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23 Treatment of Urinary Bladder Injury: Conservative Approach, Direct Repairs…

Fig. 23.4 (a) Pubectomy with Gigli saw; (b) the defect between the atretic bladder neck and the obstructed proximal urethra is 1cm; (c) acquiring the bladder ap from the anterior bladder wall; (d) reconstruction of the bladder neck and proximal urethra. (From Rong Lv etal. [10]. Creative Commons Attribution 4.0 International License)

References

1. Elkbuli A, Ehrhardt JD, Hai S, McKenney M, Boneva D.Management of blunt intraperitoneal bladder rupture: case report and literature review. Int J Surg Case Rep. 2019;55:160–3.

https://doi.org/10.1016/j.ijscr.2019.01.038. Epub 2019 Feb 1. PMID: 30739872; PMCID:

PMC6369329

2. Culhane J, Syed JR, Siddiqui S.Minimally invasive management versus open surgery in the treatment of penetrating bladder injuries: a retrospective cohort study. BMC Urol. 2021;21:138.

https://doi.org/10.1186/s12894- 021- 00900- w.

3. Roy SP, Combes AD, Perera DS.A very rare case report of an iatrogenic bladder perforation in a young female with concurrent Fitz–Hugh–Curtis syndrome. J Surg Case Rep.

References

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2021;2021(5):rjab218. https://doi.org/10.1093/jscr/rjab218. PMID: 34055300; PMCID: PMC8153801

4. Gomez RG, Ceballos L, Coburn M. Consensus statement on bladder injuries. BJU Int. 2004;94(1):27–32.

5. Morey AF, Brandes S, Dugi DD 3rd, Armstrong JH, Breyer BN, Broghammer JA, Erickson BA, Holzbeierlein J, Hudak SJ, Pruitt JH, Reston JT, Santucci RA, Smith TG 3rd, Wessells H, American Urological Assocation. Urotrauma: AUA guideline. J Urol. 2014;192(2):327–35.

https://doi.org/10.1016/j.juro.2014.05.004. Epub 2014 May 20. PMID: 24857651; PMCID:

PMC4104146

6. 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

7. EAU Guidelines. Edn. presented at the EAU Annual Congress Amsterdam March 2022. ISBN 978-94-92671-16-5. https://uroweb.org/guidelines/urological- trauma/chapter/

urogenital- trauma- guidelines.

8. Mahat Y, Leong JY, Chung PH.A contemporary review of adult bladder trauma. J Inj Violence Res. 2019;11(2):101–6. https://doi.org/10.5249/jivr.v11i2.1069. Epub 2019 Apr 13. PMID: 30979861; PMCID: PMC6646823

9. 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. PMID: 29379741; PMCID: PMC5782400

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.

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Treatment ofBladder Injury:

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Reconstructive Surgery Using

Extraurinary Autologous Tissues

Unlike the ureter and the urethra, one particularity of the bladder function is its full dependence on sympathetic, parasympathetic, and somatic nerve supplies integrity. The bladder often suffers from spine, sacral plexus, or pelvic nerves injuries, and its dysfunction represents a direct threat to the kidneys. There are multiple reconstructive techniques that the human genius has invented to alleviate neurogenic cystopathy or to palliate a congenital abnormality or a cystectomy performed for various reasons such as muscle-invasive bladder cancer. With the exception of a cutaneous urostomy, they all use bowel segments (mostly the terminal ileum) with their intact mesenteries to refashion the bladder, augment its capacity, or just drain out the urine through the abdominal wall. Although this topic deviates somehow from the sub-

ject treated in this book, as the underlying problem is mainly a congenital, neurological, or oncological pathology, a succinct overview of the techniques alluded to above would not be superuous. Indeed, the following case report would solely justify this additional effort: inadvertent cystectomy has occurred during a cesarean section complicated with severe hematuria necessitating urgent hysterectomy [1]. The entire body of the bladder and lower ureters were

removed along with the uterus leaving only the bladder neck and part of the trigone. The management included immediate cutaneous ureterostomy and elective bladder augmentation with a catheterizable continent stoma using the appendix.

