EMERGENCY &

TRAUMATOLOGY SYSTEM

DIVISION OF UROLOGY, DEPARTMENT OF SURGERY

FACULTY OF MEDICINE, UNIVERSITY OF HASANUDDIN
MAKASSAR
INJURIES TO THE GENITO URINARY
(GU) TRACT
 About 10 % of all injuries seen in the
emergency room involve the GU system to
some extent
 Any crush injury / multiple injuries which
are associated with hematuria /
(macroscopic / microscopic) or bleeding
through external meatus urethrae mean a
urinary tract rupture is present
 Blood at urethra meatus in men indicates
rupture of urethra  retrograde urethrography
should be done immediately
 If no blood is present at the meatus urethra
catheter is inserted to recover urine. If hematuri
(macro / microscopic) indicated mid or upper
urinary tract injury
 Early diagnosis and management are essential to
prevent serious complication
 Initial assessment should be done include
control of breathing & airway, hemorrhage and
shock along with resuscitation as required
INJURIES TO THE KIDNEY
 Renal injuries are the most common injuries of
the urinary system
 Most injuries occurs from traffic accidents or
sporting mishaps
 Chiefly in men and boys (90%)
 The kidney is well protected by heavy lumbar
muscles, vetebral bodies, ribs and the viscera
arterially
 Fracture ribs may penetrate the renal
parenchyma or vasculature
Ref SCOTT p. 103
 Kidney with existing pathologic condition
such as hydronephrosis, malignant tumors
or cysts are more readily rupture from
mild trauma

ETIOLOGY
 Any such wound in the flank area should

be regarded as a cause of renal injury

until proved otherwise
 Associated abdominal visceral injuries are

present in 80% of renal penetrating

wounds
Trauma May Result of :
1. Blunt trauma
a. Direct blow to the abdomen, flank or back is the most
common mechanism accounting 80-85% of all renal injury :
traffic accident, fight, sport
b. Indirect (contracoup) injury, caused by falling from a height
and landing on the feet or buttocks

Ref. Tanagho Ed.15th p.334

2. Penetrating injury cause by Knives Bullet, etc
PATHOLOGY AND CLASSIFICATION
OF INJURY
A. Early Pathology

Laceration usually occur transverse to the

long axis of the kidney or tends to radiate
from the hilus renal kidney are classified
pathologically or follows :
1. Minor renal trauma (85% of cases)
Grade I :
 Renal contusion /

echymosis Of the
parenchym
 Sub capsular

hematoma without
parechymal
laceration
Ref. Smith’s Ed. 6th p. 222 (Grd. I)
Grade II:
 Small perirenal
hematoma and cortical
laceration less than 1
cm and renal capsule is
ruptured

Ref. Tanagho Ed.15th

p.335 B Grd. II
2. Mayor Renal Trauma (15% of cases)
Grade III :
 Incomplete fissure of
parenchyma and
capsule with perirenal
hematoma : gross
hematuri (-),
erythrocyturia (+)
 Incomplete fissure of
parenchyma tend
pelvis  gross
hematuri (+), peri
renal hematoma (-)

Ref. Smith’s Ed.6th p.222 (Grd.III)

Grade IV :
 Complete fissure parenchym
and capsule, and pelvis :
gross hematuri (+) perirenal
hematoma (+), extravasion of
urine (+) Ref. Smith’s Ed.6th p.222 (Grd.IV)

 Thrombosis of segmental
renal artery with out
parenchymal laceration 
corresponding parencymal
ischemia

Ref. Tanagho Ed. 15th p. 336 (E)

Grade V :
 Thrombosis of the main renal artery
 Multiple renal laceration = fragmentation kidney

Ref.Tanagho Ed.15th p.336 (G)

3. Critical Renal Injury (1% of all blunt trauma)
 Vascular injury (critical renal injury) 1 + 1% of all blunt
trauma
Grade V. Avulsion of the main renal artery and / or vein

Ref. Scott p.103

It causes massive bleeding which may prove rapidly fatal :
mechanism of injury is falling on buttock from height.

