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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_902_Библиотеки_им_академика_М_И_Перельмана
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22.2 Investigations
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DE
Fig. 22.1 (a, b) Post-cesarean section in a 39-year old woman with persistent upper vesico-
vaginal stula (same patient discussed in the Figure20.1a, b). (a) Double-contour image on an
antero-posterior conventional cystography. (b) Lateral view after emptying the bladder showing
contrast lling the uterus (UT) and one of the fallopian tube (FT). The vesical catheter tip (CT) is
seen anteriorly to the uterus and some contrast is seen owing freely through the vagina. (Courtesy
Ashraf Abdelsalam Al Ozeni, Urology, The Royal Hospital, Muscat, Oman)
22.2.2 CT-Cystography
CT-cystography is another valuable means to diagnose a bladder perforation and is
better performed after intra-vesical contrast instillation. This has been proved to
have an accuracy comparable to that of a conventional cystography in diagnosing
bladder injuries [15] (Fig.22.2a–d).
Out of 234 patients, a level I trauma center found a nearly 100%-overall sensitivity and specicity of CT cystography in diagnosing bladder rupture, and the addition of sagittal and coronal images from the multiplanar reformation is particularly
useful in identifying the site of the lesion [16].
Expert panels recommend either technique (standard cystography or
CT-cystography) for bladder injury diagnosis when the patient presents with gross
hematuria or pelvic fracture associated with microscopic hematuria, taking into
account the advantages and drawbacks of each (time, cost) [5]. CT-cystography has
the advantage to avoid confusion with overlying bone fragments caused by pelvic
fractures, spine boards, or clothing artifacts.
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22 Presentation, Diagnostic Investigations, andGrading ofUrinary Bladder Injury
a
b
Fig. 22.2 (a, b) CT cystography showing vesicouterine stula 2 weeks after a cesarean section in
placenta accreta during which the bladder was severely damaged and immediately repaired. The
stula was treated conservatively with an indwelling catheter. (c) Cystogram at 2 weeks shows
persistent leakage. (d) Follow-up conventional cystography at 6 weeks showing complete healing
22.2.3 CT-Urography
A CT-urography after intra-vesical contrast instillation, combined with IV and oral
contrast for a whole abdomen examination is a time-saving procedure when one
wants to evaluate associated abdominal viscera injuries and obviate the need for a
separate conventional retrograde-cystography. However, a CT-cystography with
only IV contrast and passive physiological bladder lling with catheter clamping is
not recommended due to a high rate of false-negative results. Needless to say, the
use of traditional Intravenous pyelography (IVP) is obsolete, especially for this
indication [6, 11, 17–20].
22.2 Investigations
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22.2.4 Intraoperative Means
In the setting of iatrogenic bladder injury during laparoscopic or open abdominal or
pelvic surgery, the diagnosis can be readily made by the direct observation of the
breach and the intra-vesical catheter. In unclear cases where the suspicion is raised
by a sudden increase of intraperitoneal uid (urine), decreased urine output in the
urinary bag, or unexplained hematuria, an intravenous injection of indigo carmine
can be used or, more rapidly a retrograde intravesical instillation of diluted methylene blue [6].
22.2.5 Other Techniques
(a) “Sentinel clot sign”: This concept has been introduced to help in diagnosing
abdominal viscera trauma through CT observation of a focal high-density clotted blood adjacent to an organ, and showed high sensitivity and specicity in
predicting an injury of that organ [21]. In this study, the sentinel clot was the
only clue of injury in 9% of splenic trauma cases and 32% of bowel or mesenteric injuries. A subsequent study has demonstrated the value of this concept in
rening the radiological diagnosis of intraperitoneal bladder rupture following
blunt trauma. Herein a sentinel clot abutting the bladder dome showed a high
correlation with an injury at this level [22].
(b) Pneumo-CT-Cystography: CT scan of a gas-distended bladder followed by a
3-D virtual reconstruction has permitted to mimic a cystoscopy with high accuracy in patients with small bladder tumors. This technique was therefore
referred to as CT-cystoscopy [23, 24]. A recent application of this technique
using 150–300mL of intra-vesical air insufation rather than contrast material
combined with an Intravenous contrast-enhanced CT has been proposed for
bladder rupture detection, as a so-called pneumo-CT-cystography [14].
