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4. Ruiz M, Hevia V, Fabuel JJ, Fernández AA, Gómez V, Burgos FJ. Kidney autotransplantation: long-term outcomes and complications. Experience in a tertiary hospital and literature
review. Int Urol Nephrol. 2017;49(11):1929–35. https://doi.org/10.1007/s11255- 017- 1680- 1.
Epub 2017 Aug 21
5. Voelzke B. Overview of traumatic and iatrogenic ureteral injury. https://ykhoa.org/d/topic.
htm?path=overview- of- traumatic- and- iatrogenic- ureteral- injury.
6. Tonyali S, Haberal HB, Bilen CY, Aki FT. Feasibility of Boari bladder ap procedure in
patients with heterotrophic renal transplant. Exp Clin Transplant. 2019;17(5):599–603. https://
doi.org/10.6002/ect.2018.0395. Epub 2019 May 2
7. Pham NH, Visser WR, Phan-Huu QV, Hampton LJ.Renal autotransplantation for the treatment
of complete ureteral loss: a case report. Res Rep Urol. 2021;13:733–7. https://doi.org/10.2147/
RRU.S328832.
8. Jabbour ME, Desgrandchamps F, Angelescu E, Teillac P, Le Duc A.Percutaneous implantation
of subcutaneous prosthetic ureters: long-term outcome. J Endourol. 2001;15(6):611–4. https://
doi.org/10.1089/089277901750426391.
9. Andonian S, Zorn KC, Paraskevas S, Anidjar M. Articial ureters in renal transplantation.
Urology. 2005;66(5):1109. https://doi.org/10.1016/j.urology.2005.05.012.
10. Lloyd SN, Tirukonda P, Biyani CS, Wah TM, Irving HC.The detour extra-anatomic stent—a
permanent solution for benign and malignant ureteric obstruction? Eur Urol. 2007;52(1):193–8.
https://doi.org/10.1016/j.eururo.2006.11.008. Epub 2006 Nov 13
11. Gild P, Kluth LA, Vetterlein MW, Engel O, Chun FKH, Fisch M.Adult iatrogenic ureteral
injury and stricture-incidence and treatment strategies. Asian J Urol. 2018;5(2):101–6. https://
doi.org/10.1016/j.ajur.2018.02.003.
18 Renal Autotransplantation, Evolving Techniques, andTissue Engineering
Part III
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Urinary Bladder Injury
The bladder is not just a reservoir. It is also a guardian devoted to the protection of the kidneys. With time it has become even smarter, preserving
your dignity, and relieving your desires. Furthermore, out of altruism, it
spends less time crying from its own injury but might mourn all its life a
spinal cord or other neurological trauma.
Introduction toUrinary Bladder Trauma
Features of a well-functioning bladder are known, namely a good storage capacity
under low pressure and complete emptying upon voluntary commands without
reux. However, there seems to be an unknown critical advantage granted to mankind by the bladder: we probably owe our survival to the urinary bladder! Indeed, a
recent simulation model has shown that the increased storage capacity of the urinary
bladder has a linear correlation with the species’ separation from prey to predator
and overall survival since primitive species do not have such capacity, leaving continuous urine scents and increasing the trail detection rate by their predators [1].
The bladder is relatively protected by the pelvic wall. Therefore, its injury is rare.
And when this occurs in blunt trauma (such as in MVA), it is generally associated
with a pelvic shield fracture. The bladder may also be injured by penetrating agents
during an assault but is more frequently subjected to injury during surgeries, especially colorectal and gyneco-obstetrical procedures [2].
When suspected, bladder injuries are easy to conrm and also generally easy to
repair, and their healing is excellent. However, in some instances, they can be missed
due to diverted attention toward more appalling associated injuries that represent an
immediate risk to the patient’s life. The delay in the diagnosis and repair of a bladder injury is detrimental to the patient’s health and frequently gives rise to lifethreatening complications. This delay, already blameworthy in the context of
external trauma becomes a tragedy if the injury has occurred during a surgical act.
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From there, the surgeons come down from their pedestals and the lawyers take
the stage.