Ref. Tanagho Ed.15th p.334 (right)

OTHERS PATHOLOGIC LESSION ON CV
REGION INJURY
 Rupture of the renal pelvis.
Usually penetrating injury
 Incomplete total rupture
 Perirenal hematoma (+)
 Urinary extravasion (+)
 Gross hematuria
 Complete total rupture
 Perirenal hematoma (+)
 Urinary extravasion
 Gross hematuri or mild
hematuria
 OTHER ORGAN LESION
 Fracture of ribs  haemothorax
 Fracture of spine
 Intra peritoneal bleeding  spleen or liver
rupture
CLINICAL FINDING
 Gross hematuria or microscopic following
trauma to the abdomen or flank
 Stab or gunshot wounds to the flank area
or abdomen whether or Not hematuria
 The degree of renal injury does not
correspond to the degree of hematuria,
since gross hematuria, may occur in minor
renal trauma and only mild hematuria in
major trauma
 Usually visible evidence of abdominal or flank
trauma
 Pain may be localized to one flank area or over
the abdomen
 Associated injuries such as ruptured abdominal
viscera or multiple injury pelvic fractures,
cause “acute abdomen”, diffuse abdominal
tenderness on palpation, may obscure the
presence of renal injuries  catheterization :
Hematuria
 Retroperitoneal bleeding may cause abdominal
distention, ileus, nausea & vomiting
 Large retroperitoneal hematoma or urinary
extravasation can be detected with palpation and
percussion on the flank or upper quadrant of the
abdomen
 Lower ribs fracture are frequently found 
associated with hemothorax and dyspneu
 Shock due to large hemorrhage
 Hypersensitivity of the testis ipsilateral
 Colicky pain or urinary retention by blood clothing
DIAGNOSIS
1. CLINICAL FINDINGS
2. LABORATORY FINDING :
 Gross or microscopic hematuri
 Hematocril may be normal initially but a
drop may be found when serial studies are
done
 Hemoglobin drops and leucocytosis
3. X-Ray Findings :
a. Plain films :
 Non Visualization of the kidney
 Hyper dens on the injury side
 Psoas shadows disappears
 Scoliosis vertebra to the injury side
 Flexura colica tend to mid line
 May be ribs fractures is present
b. Urography Intra Vena :
 May be non visualization of the kidney  a functional
reflectories  required USG or CT Scanning
 Deformity of pelvio-calyces system
 Urinary (urografin) extravasations
 Dysplacement/deformity of the pelvis renis/ ureter due to
hematuri/urinary infiltrate
 To contral the function of the kidney contra-lateral
4. Ultrasonography : little use initially in the
evaluation of renal injuries but
sometimes can detected rupture of the
Kidney and fluid (urinary extravasation)
in the retroperitoneal space.
5. CT-Scan
 Staging/grading pathologist renal injury
 Clearly defines parechymal laceration and
urinary extravasation
 To identify non visible tissue and outlines
injuries to surrounding organ, such as the
pancreas, spleen, liver and bowel
6. Arteriography
 Arteriography defines major arterial and
parenchymal injuries when previous studies have
not fully done so
 Arterial thrombosis and avulsion of the renal pedicle
 When the kidney is not visualized on imaging
studies (excretory urogram) :
 Total pedicle avulsion
 Arterial thrombosis
 Severe contusion causing vascular spasm
 Absent of the kidney
7. Other examination such as :
 RPG
 Cystoscopy are rare used
 URS
DIFFERENTIAL DIAGNOSIS
 Lumbal muscles contusion
 Lower ribs fracture
 Vertebral column / processes transverses
fracture  - Hematuri
- Urography excretory normal
COMPLICATION
A. EARLY COMPLICATION
1. Hemorrhage : it is the most important
immediate complication :
 Retro peritoneal bleeding
 Gross hematuri
 Patient must be observed closely with careful
monitoring of blood pressure and hematocrit,
heavy retro peritoneal bleeding,  measure the
size and expansion of palpable retro peritoneal
masses , and heavy gross hematuria
 Sometimes bleeding ceases spontaneously in 80-
85% of cases
2. Shock
3. Urinary extravasation from renal rupture
may show as an expanding mass, urinoma,
in the retroperitoneum. There collections are
prone to abscess formation and sepsis
4. Infection  perinephric abscess : fever,
abdominal tenderness and flank pain
5. Heavy late bleeding (secondary bleeding
may occur 1-4 weeks after injury)
B. Late Complication
1. Hydronephrosis :
Hematoma retroperitoneal  perinephric scarring or fibrosis
 ureteral kingking  hydronephris
2. Arteriovenous fistula may occur after penetrating
injuries but are not common
3. Cutaneous fistula
4. Renal atrophy may occur from vascular
compromise
5. Hypertension  consequent on development of an
area of relative ischemia with the kidney (Goldblatt
phenomenon)
6. Calculus formation
For these reasons, at 3-6 months, a follow up excretory
urogram or CT Scan should be obtained to be certain
that complication
TREATMENT
A. EMERGENCY MEASURES
 Keep the airway clean
 Breathing
 The objective of early management are prompt
treatment of shock and hemorrhage, complete
resuscitation and evaluation of associated injuries :
 Infusion & blood transfusion if needed
 Drugs : antibiotic, analgesic & coagulation drugs
 Indwelling catheter to monitor hematuria and shock
B. CONSERVATIVE TREATMENT
 Minor renal injuries from blunt trauma account for
8,5% of cases and do not usually require operation.
Bleeding stop spontaneously with bed rest and
hydration about 2-3 weeks
C. SURGICAL MEASURES
 Indication :
1. Persistent bleeding : Detected on :
 Failure to maintain a steady blood volume with blood
transfusion
 Shock can not be overcame
 Heavy gross hematuria
 Expansion of palpable retro peritoneal masses
2. Urinary extravasation  detected on imaging
examination : UIV, CT Scan or USG
3. Penetrating injuries should be surgically explored. In 80%
of cases of penetrating injuries associated organ injury
requires operation. Renal exploration is only an extension
of this procedure
4. As part of a laparotomy in cases of trauma. In laparotomy
for abdominal injury, spleen rupture or liver rupture and
found hematoma retroperitoneal, renal exploration should
be done
SURGICAL APPROACH:
TRANSPERITONEAL APPROACH
 Easy to do it

