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Fig. 19.6 (a) CT scan in an 18-month-old girl with a history of a cloacal exstrophy variant with
an imperforate anus. There is a sagittal separation traversing the bladder (arrows). Note the wide
pubic symphyseal diastasis suggesting that this case would accurately be described as a covered
duplicate exstrophy. (b) VCUG obtained from the same patient after catheterizing both urethras
demonstrating two noncommunicating bladders in side-to-side orientation. (From Wise L and
Wyers M [16], with permission from Springer Nature)
19 Anatomy oftheUrinary Bladder
– Congenital bladder diverticulitis.
– Vesicourachal diverticulum.
– Prune belly syndrome: Also known as Eagle-Barrett syndrome. Occurs in
0.004% of live births. This syndrome describes a massively distended bladder
with incomplete emptying, associated with thin overlying abdominal wall mus-
cles. Nearly always occurring in males, in association with undescended testes.
– Urofacial syndrome: Also called Ochoa syndrome as it was rst described by
Bernardo Ochoa, a Colombian Physician [15]. This extremely rare abnormality
consists of detrusor contractions against an incompletely opened bladder outow
with a characteristic grimace when smiling or laughing, that rather resem-
bles crying.
– Duplicated bladder: Complete bladder duplication is extremely rare with
approximately 70 cases reported in the literature. Its frequency is roughly equal
in both genders. It may be associated with other malformations such as cloacal
exstrophy with an imperforate anus as well as duplication of other pelvic viscera
(vagina, uterus, and urethra) [16] (Fig.19.6a, b).
– Bladder agenesis: Fewer than 70 cases reported in the literature.
– Megacystis-microcolon-intestinal hypoperistalsis syndrome.
References
1. Ntoulia A, Papadopoulou F, Benz-Bohm G.Urinary tract embryology, anatomy, and anatomical variants. In: Riccabona M, editor. Pediatric urogenital radiology. Cham: Springer; 2018.
https://doi.org/10.1007/978- 3- 319- 39202- 8_7.
2. Shermadou ES, Rahman S, Leslie SW.Anatomy, abdomen and pelvis, bladder. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2022.
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3. Liaw A, etal. Development of the human bladder and ureterovesical junction. Differentiation.
2018;103:66–73.
4. Kassab GH, etal. Urinary tract. In: Paltiel HJ, Lee EY, editors. Pediatric ultrasound. Cham:
Springer; 2021. https://doi.org/10.1007/978- 3- 030- 56802- 3_17.
5. Mahadevan V. Anatomy of the lower urinary tract. Surgery (Oxford). 2016;34(7):318–25.
https://doi.org/10.1016/j.mpsur.2016.04.001.
6. de Groat WC, Yoshimura N.Anatomy and physiology of the lower urinary tract. Handb Clin
Neurol. 2015;130:61–108. https://doi.org/10.1016/B978- 0- 444- 63247- 0.00005- 5.
7. Ellis H. Anatomy of the urinary bladder, prostate, and male urethra. Surgery (Oxford).
2005;23(3):97–8. https://doi.org/10.1383/surg.23.3.97.63118.
8. Hickling DR, Sun TT, Wu XR.Anatomy and physiology of the urinary tract: relation to host
defense and microbial infection. Microbiol Spectr. 2015;3(4):2012. https://doi.org/10.1128/
microbiolspec.UTI- 0016- 2012. PMID: 26350322; PMCID: PMC4566164
9. de Treigny OM, Roumiguie M, Deudon R, de Bonnecaze G, Carfagna L, Chaynes P, Rimailho
J, Chantalat E.Anatomical study of the inferior vesical artery: is it specic to the male sex?
Surg Radiol Anat. 2017;39(9):961–5. https://doi.org/10.1007/s00276- 017- 1828- 9. Epub
2017 Feb 22
10. Shehata R.The arterial supply of the urinary bladder. Acta Anat (Basel). 1976;96(1):128–34.
https://doi.org/10.1159/000144666.
11. Yoshimura N, Chancellor MB.Neurophysiology of lower urinary tract function and dysfunction. Rev Urol. 2003;5(Suppl 8):S3–S10. PMID: 16985987; PMCID: PMC1502389
12. Dellon AL, Herati AS.Review of bladder pain and referred T12–L2 input as one etiology for
interstitial cystitis. J Reconstr Microsurg Open. 2019;4:e58–63.
