Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 474 - файл
.pdf
Anatomopathology ofUrinary Bladder
https://t.me/medicina_free
Injury
Four anatomopathological entities of the bladder injury are described [1–5]:
– Bladder contusions
– Extraperitoneal rupture
– Intraperitoneal rupture
– Mixed or combined bladder ruptures
1. In bladder contusions, the damage is either limited to the mucosa, including or
not the muscular coat, but without breaching the serosa/adventitia for injuries
arising intravesically (during endourological procedures such as TURBT), or
inversely lacerating the serosa/adventitia while the muscular and mucosa layers
are spared for extra-vesical trauma (penetrating agents, surgical operations). In
either case, there is no complete rupture of the bladder wall, and consequently,
no urinary leak occurs. This entity almost always remains undiagnosed, and its
incidence is therefore unknown, though it is probably the most common anatomopathological form [2].
2. Extraperitoneal bladder ruptures are reported to mostly occur in association
with pelvic fractures, due to penetration by bone spicules, or to shear forces and
distortion of the bladder wall as a contrecoup mechanism following ligamentous
injury, and their proportion is estimated to be 55–78% according to multiple
series. As logically expected, extraperitoneal rupture concerns any part of the
bladder below the peritoneal reection, be it on the anterior, lateral, or posterior
walls. Furthermore, extraperitoneal bladder injuries are divided into two types:
simple and complex. In the former, the contrast extravasation is limited to the
pelvic extraperitoneal space. In the complex type, there are large extraperitoneal
bladder ruptures associated with a rupture of the superior fascia of the urogenital
diaphragm, allowing the urine leak to spread through Dartos, Colles, and
Scarpa’s fasciae which are continuous with the urogenital diaphragm (Fig.21.1).
21
© 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_21
177
178
https://t.me/medicina_free
21 Anatomopathology ofUrinary Bladder Injury
Fig. 21.1 Complex
extraperitoneal bladder
rupture. (a) Axial CT
cystographic image shows
a defect in the anterior
bladder wall (arrow) with
contrast extravasation in
the extraperitoneal space
beyond the pelvis. (b)
Axial CT cystographic
image at more inferior
level shows contrast
extravasation into soft
tissue in bilateral thighs
(arrow). (From
Wongwaisayawan S [8],
with permission from
Springer Nature)
a
b
Therefore, the urine will extravasate into the scrotum through the inguinal canal,
the perineum, the penis, and the thighs via the obturator foramen, or into the
anterior abdominal wall, or even retroperitoneally as high as the perinephric
region [2, 6–8].
3. Intraperitoneal ruptures occur mainly with high-energy blows directly hitting an
overdistended bladder and their proportion is around 17–39%. Here the injury is
located above the peritoneal reection, mainly on the bladder dome which is the
weakest point of the bladder wall [8] (Fig.21.2).
21 Anatomopathology ofUrinary Bladder Injury
https://t.me/medicina_free
179
Fig. 21.2 Intraperitoneal
bladder rupture. (a) Axial
CT cystographic image
shows large amount of
contrast material in
bilateral paracolic gutters
and between the
mesenteric folds (*). (b)
Coronal CT cystographic
image shows a defect at the
bladder dome (arrow) with
contrast extravasation in
bilateral paracolic gutters
(*). (From
Wongwaisayawan S [8],
with permission from
Springer Nature)
a
b
4. Combined intra- and extraperitoneal ruptures of the bladder are possible and
their occurrence is estimated to be 5–8% of all bladder ruptures.
In intraperitoneal bladder ruptures the urine leaks into the abdominal cavity and
is absorbed by the peritoneal membrane, leading to an increase in blood urea nitrogen and creatinine, as well as electrolytes and metabolic imbalances (hyperchloremic metabolic acidosis, hypernatremia, hyperkalemia) [2, 5, 7]. In either intra- or
extra-peritoneal bladder rupture, there is decreased urine output.
180
https://t.me/medicina_free
Fig. 21.3 Cystogram of a
patient with a bladder neck
and prostatic injury and a
relatively small cavity. The
patient also has a malleable
penile implant. (From
Mundy and Andrich [9],
with permission from John
Wiley and Sons)
21 Anatomopathology ofUrinary Bladder Injury
A distinct and extremely rare anatomopathological entity consists of bladder
neck injury. To date, the largest series has been published by Mundy and Andrich in
2010 comprising a total of 15 men recruited over a 15-year period [9]. They all
occurred after pelvic fractures. Only 5 of the 15 cases had lesions conned to the
bladder neck and the prostatic urethra, while others were more complex, extending
to the subprostatic urethra often with posterior urethral rupture (Figs. 21.3 and
21.4). Two of the cases were particularly severe with simultaneous complete tran-
section of the bladder neck and of the membranous urethra leaving a freely oating
prostate (Fig.21.5). After this series, a few smaller series and isolated case reports
have been published here and there [3, 10].