 To make certain that injury has not

caused rupture of intraperitoneal organs

such as liver, spleen etc
 If intra abdominal lesion such as liver or

spleen rupture has been excluded, surgical

approach can be exposed through the
loan
 Kind of Lesion Repair
1. Simple mattress suture of fracture
2. Partial nephrectomy : lesion/rupture on
superior or inferior pole
3. Total nephrectomy : multiple mayor
laceration/fragmentation of the kidney or
avulsion of the kidney pedicle
NOTE : Contra lateral kidney is normal of
function
Ref. SCOTT p.108
TREATMENT OF COMPLICATION
 Retroperitoneal urinoma or perinephric abscess demands
prompt surgical drainage
 Hydronephrosis e.c fibrosis may require surgical correction
or nephrectomy
 Malignant hypertension or renal atrophy requires
nephrectomy

PROGNOSIS
 Most renal injuries have an excellent prognosis with
spontaneous healing and return of renal function
 Follow up excretory urography and monitoring of blood
pressure ensure detection and appropriate management of
late hydronephrosis, hypertension and other complication
INJURY TO THE URETER
 Ureteral injury is rare. Injury sometimes
comes from external violence or
penetrating wound or usually occur
accidentally during difficult and extensive
gynecologic operations or during
abdominal perineal resection of the
rectum
ETIOLOGY
1. From External Violence : Rare
 Penetrating injuries :
 Stab wound
Usually at the mid
 Gunshot wound portion of the ureter
 Radiation therapy may impair ureteral blood
supply  necrosis
 Endoscopic ureteral manipulation :
Uretero renoscopy, ureteral catheterization
or endoscopic basket manipulation of a
ureteral stone perforation or avulsion
2. From Internal
 An accidentally during difficult and
extensive operation, where inflammatory
adhesions or if a ureter is invaded by tumor
of the rectum, colon or ovary and uterus,
may make the ureter hard to identify :
 Inadvertently ligated :
 Totally ligated