13. Woolf AS, Lopes FM, Ranjzad P, Roberts NA. Congenital disorders of the human urinary
tract: recent insights from genetic and molecular studies. Front Pediatr. 2019;7:136. https://
doi.org/10.3389/fped.2019.00136. PMID: 31032239; PMCID: PMC6470263
14. Sandulescu SM, Vicol RM, Serban A, Carp AV, Cristian V. Congenital anomalies of urinary
tract and anomalies of fetal genitalia. In: Congenital anomalies—from the embryo to the neonate. IntechOpen; 2018. https://doi.org/10.5772/intechopen.73641.
15. Ochoa B, Gorlin RJ.Urofacial (ochoa) syndrome. Am J Med Genet. 1987;27(3):661–7. https://
doi.org/10.1002/ajmg.1320270320.
16. Wise L, Wyers M. Duplicated bladder. Pediatr Radiol. 2010;40(Suppl 1):11. https://doi.
org/10.1007/s00247- 010- 1810- 8.
167
Epidemiology, Etiology, andMechanism
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ofUrinary Bladder Injury
Due to its relative anatomical protection in the bony pelvis, the bladder is less frequently injured in blunt or penetrating trauma than the kidneys.
A 10-year study recruiting 15,169 adult patients who sustained blunt abdominal
trauma showed an occurrence of bladder ruptures in 54 patients of them (0.35%)
[1]. A 5-year review of the US National Trauma Data Bank (NTDB) revealed 8565
cases of bladder trauma with 85% being caused by blunt trauma. In 46% of the
cases, there was an associated pelvic fracture, particularly one of the pubic
rami, and in 15% there were at least two other intra-abdominal injuries [2]. Males
are predominant with 63–75%, and the average age is 38.9% [1, 2].
Conversely, another NTDB review of 31,380 patients with pelvic fracture showed
that 1444 (4.6%) had a genitourinary injury, and sole injuries of the bladder were
more common (3.39%) than urethral (0.94%) or combined bladder-urethra injuries
(0.19%) [3].
Nearly similar results were reported in a level I trauma center showing 4.2% of
lower urinary tract injuries out of 5518 cases of blunt trauma associated with a pelvic injury [4].
Extraperitoneal bladder ruptures are more common among patients with pelvic
fractures than those without pelvic fractures, with 39.1% and 14.7%, respectively,
and the presence of pelvic fractures in patients with lower urinary tract injury is
associated with increased overall injuries severity and portends increased rates of
inpatient complications and longer hospital stays [4, 5].
Motor vehicle accidents or collisions (VMAs or MVCs) are the most common cause of bladder blunt trauma accounting for 50.5%, followed by
pedestrian- cars accidents and falls from height with 29.1% and 14.5%, respectively [6–8].
MVC is also the most frequent mechanism causing pelvic injuries, associated or
not with genitourinary injury (GUI), and injured pedestrians and motorcyclists have
a statistically higher percentage of pelvic fractures with associated GUI [3]. Falls
are other causes of pelvic fractures; however, they are seldom associated with GUI
20
© 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_20
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20 Epidemiology, Etiology, andMechanism ofUrinary Bladder Injury
(5.12%) [3]. Fullness of the bladder makes it susceptible to rupture even from mild
trauma such as a fall after tripping on stairs. Alcohol consumption is a particularly
important risk factor here as it rapidly lls up the bladder, reduces the concentration
of the individual, and slower his/her reex to cushion the fall with his/her hands.
More infrequently do bladder injuries result from a penetrating injury during
assaults (re guns, stabbing) accounting for 14–49% depending on the published
series [6]. Herein gunshot wounds represent the great majority (88%) of causes.
Conversely, bladder injury has been reported to be present in 3.6% of abdominal
gunshot injuries and is also associated with 13% of penetrating injuries of the rectum and 20% of penetrating injuries to the buttock [9]. Contrary to blunt bladder
injuries which are mostly associated with pelvic fracture, penetrating bladder injuries are mostly associated with small bowel and rectum injuries [10].
A non-negligible etiological group is made of iatrogenic bladder injuries occurring in 1.8–13.8 per 1000 surgeries [6]. Out of over a million and half of the surgical
interventions recorded in the US National Surgical Quality Improvement Program
database, there were 1685 (0.11%) cases of bladder injuries [11].
It has been proposed to divide iatrogenic bladder injuries into those arising from
cystoscopic procedures and those occurring during open or laparoscopic surgery
carried out in the vicinity of the bladder [12]. The rst group includes procedures
such as cystolitholapaxy, transurethral resection of bladder tumor (TURBT), and
transurethral resection of the prostate (TURP), and the second one comprises gynecological, colorectal, general, and urological surgeries.