It is important to know that bladder neck injury is more common in children due
to the relatively unprotected anatomy of the bladder. And the rare cases reported in
adults are longitudinal (vertical) consisting of a bladder and prostatic injury. Few
cases of transversal (horizontal) bladder neck transection have been reported in children but are extremely rare in adults [11, 12] (Fig.21.6a–c).
21 Anatomopathology ofUrinary Bladder Injury
https://t.me/medicina_free
181
Fig. 21.4 (a, b) MRI of a
patient with a bladder neck
and prostatic injury and
cavitation spreading down
into the thigh. (From
Mundy and Andrich [9],
with permission from John
Wiley and Sons)
a
b
182
https://t.me/medicina_free
21 Anatomopathology ofUrinary Bladder Injury
Fig. 21.5 Representative
MRI of the two patients
with a transected bladder
neck above and a
transected membranous
urethra below a
sequestered prostate. In
each case 1 = bladder and
2 = prostatic urethra. (a)
sagittal view in patient 1;
(b) coronal view in patient
2. (From Mundy and
Andrich [9], with
permission from John
Wiley and Sons)
a
b
References
https://t.me/medicina_free
a
b
183
Fig. 21.6 (a) MRI pelvis showing complete transection noted at junction of bladder neck and
proximal prostatic urethra. From Gite VA etal. [12], with permission from Elsevier. (b, c) SPC
scopy and urethroscopy image. (From Gite VA etal. [12], with permission from Elsevier)
References
1. McGeady JB, Breyer BN.Current epidemiology of genitourinary trauma. Urol Clin N Am.
2013;40(3):323–34. https://doi.org/10.1016/j.ucl.2013.04.001. Epub 2013 Jun 12. PMID:
23905930; PMCID: PMC4016766
2. Gomez RG, Ceballos L, Coburn M, Corriere JN Jr, Dixon CM, Lobel B, McAninch
J. Consensus statement on bladder injuries. BJU Int. 2004;94(1):27–32. https://doi.
org/10.1111/j.1464- 410X.2004.04896.x. PMID: 15217426
3. Kong JP, Bultitude MF, Royce P, Gruen RL, Cato A, Corcoran NM.Lower urinary tract injuries
following blunt trauma: a review of contemporary management. Rev Urol. 2011;13(3):119–30.
PMID: 22114545; PMCID: PMC3222924
184
https://t.me/medicina_free
4. Matlock KA, Tyroch AH, Kronfol ZN, McLean SF, Pirela-Cruz MA. Blunt traumatic bladder rupture: a 10-year perspective. Am Surg. 2013;79(6):589–93. https://doi.
org/10.1177/000313481307900619.
5. Kang L, Geube A.Bladder trauma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022.
6. Ramchandani P, Buckler PM. Imaging of genitourinary trauma. AJR Am J Roentgenol.
2009;192(6):1514–23. https://doi.org/10.2214/AJR.09.2470.
7. Brandes S, Borrelli J Jr. Pelvic fracture and associated urologic injuries. World J Surg.
2001;25(12):1578–87.
8. Wongwaisayawan S, Krishna S, Sheikh A, Kaewlai R, Schieda N.Imaging spectrum of traumatic urinary bladder and urethral injuries. Abdom Radiol (NY). 2021;46(2):681–91. https://
doi.org/10.1007/s00261- 020- 02679- 0. Epub 2020 Jul 28
9. Mundy AR, Andrich DE. Pelvic fracture-related injuries of the bladder neck and prostate:
their nature, cause and management. BJU Int. 2010;105(9):1302–8. https://doi.org/10.1111/
j.1464- 410X.2009.08970.x. Epub 2009 Oct 28
10. Lv R, Jin C, Shu H, et al. Bladder neck reconstruction in girls’ pelvic fracture bladder neck avulsion and urethral rupture. BMC Urol. 2020;20:179. https://doi.org/10.1186/
s12894- 020- 00741- z.
