2 s/s 2500400.10/0 ‘Te Jove oF rae Copy 158 he Win & Woon Co Management of the Ruptured BI. Experience with 111 Cases ladder: Seven Years of JOSEPH N. CORRIERE, Jk, M.D., aND CARL M. SANDLER, MD. During a 7 year period, we have seen 111 patients with from blunt trauma and 16 due to penetrating injuries. All bladder rupture, 95 16 patients with penetrating injuries, as well as an additional 34 patients with intraperitoneal injuries, nine patients with extraperitoneal injuries, and five with both intra- and extraperitoneal injuries from blunt trauma, had formal closure of the ‘wound and urethral or suprapubie catheter drainage. All did well. A total of 39 patients with extraperitoneal bladder injuries were treated with only ‘catheter drainage and all did well. Eight patients died before institution of therapy. ‘We previously published preliminary findings on man- agement of the ruptured bladder caused by external violence and, at that time, advocated a nonoperative approach to extraperitoneal injury due to blunt trauma and operative repair for patients with intraperitoneal or penetrating injury (4). We have now reviewed the records of all patients with a bladder rupture admitted to the Hermann Hospital of The University of Texas Medical School at Houston, from 1 January 1978 through 31 December 1984, and have re-evaluated this therapy with 4 greater patient experience. MATERIALS AND METHODS "The records ofall patients were reviewed with respect to age, sex, cause of injury, presence of pelvie fracture, associated injury, patient management, and the results of the therapy. ‘The hiadder injuries ofall patients were managed by the full time faculty of the Division of Urology and all had faculty followup until their injury had resolved. Finally, the radi ‘ographs of each patient were reviewed with our utoradiologist to confirm the presence and type of bladder injury and to assess the post-trestment eystogram RESULTS A total of 111 patients with bladder ruptures from external violence was diagnosed and treated in the 7 years under review. Iatrogenic bladder injuries or injuries ue to internal migrating objects were not included in From the Division of Urology, Department of Surgery end the Departinent of Ralogy, Te tniveriy of Texas Medical School st Houston Presented in prt at the Anna Sesion of the American Assocation for the Surgery of Trauma, Boston, Massachusetts, 12-14 Septmber 1886, ‘Address for reprints: Joseph N. Comiere, Jt, M.D. Division of LUzology, Department of Surgers, 6451 Fannin, Suite 6018, Houston, ‘Tx Tn, 10 thie report. As noted in ‘Table I, 95 (86%) ofthe injuries ‘were due to biunt trauma, most commonly motor vehiele accidents involving automobile drivers or passengers, rotoreyele riders, or pedestrians. Although the majority of the penetrating injuries were due to gunshot wounds, there was one stab wound, and one man fell astride & etal spike “The patient population ranged in age from 2 to 76 years: 90 (81%) were under the age of 41 years. Sixty three (57%) patients were males and 48 were females. Eighty-five (89%) of the 95 patients who sustained blunt, trauma had an associated fracture of atleast the anterior arch of the pelvis. All but one (98%) of the 55 patients with an extraperitoneal bladder rupture due to blunt trauma had a pelvie fracture. This woman had previously undergone multiple pelvie procedures which probably had fixed her bladder dome so that it no longer bore the brunt of an abdominal blow. Twenty-six (75%) of the 35. patients with an intraperitoneal bladder rupture had a pelvic fracture as did all five of the patients who suffered combined intea- and extraperitoneal injuries, ‘There were 52 injuries of other genitourinary organs (Table Il). OF note are the L1 posterior urethral injuries in males, 17% of all males who sustained a fractured pelvis. The majority of our patients had injuries to other organ systems and 14 (12%) of them died, usually within the first 24 hours of hospitalization. None of the deaths were secondary to the urologic injury or subsequent urologic management. ‘Al patients with penetrating injuries were managed by surgical debridement of the missile tract, closure of the defect, and suprapubic or Foley catheter drainage ‘There were no complications related to the bladder injury in these patients and all had normal eystograms 10 days, later. In the blunt injury group (able I), 34 patients withVol. 26, No. 9 Tamer Etiology of bladder ruptures Blunt ium 5) ‘Moor vehicle accident ry Fling obj, erushed pelvis 7 ‘Alanna blow 2 Penetrating teauma (16) ot wend u Stab wound Fell astride spike TABLE W Genitourinary injuries associated with bladder rupture Posterior urethra 5 1 T Anterior urethra ' 1 o Female urethra 1 0 4 ‘TaDLE tr Management of bladder ruptures due to blunt trauma ineraperitoneal injuries (2) oration, clowae,eystomy 4 etraperitoneal injuries (5) Exploration, closure eystlomy 9 Paley catheter or SP tae only 9 Died bore therapy 7 Combined intra and exteapeitoneal injuries intraperitoneal injuries, nine patients with extraperito- neal injuries, and all five patients with both intra- and extraperitoneal injuries had formal closure of the badder ‘wound and either suprapubic cystotomy or Foley eatheter drainage for at least 10 days as their therapy. All had normal eystograms at that time and subsequently did well without complications. ‘A total of 39 patients with extraperitoneal bladder ruptures was managed by bladder drainage alone. Foley catheter