Indications for Surgical Repair of Extraperitoneal Bladder Rupture
Most extraperitoneal bladder ruptures should be managed conservatively with catheter drainage alone, but surgical repair is indicated when the injury is "complicated" by specific high-risk features that prevent spontaneous healing and increase morbidity.
Conservative Management: The Default Approach
Uncomplicated extraperitoneal bladder injuries heal successfully with urethral Foley catheter drainage alone, making surgery unnecessary in most cases. 1
- Standard catheter drainage for 2-3 weeks allows spontaneous healing in the majority of extraperitoneal ruptures 1
- The extent of contrast extravasation on cystography does not typically dictate the need for surgery 2
- Follow-up cystography confirms healing after catheter drainage 1
- Consider surgical repair only after 4 weeks of failed catheter drainage in non-healing injuries 1
Absolute Indications for Surgical Repair
Surgical repair is mandatory for "complicated" extraperitoneal bladder ruptures to prevent prolonged sequelae, fistula formation, and severe infection. 1
Specific High-Risk Features Requiring Surgery:
Exposed bone spicules in the bladder lumen from pelvic fractures—these must be removed surgically with concurrent bladder closure to prevent osteomyelitis and persistent fistula 1, 3
Concurrent rectal or vaginal lacerations—these create a pathway for fistula formation between the ruptured bladder and bowel/vagina, requiring immediate surgical repair 1
Bladder neck injuries—these typically do not heal with catheter drainage alone and require direct surgical repair 1
Patient already undergoing laparotomy or orthopedic surgery—when the patient requires open reduction internal fixation of pelvic fractures or repair of other abdominal injuries, concurrent bladder repair should be performed given the minimal additional morbidity and reduced complications 1, 4
Clinical Reasoning: Why These Features Matter
The rationale for surgical intervention in complicated cases centers on preventing serious complications that conservative management cannot address:
- Bone fragments adjacent to a bladder rupture create a nidus for infection and prevent mucosal healing, potentially leading to severe pelvic sepsis or permanent urinary fistula 3
- Rectal or vaginal injuries allow bacterial translocation and fistula tract formation that catheter drainage cannot prevent 1
- Bladder neck injuries involve the sphincter mechanism and require anatomic restoration 1
Subgroup analysis demonstrates that patients undergoing surgery for other indications who do NOT receive concurrent cystorrhaphy experience significantly higher urological complication rates, longer ICU stays (9.0 vs 4.0 days), longer hospital stays (18.9 vs 10.6 days), and prolonged time to negative cystography (25.5 vs 20.0 days). 4
Surgical Technique Considerations
When surgery is indicated:
- Confirm integrity of the bladder neck and ureteral orifices during repair 1
- Remove any exposed bone fragments before bladder closure 1
- Use urethral catheter drainage alone postoperatively—suprapubic tubes offer no advantage and increase morbidity 1
- Perform follow-up cystography to confirm healing in complex repairs 1
Critical Pitfalls to Avoid
- Do not assume all extraperitoneal ruptures need surgery—this represents overtreatment, as 70-90% heal with catheter drainage alone 2
- Do not miss bone fragments on imaging—CT may not reliably demonstrate small bone spicules impinging on the bladder, and endoscopic examination may be needed 3
- Do not delay repair when the patient is already in the operating room—opportunistic repair during other procedures significantly reduces complications and length of stay 4
- Do not use suprapubic tubes routinely after repair—urethral catheterization alone is the standard and reduces hospital stay 1