Further studies with larger cohorts are required to conrm the accuracy of this
technique.
22.2.6 Grading ofBladder Injury
In routine clinical practice, the American Association for the Surgery of Trauma
(AAST) grading system is not used for bladder injury as frequently as for kidney
trauma [25] (Table22.1). However, it is of paramount importance for every Urologist
to have a sound knowledge of the main characteristic of each grade of bladder
trauma, as this impacts survival and can lead to fatal outcomes if incorrectly or not
timely managed.
A radiologic classication system has also been proposed to help analyze the
different patterns of extravasation, including the atypical ones, but is seldom used
[26] (Table22.2). This grading is interesting with regard to the description of radiological features of the injury, but has to be interpreted with caution as the
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Table 22.1 AAST for bladder injury
Grade
I Hematoma
II Laceration Extraperitoneal bladder wall laceration <2cm 4
III Laceration
IV Laceration
V Laceration Intraperitoneal or extraperitoneal laceration extending into
From Moore EE [25], with permission from Elsevier
Table 22.2 Patterns of extravasation in bladder injuries
Type
1 Bladder contusion Normal
2 Intraperitoneal (IP)
3 Interstitial bladder
4 Extraperitoneal
5 Combined IP and EPCombination of type 2 and 4
22 Presentation, Diagnostic Investigations, andGrading ofUrinary Bladder Injury
Injury Description
Intramural hematoma
Laceration
Injury
rupture
injury (rare)
(EP) rupture
Simple Contrast is limited to the perivesical space with linear streaks or a
Complex The pelvic oor is breeched and contrast may track up the
Partial thickness
Extraperitoneal ≥2cm or intraperitoneal <2cm bladder wall
laceration
Intraperitoneal bladder wall laceration ≥2cm
bladder neck or ureteral orice (trigone)
Radiographic appearances (cystography)
Ill-dened contrast extravasation surrounding loops of bowel and
in the paracolic gutters and pouch of Douglas
Contrast dissects into bladder wall, causing irregularity or defect;
no contrast extravasation
sunburst pattern
peritoneal space and appear as an IP rupture; extravasation may
extend to scrotum, penis, and anterior abdominal wall
AIS90
2
3
4
4
4
Adapted from Sandler CM etal. [26]
presentation is not strictly in accordance with the severity and the prognosis of the
lesion. This is illustrated by the fact that an intraperitoneal rupture is described as
type 2 while a simple extraperitoneal rupture is labeled as type 4.
References
1. Guttmann I, Kerr HA.Blunt bladder injury. Clin Sports Med. 2013;32:239–46.
2. Brandes S, Borrelli J Jr. Pelvic fracture and associated urologic injuries. World J Surg.
2001;25(12):1578–87.
3. Esparaz AM, Pearl JA, Herts BR, LeBlanc J, Kapoor B.Iatrogenic urinary tract injuries: etiology, diagnosis, and management. Semin Intervent Radiol. 2015;32(2):195–208. https://doi.
org/10.1055/s- 0035- 1549378.
4. 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.
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5. Yeung LL, McDonald AA, Como JJ, Robinson B, Knight J, Person MA, Lee JK, Dahm
P. Management of blunt force bladder injuries: a practice management guideline from the
Eastern Association for the Surgery of Trauma [Erratum in: J Trauma Acute Care Surg 2019
Aug;87(2):511]. J Trauma Acute Care Surg. 2019;86(2):326–36. https://doi.org/10.1097/
TA.0000000000002132.
6. Coccolini F, Moore EE, Kluger Y, et al. Kidney and uro-trauma: WSES-AAST guidelines.
World J Emerg Surg. 2019;14:54. https://doi.org/10.1186/s13017- 019- 0274- x.
7. https://uroweb.org/guidelines/urological- trauma/chapter/urogenital- trauma- guidelines.
8. Morey AF, Iverson AJ, Swan A, Harmon WJ, Spore SS, Bhayani S, Brandes SB. Bladder
rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma. 2001;51(4):683–6.
https://doi.org/10.1097/00005373- 200110000- 00010.