drainage was used primarily in 20 cases, percu- taneous eystotomy in four eases, and five patients had a formal cystotomy tube placed at the time of exploration for other abdominal injuries. Followup eystograms 10 days after the injury shoved no extravasation present in S34 (87%) of the 39 patients treated in this manner. Al had their eatheters removed and voided without further complications. Extravasation persisted in five patients, and tube drainage was continued until the bladder wound healed One was closed by day 14 and one by day 21. Both of these patients had Foley catheters only. One of the three remaining male patients had a suprapubic tube in place Management of Ruptured Bladder 831 and the other two had percutaneous eystotomy tubes placed after 8 weeks of catheter drainage and continued extravasation to prevent urethral complications. Because of associated injuries that required continued bladder catheterization, these three patients were not studied with eystograms until it was felt they would be able to urinate or they no longer needed urine output ‘monitoring. All three bladder ruptures were shown to be healed on cystogram 37, 62, and 90 days after injury None of these patients developed any complications re lated to the bladder rupture or its management, DISCUSSION ‘There is little disagreement in the recent literature that the best therapy for penetrating injuries and intra: peritoneal injuries ofthe bladder due to external violence consists of exploration, debridement of devitalized tissue, ‘wound closure, and suprapubic eystotomy or Foley cath- eter drainage (2, 4, 5). We have found only five eases in the modern literature of patients with intraperitoneal injuries of the bladder successfully handled with simple Foley catheter drainage (6-8). Only one of these cases ‘was due to external violence; the other four were iatro- genic injuries secondary to transurethral instrumenta- tion, It is well known that a rapidly recognized, small intra: peritoneal injury that occurs at the time of transurethral surgery can be handled conservatively if the patient is closely followed. In our experience, the usual intraperi- toneal injury due to external violence is a large rent of at Teast 5 cm accompanied by uroascites. Foley catheters fare unsuccessful in draining bladders with such large ‘wounds, The urine seems to drain preferentially into the peritoneal cavity and leads to all of the problems asso- ciated with urine in the peritoneal cavity Most authors who advocate surgical closure of extra- peritoneal bladder injuries have little personal experience With the conservative method of management of this injury and point to minor complications (‘prolonged he ‘maturia,’ ‘intravesical bone fragment’) or reports in the literature before 1945 to support their argument (2, 3,5). It is also stated that the size of the laceration eannot be judged by eystography, Foley catheter drainage can lead to infection of the pelvic hematoma, and the size of the Foley catheter lumen is insufficient to insure adequate drainage of blood clots. It is occasionally mentioned that small, well-defined extraperitoneal bladder ruptures can be handled by Foley catheter drainage, but only in fe- males (1,3, 5) ‘The present series appears to be the largest number (39) of males and females with extraperitoneal bladder rupture treated by conservative methods. Patients were preferentially treated by this method despite the size of the rupture and only underwent formal repair if explored for another reason. In our patient sample we saw none ‘of the complications reported in the older literature832 ‘The Journal of Trauma (most of which were in patients with iatrogenic injuries, usually intraperitoneal penetrating injuries, and not due to external violence) and saw no infected pelvic hema tomas or problems with bladder hemorrhage. Clearly, if a spicule of bone is perforating the bladder, we would advocate surgical removal, None of our patients had intravesical bone spicules. Most injuries seemed to be due to the shearing force of pelvie ring disruption or, if lacerated by bone fragments, the fragments passed com pletely through the bladder. Ivis true that it is difficult to relate the extent of the rupture to the amount of contrast extravasation on the eystogram, Extravasation is related to the amount of contrast instilled as well as to the size of the injury. However, in our experience, extravasation into the penis, down the inguinal canal to the scrotum, and up the retroperitoneum as high as the kidneys has been suc cessfully treated with eatheter drainage (Figs. 1 and 2) Ifthe patient has uninfected urine and appropriate cath eter care is used, the urine quickly absorbs and the bladder rent heals. Patients with extraperitoneal bladder ruptures may be treated with simple catheter drainage and close clinical evaluation. Antibioties are not routinely used in our patients and we saw no septic complications or pelvic abscesses. However, if the patient with an extraperito- neal bladder rupture is to be explored for associated injuries and is not gravely ill, we would open the dome of the bladder, not the pelvic hematoma, repair the rupture intravesically, and place a suprapubie tube in the bladder. As seen in Table Ill, this occasion has not presented itself to us very often ‘Acknowledgments The authors would like to thank Drs. George S. Benson, Michel A. Boileau, and Stuart M. Flechner for sharing in the care ofthese patie Fic. 1. CT scan of patient with extraperitoneal ladder rupture. Note extnvaration of contrast material in tight prinepbri space Excravasation tecclved and bladder rupture healed with 10 days of father drainage September 1986 Fis Lgeam of patient with extraperitnesl bladder rupture, Note extrsasation into reotum. Extravasstion resolved and Der rupture heed with 10 days of catheter drainage 1. Brosmnan, S.A Pal J 6. ‘Obtet” 143: 65-608, 18 2 Carroll P. Ry MeAnineh Je W pal, 182: 966-257. 