1. Techniques proper for neurogenic bladder and congenital abnormalities: In these techniques, the bladder is preserved, and stratagems are carried out to increase its capacity and ensure drainage.

(a) Augmentation enterocystoplasty simply called bladder augmentation:

This technique utilizes a detubularized patch of the terminal ileum to cover a sagittally bivalved bladder. It is indicated in small bladder capacity with poor compliance, in refractory overactive bladder, in infective and inammatory disorders (TB, Schistosomiasis), after radiation therapy, etc. In childhood, it is performed for congenital abnormalities such as bladder

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24 Treatment of Bladder Injury: Reconstructive Surgery Using Extraurinary…

exstrophy or epispadias. It is also preferred over an ileal conduit in the setting of renal transplantation when the recipient has bladder dysfunction [2, 3].

(b) Mitrofanoff appendicovesicostomy: This technique was introduced in

1976 and published in 1980 by the French pediatric urologist Paul Mitrofanoff as a continent catheterizable diversion anastomosing the appendix tip to the bladder and its base to the skin in children with neurogenic bladder. The cystostomy thus created was combined with a closure of the bladder neck at the same time. Bladder augmentation is often performed along with a Mitrofanoff appendicovesicostomy [4–6] (Fig.24.1a–d).

Fig. 24.1 (a) Appendicovesicostomy with the Mitrofanoff principle showing an anti-reux extra- vesical reimplantation technique (arrow head) as the anti-incontinence mechanism. (b) Continent urinary diversion with the Mitrofanoff principle using an ileal segment for a transverse ileal tube (Yang-Monti) (arrow) and a double tube (Monti technique) (arrow head). (c) Umbilical stoma in a patient who underwent an Appendicovesicostomy and Malone antegrade continence enema (MACE) procedure. (d) V-Quadrilateral-Z (VQZ) plasty stoma in a patient with a complex urethral stricture. (From Chavarriaga J etal. [6]. Creative Commons Attribution License)

24 Treatment of Bladder Injury: Reconstructive Surgery Using Extraurinary…

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203

Many techniques arose utilizing the Mitrofanoff principle with other gastro-

intestinal segments than the appendix [5, 6]:

– Yang-Monti tube: Uses a detubularized 2–3cm ileal segment, and transversally

retubularized over a 14–18Fr catheter. One end of the tube is tunneled submucosally and anastomosed to the bladder while the other end is attached to the skin as a stoma.

– Other tissue sources include coecum associated with the appendix, stomach, ure-

ter, etc.

2. Techniques after cystectomy. Here the bladder has been removed and the chal- lenge consists of its replacement whenever possible, or just of urine drainage.

(a) Cutaneous urostomy: This is an exception in this chapter as it doesn’t uti-

lize extra-urinary tissue. When the bladder has been removed and there is no suitable bowel segment to create a diversion or the patient is not t for a major reconstruction, the ureters can be brought directly through the abdominal wall to the skin. This is considered a better alternative to permanent percutaneous nephrostomy [7].

(b) Ileal conduit urinary diversion: This incontinent diversion is very popular

and is used for all patients undergoing a radical cystectomy who are unt for bladder replacement (neo-bladder). The most popular is the Bricker tech- nique where the spatulated ureters are reimplanted separately in an end-toside technique to the proximal end of a 12–20cm ileal conduit whose distal end is anastomosed to the abdominal skin through the rectus muscle sheath [8]. The two ureters may also be anastomosed conjointly in an end-to-end fashion on the proximal end of the ileal conduit, according to Wallace technique. Jejunal and colonic conduits can also be used, but are associated with more metabolic disturbances.

Fig. 24.2 The Kock pouch: completed ileal reservoir in situ. (From Kock NG etal. [9], with permission from Wolters Kluwer Health)

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24 Treatment of Bladder Injury: Reconstructive Surgery Using Extraurinary…

– Kock pouch: It is made of a reservoir fashioned from a 60–70cm ileal segment,

having an afferent limb connected to the ureters and an efferent limb connected to the skin through a catheterizable stoma [9] (Fig.24.2).