9. Avey G, Blackmore CC, Wessells H, Wright JL, Talner LB. Radiographic and clinical
predictors of bladder rupture in blunt trauma patients with pelvic fracture. Acad Radiol.
2006;13(5):573–9. https://doi.org/10.1016/j.acra.2005.10.012.
10. Fuhrman GM, Simmons GT, Davidson BS, Buerk CA.The single indication for cystography
in blunt trauma. Am Surg. 1993;59(6):335–7.
11. Corriere JN, Sandler CM.Bladder rupture from external trauma: diagnosis and management.
World J Urol. 1999;17:84–9.
12. Carroll PR, McAninch JW. Major bladder trauma: the accuracy of cystography. J Urol.
1983;130(5):887–8. https://doi.org/10.1016/s0022- 5347(17)51551- 7.
13. Cass AS.False negative retrograde cystography with bladder rupture without pelvic fracture.
J Urol. 1984;124:168–9.
14. Trinci M, Cirimele V, Cozzi D, Galluzzo M, Miele V.Diagnostic accuracy of pneumo-CTcystography in the detection of bladder rupture in patients with blunt pelvic trauma. Radiol
Med. 2020;125(10):907–17. https://doi.org/10.1007/s11547- 020- 01190- 2. Epub 2020 Apr 9
15. Peng MY, Parisky YR, Cornwell EE 3rd, Radin R, Bragin S.CT cystography versus conventional cystography in evaluation of bladder injury. AJR Am J Roentgenol. 1999;173(5):1269–72.
https://doi.org/10.2214/ajr.173.5.10541103.
16. Chan DP, Abujudeh HH, Cushing GL Jr, Novelline RA.CT cystography with multiplanar
reformation for suspected bladder rupture: experience in 234 cases. AJR Am J Roentgenol.
2006;187(5):1296–302. https://doi.org/10.2214/AJR.05.0971.
17. Gomez RG, Ceballos L, Coburn M. Consensus statement on bladder injuries. BJU Int.
2004;94(1):27–32.
18. Vaccaro JP, Brody JM.CT cystography in the evaluation of major bladder trauma. Radiographics.
2000;20(5):1373–81. https://doi.org/10.1148/radiographics.20.5.g00se111373.
19. 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.
20. Rehm CG, Mure AJ, O'Malley KF, Ross SE. Blunt traumatic bladder rupture: the role
of retrograde cystogram. Ann Emerg Med. 1991;20(8):845–7. https://doi.org/10.1016/
s0196- 0644(05)81424- 6.
21. Orwig D, Federle MP.Localized clotted blood as evidence of visceral trauma on CT: the sentinel clot sign. AJR Am J Roentgenol. 1989;153:747–9.
22. Shin SS, Jeong YY, Chung TW, Yoon W, Kang HK, Kang TW, Shin HY. The sentinel clot
sign: a useful CT nding for the evaluation of intraperitoneal bladder rupture following blunt
trauma. Korean J Radiol. 2007;8(6):492–7. https://doi.org/10.3348/kjr.2007.8.6.492.
23. Vining DJ, Zagoria RJ, Liu K, Stelts D.CT cystoscopy: an innovation in bladder imaging. AJR
Am J Roentgenol. 1996;166(2):409–10. https://doi.org/10.2214/ajr.166.2.8553956.
24. Gualdi GF, Casciani E, Rojas M, Polettini E.Cistoscopia virtuale delle neoplasie della vescica.
Esperienza preliminare [Virtual cystoscopy of bladder neoplasms. Preliminary experience].
Radiol Med. 1999;97(6):506–9. Italian
25. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, Flint LM,
Gennarelli TA, Malangoni MA, Ramenofsky ML, etal. Organ injury scaling: spleen, liver,
and kidney. J Trauma. 1989;29(12):1664–6. https://doi.org/10.1016/S0039- 6109(16)46589- 8.
26. Sandler CM, Hall JT, Rodriguez MB, Corriere JN Jr. Bladder injury in blunt pelvic trauma.
Radiology. 1986;158:633–8.