 Partially ligated
 Inadvertently cut :
 Complete devided

 Partially devided

 Devascularization may occur with extensive lymph

nodes or tumor dissection
 Ureteral necrosis
 Ureteral fibrosis  stricture
PATHOGENESIS AND PATHOLOGY
1. Ligated
 If the ureter may be inadvertently ligated
totally or partially is unrecognized at during
operation, progressive hydronephrosis will
develop and severe renal damage usually
occur post operatively
 Renal infection may then occur
 Because of ischemia, the ureter may slough
at the site of ligation  delayed
extravasation or fistula formation
 Necrosis at the site of ligation
↓
Urinary extravasation  urinoma

Intraperitoneal Extra (retro) peritoneal

↓ ↓
difusse peritonitis + paralytic ileus Urinary infiltrate
↓
Fistula Sepsis Absces
↓
Ureterovaginalis Ureterocutaneus Fistula
2. Cut – Devided
 If the ureter is completely or partially divided
during surgery but the surgeon is unaware of the
accident urinary extravasation will occur
Urinary extravasation

Intraperitoneal Extraperitoneal

Peritonitis+ paralytic Ileus Urinary infiltrat/urinoma

Absces

Fistula
(ureterocutaneus fistula)
3. Endoscopic Ureteral Manipulation
 Perforation of the ureter
 Avulsion of the ureter  urinary
extravasation  urinary infiltrate / urinoma
 absces  fistula
4. Ureteral injuries from external
penetrating injuries, usually associated
vascular and other abdominal visceral
injuries
CLINICAL FINDING (POST OPERATIVE)
SYMPTOMS & SIGNS
 If the ureter has been totally ligated

during operation the post operative course

is usually :
 Severe flank and abdominal pain
 Sometimes referred pain to shoulder
 Nausea and vomiting
 Acute progressive hydronephrosis
 Oliguria or anuria (bilateral ureter is ligated)
 Sometimes paralytic ileus is present
 If the ureter has been completely or partially
divided during operation, the post operative
course is usually
 Flank and abdominal lower quadrain pain
 Fever, 39,30 – 38,80 C
 Such patients often experience paralytic ileus
 Nausea & vomiting
 Intraperitoneal extravasation
 Diffuse Peritonitis + ileus
 Urinary infiltrat / absces  septic shock
 Urinary fistula  fistulacutaneus  vagina
fistula (Hystrectomy)
 Erythrocyturia
 Urine through surgical wound
DIAGNOSTIC
 CLINICAL FINDING
 LABORATORY FINDING :
 Ureteral injury from external violence 
hematuria : macroscopic / microscopic
 Serum creatinin level usually quickly rise if
bilateral ureteral obstruction (ligated)
 Creatinin ratio between watery discharge from
the wound and plasma
 X-Ray findings
 A plain film of the abdomen :
 Increased density in the pelvis or in area retro
peritoneum where injury is suspected (urinary
extravasation)
 PSOAS line disappeared

 Urography intravena (UIV):

 Ureteral ligated :
 Hydronephrosis
 Ureteral obstruction in where the ureter is ligated