Finally, it should be borne in mind that iatrogenic injuries also prolong patients’
hospital stays and increase medical costs which can reach exorbitant amounts. It is
worth remembering that the total economic impact of medical errors, in general, has
been estimated to reach 1 trillion per year in the USA and one should better be
inspired not to play any role in it [3]. Praemonitus praemunitus (forewarned is
forearmed).
Urinary Bladder Injury
References
1. McCarthy M, McCarthy L. The evolution of the urinary bladder as a storage
organ: scent trails and selective pressure of the rst land animals in a computational simulation. SN Appl Sci. 2019;1:1727. https://doi.org/10.1007/
s42452- 019- 1692- 9.
2. Cohen AJ, Packiam VT, Nottingham CU, Pariser JJ, Faris SF, Bales GT.Iatrogenic
bladder injury: national analysis of 30-day outcomes. Urology. 2016;97:250–6.
https://doi.org/10.1016/j.urology.2016.05.002. Epub 2016 May 12.
3. Andel C, Davidow S, Hollander M, Moreno D.The economics of health care
quality and medical errors. J Health Care Finance. 2012;39:39–50.
Anatomy oftheUrinary Bladder
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19.1 Embryology
The bladder mostly derives from the mesoderm. The partition of the cloaca by the
urorectal septum takes place between the 4th and 7th weeks. Producing the primi-
tive urogenital sinus ventrally and the anorectal canal dorsally. The primitive uro-
genital sinus undergoes further division into a cranial vesical part that is continuous
with the allantois, a middle pelvic part, and a caudal phallic part. The bladder
mainly arises from the vesical part and the trigone develops from the caudal ends
of the mesonephric ducts which connect to the posterior bladder wall. The middle
pelvic part of the primitive urogenital sinus will give rise to the bladder neck, the
male prostatic urethra, and the entire female urethra. The urachus develops
from the allantois’ anterior portion [1–4] (Fig.19.1).
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_19
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19 Anatomy oftheUrinary Bladder
Fig. 19.1 Diagram depicting the sequential division of the cloaca into the urogenital sinus and the
rectum, as well as the development of the urinary bladder and urethra. The association between the
developing kidneys and gonads, as well as their relationships to the cloaca, urogenital sinus, and
bladder are shown. Panels (a, c, e, g, h) are lateral views. Panels (b, d, f) are dorsal views. (From
Kassab GH etal. [4], with permission from Springer)
19.3 Topography
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19.2 General Aspects
The urinary bladder is an extraperitoneal hollow viscus, having a tetrahedral shape
while empty, and becoming globular on repletion. In adults, it occupies the true or
lesser pelvis when empty, and with lling, it develops toward the greater pelvis and
may even reach the lower abdominal cavity. However, in neonates and infants, it lies
in the lower abdomen even when empty because the pelvic cavity is relatively small
and shallow at these ages. It is estimated that the pelvis acquires sufcient volume
and depth to accommodate the bladder only by the age of 7–8years and that this
viscus becomes a true intrapelvic organ on emptiness only at puberty [5].
The bladder can be divided into two components on each side of a horizontal line
passing at the level of the ureteral orices: a body lying above this line and a base
formed by the trigone and bladder neck. The body contains fascicles of myobrils in random directions. The base forms the bladder outlet in addition to the urethra and the striated urethral sphincter or rhabdosphincter.
The wall of the bladder base is formed by the following layers from insideoutside: a supercial mucosal coat, a submucosa, a muscle coat that is continuous
with the detrusor of the bladder body, the serosa in some areas or the adventitia in
others, and the perivesical fat. The mucosa is made of transitional epithelium and
a basement membrane. The submucosal coat is an areolar connective tissue also
referred to as the lamina propria. The muscular coat is also referred to as muscu-
laris propria and is made of three layers: an inner longitudinal, a middle circular,
and an outer longitudinal. The serosa is just a visceral reection of the perito-
neum. Therefore, it covers only the bladder dome (superior surface and the upper
lateral surfaces). The adventitia is a connective tissue encountered on the remaining walls not covered by the peritoneal serosa. The perivesical fat surrounds either
the serosa or the adventitia.
Contrary to men, an anatomic smooth-muscle sphincter at the bladder neck
is not obvious in women. Anyway, in either gender, the function of the bladder
neck in the maintenance of continence is not clearly determined because this faculty
is preserved after the destruction or opening of the bladder neck [6].