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Treatment ofUrinary Bladder Injury:
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Conservative Approach, Direct Repairs,
23
andReconstructive Techniques Using
Urinary Tract Tissues
Bladder rupture is a potentially fatal event if not timely diagnosed and repaired.
Except for some cases of complex bladder base and bladder neck injuries, the repair
of this hollow viscus is generally technically easy and less challenging than that of
a kidney, ureter, or urethra.
The management of bladder injury differs from other urinary system
trauma in the following aspects:
– Renal trauma management is mainly conservative and intervention is only indi-
cated upon patient hemodynamic instability. When intervention is required, it
rst consists of a minimally invasive procedure (angioembolization) and when
an open exploration is required, it often results in nephrectomy, and rarely partial
nephrectomy.
– Ureteric injury can be temporarily managed by urinary diversion with a percuta-
neous nephrostomy until further treatment. Sometimes an antegrade DJ stenting
can be inserted without the need for invasive surgery. When surgical repair is
necessary, it might require complex reconstructive techniques as discussed in the
previous chapter.
– We will see in the next section of this book that urethral rupture is provisionally
managed with a suprapubic catheter until an elective repair is performed, which
potentially involves complex techniques.
Contrary to the above injuries, and with the exception of a simple extraperi-
toneal injury, bladder ruptures have no alternative than urgent surgical repair.
Fortunately, bladder repair is generally a simple procedure and seldom requires
complicated reconstructive techniques. Usually, the intervention is carried out
through an open procedure and the detection of the bladder site injury is generally
easy [1] (Fig.23.1). The laparoscopic approach is also an option for selected intraperitoneal cases in expert hands, with the advantage of lower morbidity and a shorter
hospital stay [2, 3] (Fig.23.2).
© 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_23
193
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23 Treatment of Urinary Bladder Injury: Conservative Approach, Direct Repairs…
Fig. 23.1 (a)
Intraoperative view of low
midline laparotomy
showing ruptured bladder
dome with bladder catheter
and inated balloon. (b)
Ruptured bladder wall held
with Babcock forceps.
(From Elkbuli A etal. [1].
Open-access article under
the CC BY license)
a
b
The principles of management of a bladder trauma are based on the anatomopa-
thology of the lesion, being either extraperitoneal or intraperitoneal, or mixed.
Bladder hematoma or rupture with an extraperitoneal urinary leak should be
rst addressed with conservative management consisting of indwelling drainage
and prophylactic antibiotics. In large peri-vesical hematoma with distortion of the
bladder, the catheter should be maintained until signicant hematoma resorption
and near normalization of the bladder anatomy is achieved. Additionally, since the
patient will frequently have an associated pelvic fracture, the catheter should be
kept until he/she ambulates [4, 5]. More than 85% of bladder injuries kept on
indwelling catheter heal by the 10th day, and nearly all heal within 3weeks [4, 6].
A rupture with intraperitoneal or mixed urinary leak calls for urgent interven-
tion which should be performed through a midline laparotomy incision, followed by
23 Treatment of Urinary Bladder Injury: Conservative Approach, Direct Repairs…
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Fig. 23.2 Intraoperative
photo showing the tip of
Foley catheter protruding
through the bladder wall
and subsequent repair.
(From Roy SP etal. [3],
with permission from
Oxford University Press)
195
suction of the effused urine, watertight repair of the bladder breach using absorbable
sutures in two layers (mucosa-muscular layers and serosa), and intraperitoneal
drain. The two-layer closure remains very popular among surgeons despite there
being no evidence of its superiority over a watertight single-layer technique [7].
Some rare cases of small uncomplicated intra-peritoneal bladder perforations that
occur during endoscopic procedures (TURBT) can be managed conservatively
under closed observation and antibiotic prophylaxis [7].
In the exclusion of bladder rupture with obvious massive intraperitoneal urine
extravasation, and in the absence of randomized studies, experts have reached a
consensus on when to proceed to surgical repair in extra-peritoneal rupture, either
through minimally invasive or open surgery [4–8]:
– Inadequate bladder drainage, either due to catheter block by a clot or persistent
extravasation.