– Indiana pouch: Developed at Indiana University (Michigan, USA), it consists

of a reservoir fashioned from a detubularized coecum and a segment of the ascending colon. The ureters are tunneled and implanted along the cecal tenia to ensure an antireux mechanism while the plicated terminal ileum and the ileocecal valve provide incontinence to the catheterizable stoma [10–12] (Fig.24.3).

(d) Orthotopic bladder substitution: This is also known as neo-bladder, and is

made from a detubularized long ileal segment (50–60cm) which is roughly refashioned as a sphere and anastomosed proximally to the ureters and distally to the urethra. Its continence relies on the natural external urethral sphincter. Many techniques have been proposed for the creation of a neo-bladder and are referred to by eponyms: Camey-Leduc (U- and Z-shaped), Hautmann (W-shaped), Kock, Studer, Abol-Enein and Ghoneim, the Vescica Ileale

Fig. 24.3 The Indiana pouch. Diagrams illustrate the technique for anastomosis of the ureters to the cecum along the tenia. (From Rowland RG [10], with permission from Springer Nature)

References

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205

Padovana (circular shape), etc. Mainz and Le Bag pouches are characteristically fashioned from ileocolonic segments while the Reddy pouch is made of the sigmoid colon [13–17].

(e) Ureterosigmoidostomy: Published for the rst time in 1857 by Mr. Simon, this

technique was rst performed in a child with bladder exstrophy [18]. The ureters are anastomosed end-to-side to the sigmoid colon in an anti-reux manner (Coffey, Petit-Leadbetter, Mainz) with the obvious advantages of obviating the need for a stoma, hence providing better cosmetic results. The continence is ensured by the anal sphincter. Besides other complications such as chronic diarrhea, the increased incidence of colorectal cancer associated with this technique has caused it to be disregarded for many decades before regaining some interest due to the ease of its performance through newly developed minimally invasive approaches [19, 20].

24.1 Future Perspectives

The unlimited human genius was not satised with surgical reconstruction alone but did imagine ways to recreate a new bladder or produce tissues that would mimic a natural reservoir. Hence the concept of tissue engineering and regenerative medicine. The used scaffolds are biomaterials that are roughly divided into three categories [21–25]:

– natural matrices, including collagen, – acellular tissue matrices, such as bladder submucosa, – synthetic matrices, such as poly(lactic-co-glycolic acid) (PLGA), Teon, silicon.

There is still a long way to the successful production of a bladder or any other biological organ (pancreas, kidney, etc.) with desired characteristics and properties. Nonetheless, human determination and abnegation will not stop until success, and the advent of nanotechnology will surely stimulate further research and open doors to unsuspected achievements.

References

1. Alahmadi M, Ghazi AA.Case reported for iatrogenic cystectomy during cesarean delivery. Urol Case Rep. 2020;31:101180. https://doi.org/10.1016/j.eucr.2020.101180.

2. Biers SM, Venn SN, Greenwell TJ.The past, present and future of augmentation cystoplasty. BJU Int. 2012;109(9):1280–93. https://doi.org/10.1111/j.1464- 410X.2011.10650.x. Epub 2011 Nov 25

3. Veeratterapillay R, Thorpe AC, Harding C. Augmentation cystoplasty: contemporary indications, techniques and complications. Indian J Urol. 2013;29(4):322–7. https://doi.

org/10.4103/0970- 1591.120114.

4. Mitrofanoff P.Trans-appendicular continent cystostomy in the management of the neurogenic bladder. Chir Pediatr. 1980;21:297–305.

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5. Veeratterapillay R, Morton H, Thorpe AC, Harding C. Reconstructing the lower urinary tract: the Mitrofanoff principle. Indian J Urol. 2013;29(4):316–21. https://doi.

org/10.4103/0970- 1591.120113.

6. Chavarriaga J, Fernández N, Campo MAO, Bolivar J, Patiño G, Perez J. Self-perception, quality of life and ease of catheterization in patients with continent urinary diversion with the mitrofanoff principle. Int Braz J Urol. 2020;46(5):743–51. https://doi.org/10.1590/

S1677- 5538.IBJU.2019.0388.