Bladder injuries are reported to occur in 0.36% of gynecological interventions,
0.35% of open colorectal surgeries, and 0.08% of general surgery [11].
Risk factors of iatrogenic bladder or ureteral injury in gynecological surgeries
include prior abdominal surgery or laparotomy, history of cesarean section, endometriosis, adhesions of any origin, broad ligament broids, high blood loss during
surgery provoking panic and blind mass ligation, and low-volume surgeons, in addition to complete placenta praevia and accrete, which are specic risk factors in
cesarean section [13, 14].
In a single institution, it was found that out of 127 patients with nonendoscopic
iatrogenic bladder injuries, they were more women than men (87% vs. 13%), the
mean age was 51years, the most associated risk factors were prior surgery, presence
of inammation, and increased tumor burden [15]. This study also showed that
gyneco-obstetrical surgery caused the highest percentage of injuries (65%),
followed by general surgery and non-endoscopic urologic procedures with 22%,
and 13%, respectively. Among gyneco-obstetrical procedures, hysterectomy is
the most incriminated cause followed by cesarean section. The incidence of
bladder injury during cesarean section has been evaluated to be 0.08–0.94%,
and the risk increases with repeat surgeries [16–18]. This apparently low inci-
dence should be taken with caution when one knows that over 30% of deliveries in
the United States occur through a cesarean section [19] and that the current estimated birth number in this country is over 3.6 million per year [20].
In cesarean sections, the inadvertent bladder cutting or laceration may occur
either during entry into the peritoneal cavity (bladder not emptied, or presence of
20 Epidemiology, Etiology, andMechanism ofUrinary Bladder Injury
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171
adhesions), during the bladder ap creation, or during uterine incision or fetal
extraction. The bladder may also be included in the suture of the uterine incision,
arising in the development of a secondary vesicovaginal or vesicouterine stula [13]
(Fig.20.1a, b).
Bladder injury during a cesarean section can be considered non-negligent
or defendable in scenarios of postoperative adhesions, abnormal anatomy, or
in a fully dilated cervix with the fetal head lying deep in the pelvis. However,
injuries occurring without anatomic abnormalities are considered technical
mishaps, and non-recognition and repair of any injury intra-operatively might
be litigated as negligence [18]. An exception to this rule is where there is a placenta
praevia or accreta with massive life-threatening bleeding, where the immediate purpose is to control the hemorrhage by packing and/or ballooning with the plan to take
back the patient after 1–2days for reevaluation and completion of the treatment [21].
Many tricks have been proposed to prevent bladder injury during cesarean section, including bladder catheterization, Pfannenstiel incision as opposed to a midline sub-umbilical one, prevention of adhesions by careful handling and closure of
the tissues and correct hemostasis, double layers suturing of the uterus, sharp incision of the adhesions as opposed to blunt dissection using gauzes, etc. However, the
creation of a bladder ap, the type of uterine incision, the exteriorization of the
uterus after fetus delivery, and the closure of the peritoneum are controversial in
preventing adhesions. Indeed, most bladder injuries occur during the creation of the
bladder ap [16]. It is traditionally recommended to catheterize and empty the bladder to avoid injury. However, a paradoxical approach was recently proposed by a
DE
Fig. 20.1 (a) Cystoscopy showing a 2-cm large vesico-vaginal stula at the posterior vesical wall
in a 39-year old lady 2 months after a cesarean section. (b) Vaginoscopy showing a guide wire
exiting through the stula into the upper third of the vagina just below the uterine cervix (same
patient discussed in the Fig.22.1a, b. (Courtesy Feroz Amir Zafar, Urology, the Royal Hospital,
Muscat, Oman)
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20 Epidemiology, Etiology, andMechanism ofUrinary Bladder Injury
randomized controlled trial that demonstrated the effectiveness of cystoination
with 300 mL normal saline to well expose the bladder for safe adhesiolysis in
repeated cesarean sections [22].
The risk factors associated with bladder injury during trans-urethral cystoscopic
procedures, namely TURBT and TURP, have not been specically studied. However,
based on the experience, one can assume that these include large tumor size, high
stage of the tumor requiring deeper resection, location of the tumor at bladder dome
where the wall is the thinnest and most vulnerable, or at the lateral walls where there
is a high likelihood of an obturator reex, and the limited surgeon experience.
