominal organs . thus , intraperitoneal perforation is usually resolved by surgical treatment . during laser enucleation and morcellation of the prostate , the enucleation procedure may thin or even perforate the prostatic capsule , leading to significant extraperitoneal accumulation of irrigation fluid . furthermore , the morcellation procedure may unintentionally involve the bladder mucosa or full - thickness bladder , eventually resulting in excessive bleeding , bladder perforation , intraperitoneal irrigant extravasation , or significant hemodynamic instability . thus , anesthesiologists should consider the possibilities of both intraperitoneal and extraperitoneal bladder perforation during laser enucleation and morcellation of the prostate . in our case , generalized massive abdominal distension corresponds more with intraperitoneal bladder perforation rather than extraperitoneal perforation . extraperitoneal bladder perforation is usually accompanied by tenderness and swelling of suprapubic and perineal area . interestingly , cystogram and ct scan of the abdomen and pelvis did not reveal any contrast leakage or bladder wall discontinuity in this patient , even though they are the diagnostic standard of bladder rupture . it could be explained by well aligned injury of the bladder wall or blocked wound orifice by hematoma . in addition , a tiny bladder wall defect , which could not be detected by the ct scan , might have occurred during the surgical procedure . fluid leakage via the tearing site could have sustained during the operation and paradoxically , increased intraabdominal pressure by fluid accumulation may have prohibited contrast dye leakage during cystogram . although the patient exhibited massive fluid collection on the abdominal pelvic ct scan , he had a stable hemodynamic status and the abdominal distension was relieved by following ultrasonography - guided percutaneous drainage . this case is worthy of note in that the radiologic images did not reveal definite bladder wall discontinuity and his clinical course was relatively less severe . we regret not performing a careful abdominal physical examination during the surgery and upon tracheal extubation . although ct scan showed negative finding for definite bladder wall perforation , massive fluid collection in the abdominal pelvic cavity was a sign of bladder wall injury , which underscores the importance of monitoring physical signs of patients . differential diagnosis of increased airway pressure must have taken place , by confirming the depth of endotracheal tube to rule out endobronchial intubation and suctioning the endotracheal tube . in addition , we regret not having performed additional laboratory tests such as arterial blood gas analysis , radiologic workup such as chest x - ray , and direct communication with the surgeon during the procedure . these neglected managements would have been helpful to avoid an unnecessary re - intubation and difficult postoperative care in this patient . the current report describes severe postoperative dyspnea caused by neglected massive intraperitoneal fluid collection during laser enucleation and morcellation of the prostate . although hemodynamic and respiratory parameters are monitored generally stable during the laser surgery of the prostate , anesthesiologists should always be aware of negligible changes of patient status which might be associated with infrequent surgical complications . early detection and meticulous physical examination are always requisite to prevent progression to severe complications .
laser enucleation and morcellation of the prostate is an increasingly used surgical management of benign prostatic hyperplasia . 
 however , it can cause several complications including capsular perforation , ureteral orifice injury , and bladder mucosal morcellation injury . 
 herein , we report a case of severe postoperative dyspnea caused by neglected massive intraperitoneal fluid collection during laser surgery of the prostate . 
 the patient experienced massive abdominal distension and severe respiratory difficulty after the procedure . 
 although immediate postoperative cystogram showed no leakage of contrast dye , the computed tomography scan of the abdomen and pelvis showed massive fluid collection in the abdominal pelvic cavity suggesting bladder wall injury . 
 after percutaneous drainage of intraperitoneal fluid , abdominal distention and dyspnea were relieved .