What is the management approach for bladder trauma repairs?

Management of Bladder Trauma Repairs

All intraperitoneal bladder ruptures require immediate surgical exploration and primary repair, while uncomplicated extraperitoneal bladder ruptures can be managed conservatively with catheter drainage alone. 1

Initial Assessment and Diagnosis

The presence of gross hematuria (seen in 95% of cases) with pelvic trauma or penetrating injury with pelvic trajectory mandates evaluation for bladder injury 1, 2. Retrograde cystography has a 95.9% accuracy rate and remains the diagnostic gold standard, though CT cystography is acceptable when patients require abdominal CT for other injuries 3, 4.

Management Algorithm by Injury Type

Intraperitoneal Bladder Rupture (IBR)

Surgical repair is mandatory for all intraperitoneal ruptures 1:

• Open surgical repair is performed in a double-layer fashion using monofilament absorbable suture 1
• Laparoscopic repair is a viable alternative for isolated IBR in hemodynamically stable patients without other indications for laparotomy 1
• Single-layer repair is acceptable during laparoscopic approach 1
• During repair, confirm integrity of the bladder neck and ureteral orifices 1

Extraperitoneal Bladder Rupture (EBR)

Uncomplicated EBR should be managed conservatively with urethral catheter drainage, clinical observation, and antibiotic prophylaxis 1:

• Injury healing occurs within 10 days in more than 85% of cases 1
• Catheter drainage for 2-3 weeks is standard, though longer duration is acceptable with concurrent injuries 1
• Follow-up cystography confirms healing before catheter removal 1, 2

Complex EBR requires surgical repair in the following situations 1:

• Bladder neck injuries
• Injuries associated with pelvic fractures requiring internal fixation with exposed bone spicules
• Concurrent rectal or vaginal injuries (risk of fistula formation)
• Non-resolution of urine extravasation after 4 weeks of conservative management 1
• When laparotomy is performed for other indications 1
• During surgical exploration of prevesical space for orthopedic fixations 1

Penetrating Bladder Injuries

All penetrating bladder injuries generally require surgical exploration and primary repair 1:

• Gunshot injuries commonly have through-and-through wounds requiring complete pelvic inspection 1
• Associated rectal injuries are common and prompt fecal diversion 1

Urinary Drainage Strategy

Urethral catheterization alone (without suprapubic tube) is the standard for adult patients after surgical repair of bladder injuries 1:

• Urethral catheters adequately drain the repaired bladder and result in shorter hospital stay and lower morbidity 1
• Routine suprapubic tube placement is no longer recommended 1
• Suprapubic catheterization may be reserved for associated perineal injuries 1
• In pediatric patients, suprapubic cystostomy is recommended after surgical repair 1

Damage Control Scenarios

In hemodynamically unstable patients, urethral or suprapubic catheter may be inserted as a temporary measure and bladder repair postponed 1. For severe IBR during damage control procedures, urinary diversion via bladder and perivesical drainage or external ureteral stenting may be used 1.

Follow-Up Protocol

CT scan with delayed phase imaging is the method of choice for follow-up of bladder injuries 1. Follow-up cystography should confirm healing in complex repairs but may not be necessary in simple repairs 1. Catheters left in place greater than 14 days are associated with a 21% complication rate compared to 0% for removal within 14 days 2.

Common Pitfalls

Delayed diagnosis occurs when gross hematuria is absent on presentation or when patients leave the emergency room before bladder injury studies are performed 3. The accuracy of abdominal CT alone for bladder injury is only 60.6%, making dedicated cystography essential when bladder injury is suspected 3. Mortality from bladder trauma (5-8%) is primarily due to associated injuries rather than the bladder injury itself 4, 5.