Spinal anesthesia doesn’t prevent obturator reexes. Therefore, if general anesthesia is not used, and the tumor site is in the lateral bladder wall, a nerve block should
be considered. A prospective study has evaluated a technique of obturator nerve
block using 2% Lidocaine injected through the thigh inter-adductor approach in the
Lithotomy position showing an efcacy of 94% out of 542 cases [23]. Another prospective study showed that the use of the combination of spinal anesthesia with
obturator nerve block was an effective safety measure to reduce obturator reex
and prevent bladder perforation during resection of lateral wall tumor, either for
monopolar or bipolar TURBT [24]. Furthermore, a comparison between bipolar and
monopolar TURBT without the use of a nerve block did not show any superiority of
the former in the prevention of obturator block and bladder injury [25]. Interestingly,
microscopic and immunohistochemical studies of the bladder tissue from patients
who developed bladder perforation during TURBT permitted to rule out an intrinsic
deciency in the bladder wall structure, leaving the main responsibility to the surgical technique [26].
Rare causes of iatrogenic bladder injuries include inguinal hernia repair, vascular
surgery (femoral–femoral bypass graft) (Fig.20.2), laparoscopic procedures (appen-
dicectomy, nephrectomy, etc.) with too-low insertion of a port in a patient with full
bladder (Fig.20.3), sling operation for incontinence, positioning the reservoir during articial sphincter or penile prosthesis, transvaginal oocytes retrieval for in-vitro
fertilization, and even a simple catheter insertion [27–31].
Fig. 20.2 Abdominal CT
angiogram demonstrating a
thrombosed femoralfemoral graft traversing
through the bladder. A
patent femoral-femoral
graft is seen in the
subcutaneous tissue. (From
Nakamura LY etal. [28],
with permission from
Elsevier)
20 Epidemiology, Etiology, andMechanism ofUrinary Bladder Injury
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Fig. 20.3 Sagittal plane of a CT-urography in a 13-year-old boy who underwent an emergency
laparoscopic surgery for a perforated appendix 24h earlier. A 5-mm port was inserted too low near
the pubis (P) with no urinary catheterization. It transpierced the bladder at the antero-superior
aspect, and this event was unnoticed during all the procedure. A drain was introduced through the
same port at the end of the operation. The alert was sounded the next day when excessive uid was
noted in the drain bag with high creatinine concentration, prompting this CT-urography showing
the drain (D) crossing the urinary bladder (UB). The contrast seen in the sigmoid colon (S) and the
rectum (R) was from the initial CT scan study with IV and oral contrast performed to diagnose the
perforated appendix at presentation. (Courtesy Mohamed Abdul Salam Al-Qadri, General Surgery,
The Royal Hospital, Muscat, Oman)
173
Table 20.1 gives an overview of the incidence of bladder trauma in various surgical procedures [32].
Finally, before closing this chapter, let’s mention some exceptional cases of
spontaneous intraperitoneal bladder rupture that have been reported in the literature,
secondary to prostatic adenoma with urinary retention and bladder distention, and
also in near term pregnancies, during childbirth, or after a normal delivery. This is
considered an extremely rare event with an incidence of 1:126,000 deliveries but
has a high mortality rate of 50% due to delayed management [33–36]. Underlying
pathologies such as cystitis, diverticulum, and tumors are suggested to explain the
bladder fragility and the pressure exerted by a gravid uterus or an acutely distended
bladder are the triggering factors.
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20 Epidemiology, Etiology, andMechanism ofUrinary Bladder Injury
Table 20.1
iatrogenic bladder trauma
during various procedures
Incidence of
Procedure Percentage (%)
Obstetrics and gynecology
Laparoscopic/robotic radical
hysterectomy (malignant)
Abdominal radical hysterectomy
(malignant)
Hysterectomy laparoscopic/
abdominal/vaginal (benign)
Caesarean delivery 0.08–0.94
General surgery
Abdominal cytoreductive surgery 4.5
Rectal procedures 0.27–0.41
Small/large bowel procedures 0.12–0.14
Laparoscopic inguinal hernia repair 0.04–0.14
Urology specic
Transurethral resection of the bladder 3.5–58
Retropubic male sling 8.0–19
Mid-urethral sling (retropubic route) 4.91–5.5
Transvaginal mesh surgery 2.84
Pubovaginal sling 2.8
Laparoscopic sacrocolpopexy 1.9
Mid-urethral sling (transobturator
route)
Burch colposuspension 1.0–1.2
Native tissue colporrhaphy 0.53
From the EAU guidelines [32], with permission
from the EAU
4.19–4.59
2.37
0.1–2.5
1.61
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20 Epidemiology, Etiology, andMechanism ofUrinary Bladder Injury
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