19.3 Topography
The bladder is in relation to the following organs and structures [5, 7, 8] (Figs.19.2,
19.3 and 19.4):
– Superiorly: the pelvic peritoneum, covering the dome of the bladder and being
densely attached to its surface, and coils of the small intestine and the sig-
moid loop.
– Postero-superiorly: the anteverted body of the uterus in females.
– Anteriorly: the pubis, the median umbilical ligament (the obliterated remnant
of the urachus). Between the pubis and the bladder is the Retzius space which
extends laterally and contains loose perivesical fat and connective tissue. This
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19 Anatomy oftheUrinary Bladder
Ureter
External iliac artery and vein
Ovarian follicles
Uterine fundus
Inferior epigastric artery and vein
Parietal peritoneum
Linea alba
Median umbilical
ligament
Internal urethral
orifice
Corpus cavemosum
clitoris
Frenulum of clitoris
Labium minor
Labium majus
Sigmoid colon
Rectal ampulla
Recto-uterine pouch
Cervix
Rector-vaginal fascia
Ureteric orifice
External urthral orifice
Fig. 19.2 Sagittal view of female pelvic cavity showing relations of urinary bladder and relationship of the peritoneum to the bladder. (From Mahadevan V [5], with permission from Elsevier)
Internal urethral meatus
Sigmoid colon
Small intestine
Median umbilical ligament
Retropubic space
(of Retzius)
Linea alba
Pubic symphysis
Suspensory ligament of penis
Deep dorsal vein of penis
Dorsal vein of penis
Fig. 19.3 Sagittal view of male pelvic cavity showing relations of urinary bladder and the various
segments of the urethra. (From Mahadevan V [5], with permission from Elsevier)
Urethral orifice
Rectovesical pouch
Rectal ampulla
Denonvilliers fascia
Prostate
Visceral pelvic fascia
Anococygeal ligament
External anal sphinoter
Internal and sphinoter
Deep transverse perineal muscle
Perineal membrane
Membranous urethra
Bulb of penis
19.3 Topography
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Median umbilcal ligament
(urachus)
Bladder
Vas deferens
Obturator nerve,
artery, vein
Vas deferens
Obturator internus
Obturator externus
Rectovesical pouch
Levator ani
Ischium
Pudendal nerve, artery, vein
Crus of penis
Deep transverse perineal muscle
Medial umbilical ligament
(obliterated umbilical artery)
Lateral umbilical ligament
(inferior opvastric artery and vein)
Ampulla of vas deferens
Bulbourethral gland
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Ureter
Vas deferens
Seminal vesicle
Venous plexus
Ischio-anal fossa
Prostate
Crus of penis
Bulb of penis
Fig. 19.4 Coronal view of male pelvic cavity (viewed from behind) showing lateral and inferior
relations of urinary bladder, and relationship of peritoneum to the bladder. (From Mahadevan V
[5], with permission from Elsevier)
space is particularly important as it is one of the potential sites for urine or blood
collection in bladder trauma.
– Posteriorly: the rectum, the vasa deferentia, and the seminal vesicles in males;
the vagina and the cervix in females. It receives the ureters at its lateral angles.
– Infero-laterally: the levator ani and obturator internus muscles.
– Inferiorly: the prostate in males, and the pelvic fascia in females.
During cystoscopy, a transversal mucosal fold called the interureteric bar or
Mercier’s bar runs between the two ureteric orices which are located posteriorly
and separated by 3cm on emptiness or 5cm on repletion [5].
As suggested by its name, the trigone is a triangular area situated between the
ureteric and the urethral orices. Contrary to the mucosa of the bladder body, the
trigone has a smooth surface and is the least mobile part of the bladder, being
rmly xed to the upper surface of the prostate in males and to the anterior
vaginal wall in females. In chronic bladder outlet obstruction, characteristic tra-
beculations, sacculations, and even pseudodiverticula appear on the bladder body
due to muscle hypertrophy and mucosa herniation [5, 7].