7. Kearney GP, Docimo SG, Doyle CJ, Mahoney EM.Cutaneous ureterostomy in adults. Urology. 1992;40(1):1–6. https://doi.org/10.1016/0090- 4295(92)90426- w.

8. Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am. 1950;30(5):1511–21. https://doi.org/10.1016/s0039- 6109(16)33147- 4.

9. Kock NG, Nilson AE, Nilsson LO, Norlén LJ, Philipson BM. Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Urol. 1982;128(3):469–75. https://doi.

org/10.1016/s0022- 5347(17)53001- 3.

10. Rowland RG, Mitchell ME, Bihrle R.The cecoileal continent urinary reservoir. World J Urol. 1985;3:185–90. https://doi.org/10.1007/BF00326991.

11. Rowland RG, Mitchell ME, Bihrle R, Kahnoski RJ, Piser JE.Indiana continent urinary reservoir. J Urol. 1987;137(6):1136–9. https://doi.org/10.1016/s0022- 5347(17)44428- 4.

12. Bihrle R.The Indiana pouch continent urinary reservoir. Urol Clin N Am. 1997;24:773.

13. Chang DT, Lawrentschuk N.Orthotopic neobladder reconstruction. Urol Ann. 2015;7(1):1–7.

https://doi.org/10.4103/0974- 7796.148553.

14. Couvelaire R. Le réservoir iléal de substitution après la cystectomie totale chez l'homme [substitute ileal reservoir following total cystectomy in the male]. J Urol Medicale Chir. 1951;57(6):408–17.

15. Lilien OM, Camey M. 25-year experience with replacement of the human bladder (Camey procedure). J Urol. 1984;132(5):886–91. https://doi.org/10.1016/s0022- 5347(17)49934- 4.

16. Camey M, Le Duc A.L'enterocystoplastie avec cystoprostatectomie totale pour cancer de la vessie. Ann Urol. 1979;13:114.

17. Hautmann RE. Ileale Ersatzblasen [Ileal bladder substitute]. Urologe A. 2008 . German;47(1):33–4. https://doi.org/10.1007/s00120- 007- 1606- 0.

18. Simon C. Ektopia vesicae: operation for diverting the orices of the ureters into the rectum: temporary success; subsequent death; autopsy. Lancet. 1857;2:568–70. https://doi.

org/10.1016/S0140- 6736(02)63646- 3.

19. Przydacz M, Corcos J. Revisiting ureterosigmoidostomy, a useful technique of urinary diversion in functional urology. Urology. 2018;115:14–20. https://doi.org/10.1016/j.urol-

ogy.2018.01.003. Epub 2018 Jan 31

20. Hansen MH, Hayn M, Murray P.The use of bowel in urologic reconstructive surgery. Surg Clin N Am. 2016;96(3):567–82. https://doi.org/10.1016/j.suc.2016.02.011.

21. Atala A, Bauer SB, Soker S, Yoo JJ, Retik AB. Tissue-engineered autologous bladders for patients needing cystoplasty. Lancet. 2006;367:1241–6. https://doi.org/10.1016/

S0140- 6736(06)68438- 9.

22. Atala A.Tissue engineering of human bladder. Br Med Bull. 2011;97:81–104. https://doi.

org/10.1093/bmb/ldr003.

23. Aboushwareb T, Atala A.Stem cells in urology. Nat Clin Pract Urol. 2008;5:621–31. https://

doi.org/10.1038/ncpuro1228.

24. Soler R, Fullhase C, Atala A.Regenerative medicine strategies for treatment of neurogenic bladder. Therapy. 2009;6(2):177–84. https://doi.org/10.2217/14750708.6.2.177.

25. Subramaniam R. Regenerative medicine in bladder reconstructive surgery. Eur Urol Suppl. 2016;16:23. https://doi.org/10.1016/j.eursup.2016.10.005.

24 Treatment of Bladder Injury: Reconstructive Surgery Using Extraurinary…

Prognosis, Complications,

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andFollow-Up ofBladder Injury

A well-repaired bladder rupture has an excellent prognosis since this organ has a good blood supply which allows rapid and complete healing.