108, 1. Cats, A'S, Johnson, C.F, Khan, A. U, et ak: Nonoperative "aanagemont of bladder rupoare Irom extcrsal trun. Urol 4. Hayes, EB Sendler, C. M, Cotriee, J. N. Je: Management of the ruptured badder secondary eo bunt abdominal tase, J Ura, 12: 946-aa, 188 McConnell. D., Wilkerson, M.D, Peters, P. Cz Rupture of the adr. rol Gl No Amer 8: 288-296, 1982 6. Mulkey, A. B, Witherington, Rs Conservative management of ese rapture, Urge €20-120, 1074 Richardson, dR Jr, Lesdbeter, GW, Ie: Nonoporstive teat ‘ment ofthe ruptured bladder Url, 124: 209 1. Robards, VlaJe, gland, RV, Lubin, EN ‘of ratare ofthe bladder. Urol, 1462 Vi rauma ofthe bladder. Surg. Gynec Maior bladder trauma: Mecha. fand a unified method of diagnosis and sepa. J DISCUSSION Da. Jack W. MCANINeH (University of California, San Franciseo General Hospital, San Francisco, 94110): T would like to congratulate Doetor Corrie on his presentation of this very large series, and exprese my thanks to him for having provided me with the manuscript well in advance 1@ area of special interest in this paper evalves around the management of extraperitoneal rupture utilizing, catheter drainage only. Some 39 patients constitute the group, all man ‘aged by catheter drainage without operation. Tt is remarkableVol. 26, No. 9 ‘that the complications were limited to only 6 patients (13%) ‘who had persistent extravasation at 10/days. These all resolved ‘on prolonged drainage without complication or operation. In San Francisco we continue to explore and close all bladder ruptures, and remain concerned that catheter drainage only will result in problems: 1) pelvic hematoma infection, since we Know that catheterization will result in bacterial colonization of the bladder within 72 hours, 2) pseudodiverticula of the bladder tay well develop; and 3) persistent extravasation te- quiring operation Tuan elfort to select patients for such management, Doctor Corrier, did you use the cystogram in any way? You may have already answered thal question, hut T wobld like to reopen the issue. Our experience would suggest that the degree of extra- vvasation seen on eystogram is not related to the number and extent of blader lacerations This study should stimulate us to consider utilizing catheter Arainage only in exteaperitoneel bladder eupture when the need Tor laparotomy is Hot present, T sould Tike to thank the Association for allowing me to discuss this excellent paper. Thank you Da. Twowas Puuars (Department of Surgery, Downstate ‘Medical Center, Brooklyn, NY 11203): Fenjoyed the paper very much. Tam ot sure Lunderstood Doctor Corriere’s conclusion ‘mone point. We recently managed a patient with a penetrating extraperitoneal wound of the bladder, in which we used CT'to Identify that there was no other visceral penetration, followed bby an angiogram to make sure there was no associated vascular injury. We manayed it conservatively and were very pleased to have results identical to hi with blunt trav Tt looked from his paper as if he was advocating this for blunt trauma, but Tam pot site he made a statement about penetrating trauma to the extraperitoneal bladder. which is viously nol very common. We have had-one anectital expe Management of Ruptured Bladder 833, rience with it, and T would like to hear his comments about his Du. F. Caren Nance (St. Bernahas Medical Center, Old Short Hills Road, Livingston, NI 07039): [ would like to know ‘why this can’t be applied to intraperitoneal injuries aso, In. (Closing): In answer to Doctor Dr. doskris N, ConRtER Mednineh's comment abou ‘when we affirm there is an extraperitoneal injury, use urethral catheterization on all patients, all comers, despite the amount fof extravasation and have not had a problem with it. Unless the technique of performing eystogram is very well controlled, i you want to see a lange extravaration just have the reside pula litle more contrast in than if you want to see a smal extravasation! TT yon) want lo operate, use more contrast and you ean be seared by the amount of extravasation and operate ‘ma Jot more patients! don't know where in the bladder the injuries are usually seen. People ask me that all the time. They ask how we knose they are not at the hase? How do we know they do not involve the ureter? We do a urogram on all the patients, end don't worry about localizing the injuries but the patients have all done well with oar therapy. Doctor Phillips, our routine for penetrating injuries is to explore them all think you are probably right. With the use ‘of CT now and a good eystoxtam you probably could make sure you have only an extraperitoneal injury, and Tassume you could fo ahead and treat it as we have outlined, In-answer to Doctor Nance, in ou experience with inteaper- itoneal bladder injuries im hivnt injuries they are usually sith full bladder, snl in my experience the entire dome has a buge rent and the urine preferentially leaks into the peritoneal cavity. A catheter will not drain i well, and you can develop Thank you very much,