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19 Anatomy oftheUrinary Bladder
19.4 Vascularization
The blood supply to the urinary bladder originates from the internal iliac arteries on
both sides. The superior and inferior vesical arteries derive from the anterior
division of the internal iliac artery and are the principal suppliers of blood to the
bladder. The territory supplied by the superior vesical artery includes the superior
and anterior aspects of the bladder, while the inferior vesical artery supplies the
inferior and posterior aspects of the bladder, including the bladder neck [5].
There is a controversy among anatomists since some authors state that the inferior artery as described above is specic to the male gender, being replaced in
females by branches of the vaginal or uterine artery. The contradictions are prob-
ably nourished by the multiple variations of the origin of the inferior vesical
artery in females, being either the internal iliac, the umbilical, the uterine, the
vaginal, or the obturator artery [9].
In addition to the two abovementioned main contributors, other vessels such as
the obturator and inferior gluteal arteries contribute to a minor degree to the blood
supply of the inferior part of the bladder. In females, other minor contributors
include the uterine and vaginal arteries, and in some individuals, the inferior vesical
artery may even mainly arise from the vaginal artery [5].
In fetuses and newborns, many other vessels supplying the bladder have been
described in addition to the superior and inferior vesical arteries: urachal artery,
middle vesical artery, vesico-deferential (males), and uterine (females) arteries [10].
The venous drainage of the urinary bladder starts with a rich, delicate valveless
plexus, circumferentially situated around the lower part of the bladder which is
called the perivesical venous plexus. In males, this plexus is continuous with the
extracapsular peri-prostatic venous plexus lying at the anterior and lateral aspects of
the prostate. In females, it is continuous with the plexus around the intra-pelvic
vagina and at the base of the broad ligament of the uterus. The perivesical venous
plexus coalesces and gives rise to larger veins that accompany the vesical arteries
and drain into the internal iliac veins bilaterally [5].
19.5 Innervation oftheBladder
The urinary bladder is supplied by three types of efferent nerve bers [2, 11, 12]
(Fig.19.5):
(a) Parasympathetic: Arising from the sacral roots S2–S4, these bers are con-
tained in the pelvic splanchnic nerves. They stimulate urination through detrusor muscle contraction.
(b) Sympathetic: Exiting from T12–L2, they are conveyed by the superior and infe-
rior hypogastric nerve. They are responsible for the relaxation of the detrusor muscle.
19.6 Congenital Malformations
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165
Inferior hypogastric
plexus
Muscle
Detrusor
External
Sphincter
Stretch receptor
Post-ganglionic
Sympathetic (efferent)
Bladder
Urethra
Visceral (afferent)
Sympathetic
(efferent)
Pre-ganglionic
Post-ganglionic
Pelvic
plexus
preganglionic
Parasympathetic (efferent)
Pudendal nerve
Somatic (afferent)
Somatic (efferemt)
Skin
IIioinguinal
lliohypogastric nerves
T12
L1
Genitofemoral nerve
L2
L3
L4
L5
S1
S2
S3
S4
S5
Somatic afferent
Fig. 19.5 Illustration of three separate contributions to bladder innervation, thoracolumbar, sacral
visceral, and sacral somatic, each of which contains both afferent and efferent bers. (From Dellon
AL and Herati AS [12], with permission from Georg Thieme Verlag KG)
(c) Somatic: Originating from the Onuf’s nucleus1 at S2–S4, they travel through
pudendal nerves up to the external urethral sphincter, and control the voluntary
micturition.
There are also sensory or afferent nerve bers that convey messages related to
stretch and pain (bladder distension) from mechanoreceptors in the bladder wall to
the central nervous system (up to the brain cortex). These bers travel through the
hypogastric and pelvic splanchnic nerves.
19.6 Congenital Malformations [4, 13, 14]
– Bladder exstrophy: 0.002% births. Constantly associated with epispadias.
– Megacystis: neurodysplastic disease, due to abnormal or decient innervation,
leading to a bladder dilatation over 7cm in diameter in the fetus and the new-
born. Incidence: 0.06–0.30% in the rst trimester with male-to-female ratio of 8:1.
1
The Onuf’s nucleus is named after the American Neurologist Bronislaw Onuf Onufrowicz
(1863–1928), who rst discovered it in NewYork in 1899.
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