However untreated or poorly treated cases carry a grim prognosis because of the complications arising from the bladder injury itself or from the associated organs trauma. A population-based review recruiting 111 patients with AAST bladder injury grade≥II who underwent laparotomy showed a complication rate of 38% and a mortality rate of 11% either due to associated injuries or complications of mismanaged bladder injury, and patients with systemic, non-urinary complications were more prone to a fatal outcome (26.2% of 42 patients) than the non- complicated cases (1.4% of 69 patients) [1]. The authors found that ISS >25, systolic pressure <90mmHg, a revised trauma score (RTS) <7.84, and the presence of a pelvic fracture were the most important predictors for complications in bladder trauma [1]. The same mortality rate (11%) was found in a 10-year population study at a level I center [2].

An National Trauma Data Bank (NTDB) review showed that surgical bladder repair reduces in-patient mortality by 59%, and factors associated with increased mortality were African-American and native American races, presence of pelvic injuries, penetrating trauma, and multiple abdominal injuries [3].

Suboptimal bladder wall repair with continuous peri-vesical urine extravasation may give rise to abdominal wound dehiscence. Missed urinary extravasation gives rise to urinary ascites, ileus, abdominal distension, dyspnea, sepsis, localized pelvic abscess, or generalized peritonitis.

Complications surely arise from delayed diagnosis and treatment or from suboptimal repair, but also depend on the anatomopathology of the injury [4–7]:

– For intraperitoneal urine leak: electrolytes imbalance, urea reabsorption,

and uremia.

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25 Prognosis, Complications, andFollow-Up ofBladder Injury

– If there is a simple and isolated bladder rupture, the complications consist of

persistent hemorrhage (haematuria or increased perivesical or intravesical

hematoma), the occurrence of urinary infection, decreased bladder capacity, and

rarely a secondary bladder pseudodiverticulum at the breach due to mucosa heal-

ing without muscular layer repair.

– In a massive rupture, over-debridement during repair may decrease bladder

capacity and cause urinary urgency.

– Delay in the bladder neck, vagina, and rectum repair causes urinary incontinence

or stricture, vesicovaginal or vesica-rectal stula, and stricture.

– Bladder neuropathy due to major injury to the sacrum, sacral roots, or pelvic

nerves. If it is only neuropraxia, temporary intermittent self-catheterization may

be an effective solution. If the sacral plexus damage is permanent, it will result in

a hypotonic neurogenic bladder, with most likely an associated erectile

dysfunction.

For extraperitoneal bladder injuries, a large prospective multicentric study conducted in the United States, including 157 patients showed that 43% of them underwent an operative repair in the initial management and revealed the following complications classied by whether the patients were operated on (OP) or not (NOP): Overall complications (23% NOP vs. 19% OP), pelvic infection/Urinoma (1% NOP vs. 6% OP), persistent urinary extravasation (18% NOP vs. 13% OP),urinary tract to skin stula (1% NOP vs. 4% OP), non-union of the pelvic fracture (1% NOP vs. 1% OP), hardware infection/removal (4% NOP vs. 7% OP), et pelvic osteomyelitis (0% NOP vs. 3% OP) [8]. This study also showed that bladder neck injury and combined urethral trauma are the only statistically signicant predictors of complications. While this study supports the concept of conservative management in extraperitoneal bladder injury, the non-statistical difference in the complications prole between the two groups must be interpreted with caution due to selection bias in the management decision, and one can logically assume that patients in the operated group had more complex injuries [8].

A follow-up retrograde cystography performed at 10–14days to ascertain bladder healing before catheter removal has been advocated by many authors and expert boards [9]. However, the Eastern Association for the Surgery of Trauma limited

the indications for this study only to patients with a moderate or high risk of a urinary leak, namely those who had a repaired complex intra-peritoneal or extra-peritoneal bladder injury or those who presented with a simple extraperitoneal leak treated conservatively. The panel recommended against follow-up

cystography in low-risk patients, dened as those who beneted from an operative repair of simple intraperitoneal or extraperitoneal bladder ruptures, estimating that 999 out of 1000 cystographies in these patients would be unnecessary [10].

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