– Concomitant pelvic hollow viscus injury (vagina, rectum).
– Severe bladder neck injury or avulsion.
– Patients undergoing internal xation for a pelvic fracture should have a bladder
repair to avoid urinary extravasation and contamination/infection of orthopedic
implants.
– Finally, any patient undergoing laparotomy for extra-urological injuries should
have his/her bladder evaluated if suspicions are present (hematuria, mechanism
of trauma, low urine output, suprapubic pain/tenderness), and repaired.
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23 Treatment of Urinary Bladder Injury: Conservative Approach, Direct Repairs…
– Other indications: all penetrating injuries, ureteric orice involvement in the
bladder injury, bony fragments compressing or incrusted in the bladder, and
failed conservative management, such as persistent urine extravasation, continu-
ous bleeding, or occurrence of an abscess.
Technically, domal and anterior lacerations can be directly repaired, but posterior
wall, trigonal, and bladder neck wounds should be approached transvesically
through an anterior midline book-opening vertical incision of the bladder, thus
avoiding disturbance of the pelvic hematoma and a perilous peri-vesical dissection
with risk of life-threatening hemorrhage.
The optimal duration of an indwelling catheter after bladder repair is not codied
by current guidelines. However, a 7–14-day duration is commonly preached and
observed. Placement of a suprapubic catheter should only be indicated by the presence of complex bladder neck injury or associated urethral trauma where urethral
catheterization is contra-indicated. It should not be a routine practice since it doesn’t
add to the effective drainage of a urethral catheter in the majority of cases while
increasing unnecessarily the morbidity and hospital duration [5, 8].
In the extremely rare cases of bladder injury due to iatrogenic injury where the
bladder is pierced by a sharp and thin instrument, such as during oocyte retrieval, or
SLING surgery for incontinence, there might be severe bleeding out of proportion
to the needle passage. In these cases, intravesical insertion of a three-way catheter
is mandatory to wash out the clots and proceed to bladder irrigation. If this management fails, the patient should be taken for cystoscopy under general anesthesia, the
clot should be removed with an Ellik evacuator, and the bleeding sites (entrance and
exit) be examined and eventually fulgurated.
In cases of bladder neck transection, an immediate suprapubic catheter should be
inserted but there is controversy about the optimal timing of the denitive operation.
On the one hand, an immediate repair might be justied because these injuries do
not have a spontaneous tendency to heal. On the other hand, delaying the intervention for a few months (generally three) to avoid disturbance of the blood clot and
massive bleeding is also a defendable strategy. The repair is performed after a subumbilical incision (midline, or inverted “Y” incision, or Pfannenstiel) [9]. The
patient can also undergo a combined vaginal and transpubic approach while in a
lithotomy position [10]. The retropubic area is approached after releasing brosis,
and a segment of the pubic bone may need to be cut for better exposure of the atretic
bladder neck and the proximal urethra [10]. The bladder is opened horizontally at
the level of the bladder neck. A metallic sound is inserted retrogradely to identify
the prostatic urethra end which is then longitudinally opened with a knife. The periurethral brous tissue is excised and the proximal ureteral end is spatulated. Now an
end-to-side anastomosis is performed over an indwelling silicone catheter. If the
cd
23 Treatment of Urinary Bladder Injury: Conservative Approach, Direct Repairs…
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197
defect is too long, a T-shaped incision is made at the anterior bladder wall to create
two well-vascularized aps (around 1.3–3cm long and 1–2cm wide). These aps
are positioned downwards to augment the ventral part of the bladder neck and proximal urethra. A safety suprapubic catheter (SPC) is replaced and a drain is left in the
Retzius space before closing the abdominal wall [9, 10] (Figs.23.3 and 23.4).
a
b
Fig. 23.3 (a–c) Preoperative voiding cystourethrography showed complete atresia of the bladder
neck in a young girl with a history of pelvic fracture bladder neck avulsion and urethral rupture;
(d) preoperative voiding cystourethrography showed vesicovaginal stula. (From Rong Lv etal.
[10]. Creative Commons Attribution 4.0 International License)
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