11. Sawant AS, Kapadnis LA, Kumar V, Pawar P, Tamhankar AS.Paediatric post-traumatic bladder neck distraction injury: case series. J Clin Diagn Res. 2017;11(2):PR03–4. https://doi.
org/10.7860/JCDR/2017/20782.9244. Epub 2017 Feb 1
12. Gite VA, Singal A, Nikose JV, Jain HM. Post traumatic isolated bladder neck transection:
unreported and undescribed injury. Urol Case Rep. 2017;17:67–9. https://doi.org/10.1016/j.
eucr.2017.12.001.
21 Anatomopathology ofUrinary Bladder Injury
Presentation, Diagnostic Investigations,
https://t.me/medicina_free
andGrading ofUrinary Bladder Injury
22.1 Presentation
In a patient who sustained a pelvic or abdominal, blunt or penetrating injury, the
presence of a bladder injury is often suggested by the following classical triad of
symptoms [1]:
– gross hematuria,
– suprapubic or abdominal pain or tenderness, and,
– difculty or inability to void.
Hematuria is the most common symptom being present in 100% of cases of
bladder injury. However, in less than 5% of cases, it might only be microscopic [2].
The physical examination of the patient has to be carefully performed in penetrating injuries, especially after a gunshot, where the entrance and exit wounds
should be identied in the lower abdomen, the perineum, or the buttocks.
For the iatrogenic causes, intraoperative bladder injuries are generally easily recognized and repaired without delay. About 80% of injuries are recognized during
surgery as the result of direct visualization of the injury site, either during extravesical surgery (open or laparoscopic) or cystoscopies. Additionally, during noncystoscopic abdominal or pelvic procedures, suspicion of a bladder injury may be
raised by the presence of urine in the operative eld, or air in the urinary bag, or
more directly by visualization of the Foley catheter [3].
When one doesn’t directly observe a bladder perforation during cystoscopic procedures (chiey transurethral resection of bladder tumour (TURBT), but also transurethral resection of the prostate (TURP)), this can be suspected through a newly
appearing abdominal distension, or difculty in maintaining bladder distension with
the irrigation uid, or mismatch between the instillated and the drained uid with
the latter appearing signicantly low.
22
© 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_22
185
186
https://t.me/medicina_free
22 Presentation, Diagnostic Investigations, andGrading ofUrinary Bladder Injury
22.2 Investigations
22.2.1 Conventional Cystography
Immediate retrograde cystography is absolutely indicated and is the mainstay
of diagnosis in blunt trauma patients who are hemodynamically stable and
present with the classic combination of pelvic fracture and gross hematuria [4–7].
However, this procedure should be performed only after the exclusion of an associated urethral injury which can be suspected when one observes blood at the external urethral meatus. Moreover, retrograde cystography can be spared for patients
with isolated hematuria or pelvic fracture alone [4, 5, 8]. This reduces possible
hazards to the patient and saves time and money.
Cystography might be postponed in a scenario of pelvic fracture with massive
bleeding requiring angiographic embolization because the extravasated contrast
material in the pelvis is likely to impair the accuracy of the angiography [6].
Microscopic hematuria is a poor indicator of bladder rupture and even its association with a pelvic fracture constitutes only a relative indication for retrograde
cystogram, as is the presence of gross hematuria without pelvic fracture. A retrospective study including 721 cases of blunt pelvic fracture has demonstrated that
hematuria values <30 RBC/HPF are poorly correlated with the presence of bladder
injury. This study also rened pelvic fracture characteristics that predict a high likelihood of bladder injury, namely diastasis of the pubic symphysis >1cm, and fracture of the obturator ring with displacement >1 cm. No patient with an isolated
acetabular fracture was shown to have a bladder injury [9]. Conversely, out of 31
patients with gross hematuria after blunt pelvic trauma, only those who had a concomitant pelvic fracture (26%) were found to have a bladder injury in a randomized
prospective study [10].
The accuracy of cystography has been estimated to be 85–100% according to
published series. For optimal results, the bladder should be lled with at least
300–400mL of diluted contrast medium. False-negative results are due to inadequate distention of the bladder and absence of post-drainage lms because small
anterior or posterior extravasations might be covered by the full bladder in an
anteroposterior picture and would not become obvious until the bladder is emptied
[11–13] (Fig.22.1a, b).
One of the explanations for false-negative cystograms has been suggested to be
small-caliber bullet wounds where the omentum or blood clots might plug the
breach [11]. Other causes of false negative are pelvic hematoma not leaving space
for the contrast to freely extravasate, contraction of the detrusor muscle provisionally sealing a small perforation, presence of a Foley catheter balloon blocking a
small tear, gravity, impossibility to turn the patient in a prone position in pelvic
trauma (missing a small breach in the anterior vesical wall) [14].
Соседние файлы в папке @xirurgi_2025