 Ureteral divided :
 Urinary extravasations
 Retrograde urography  demonstrate the
exact site of obstruction or extravasation
 Ultrasonography
 Ligated : Hydro uretero nephrosis
 Divided : Urinary extravasation / urinoma
 Tests : watery discharge from the wound
or vagina fistula may be identified as urine
by IV injection of 10 ml of indigo carmine,
which will appear in the urine as dark blue
 DIFFERENTIAL DIAGNOSIS
1. Post operative bowel obstruction and peritonitis
 symptoms similar to those of acute ureteral
obstruction
 sonography or excretory urography/RPG to
establish whether ureteral injury has occured
2. Post operative deep wound infection in patients
with fever, ileus and localized tenderness  the
same findings are consistent with urinary
extravasations and urinoma formation
 sonography / UIV & RPG
3. Acute pyelonephritis in the early post operative
period
4. Oliguria / anuria post operatively caused by
dehydration or shock
5. Drainage of peritoneal fluid through the wound
from impending eviceration  confused with
ureteral injury an urinary extravasation
 creatinin ratio
 IV inj.indigo carmine
6. Vesico vaginal fistula  DD with
ureterovaginal fistula
 cystoscopy
COMPLICATIONS
1. Urinary extravasation  urinoma / urinary
infiltrate  infection / absces
 fistula
 sepsis
2. Stenosis stricture formation  hydronephrosis
 infection  pyelonephritis
3. Urinary extravasation intra peritoneal 
peritonitis : paralytic ileus
 sepsis
4. Bilateral ureteral ligated  acute progressive
hydronephrosis and uremia
TREATMENT
1. When the ureteral injury occurs and
recognized during operation or post
operative early :
a. Ligated : where a segment of ureter is
ligated, should been excised to relieve the
obstruction them an oblique end to end
anastomosis
Ref. SCOTT p.154
b. Cut : an oblique end to end anastomosis should be
carried out
The use of ureteric split or double J-Stent and
retroperitoneal drainage
c. Perforation of the ureter caused ureteral catheter
manipulation, usually no need operated
d. Is anastomosis may prove impossible where the
part removed is too long. Several options of
techniques can be done to bridge the defect :
 Lower ureteral injury:
 Reimplantation into the bladder alone uretero-neocystostomy
procedure of choices or combined with a psoas-hitch
procedure to minimize tension on the ureteral anastomosis
 Boari flap may help to overcome any deficiencies in length of
the ureter
 An anti reflux procedure should be done at the anastomosis
Ref. SCOTT p.155
 Mid Ureteral Injury:
 Trans uretero-ureterostomy
 A loop of small bowel with its associated blood

supply can be used to bridge the defect

 Ileal loop conduit  Bricker’s procedure

Ref. SCOTT p.415

 Upper ureteral injury:
 If there is extensive loss of the ureter :
 Anto transplantation of the kidney
 A loop of bowel replacement of the ureter
 Trans uretero-ureterostomy

Ref. SCOTT p.417

Bricker’s Procedure
2. If the injuries is not recognized until 7-10
days after the event and no infection,
absces or other complication exist 
immediate reexploration and repair but if :
 The patient has significant complication
 Urinoma / urinary infiltrate
Such as :
 Infection absces
 Immediate percutaneus / open nephrostomy

 Exploration to repair the ureter if the infection /

absces has been overcome

PROGNOSIS
1. Prognosis is excellent if the diagnosis is
made early and prompt corretive surgery
is done
2. Delay in diagnosis worsens the prognosis
because of infection, abscess,
hydronephrosis, fistula formation and
sometimes nephrectomy is needed
 INJURIES TO THE BLADDER
 Bladder injuries occur most often from
external forces
 It is an emergency case in urology
 Accident account for a large number traffic
of cases  male more than female
ETIOLOGY
1. From External Forces :
a. Direct injuries :
 Blunt injury. A sudden blow to the full bladder
causes increased intravesical pressure ; this may
either confuse the wall or split it. If the bladder
ruptures it will usually rupture into the peritoneal
cavity
 Penetrating injury :
 Stab wound
 Gunshot
REF. SCOTT p. 166
b. Indirect trauma
When the pelvis is fractured by blunt trauma,
fragment from the fracture site may
penetrate the bladder. This penetration
usually result in extra peritoneal rupture.
About 90% of all pelvic fractures are
associated with bladder rupture

REF. SCOTT p.168

2. Iatrogenic injury
a. In the course of surgery
The procedures which carry the highest risk
to the bladder include :
 Hysterectomy
 Surgery of the lower part of the colon and
rectum
 Repair of inguinal and femoral hernia
 Vaginal repair inprolapse operation
 b. Urological endoscopic procedures
 TUR Bladder tumor
 TUR Prostate
 Biopsy
 An unskilled practitioner forces an instrument or
fluid into the bladder
3. Spontaneous rupture of the bladder has
been reported where the bladder has
been quite healthy :
 Bladder carcinoma
 Severe infection
PATHOGENESIS & PATHOLOGY
1. Penetrating trauma in the pelvic area 
hematuria  bladder rupture
2. Blunt trauma :
 Contusion / laceration of the bladder mucosa
 Rupture :
 Partial rupture
 Total rupture
 Totally bladder rupture can be :
 Intraperitoneal : + 20%
 Extraperitoneal : + 80%
REF.SCOTT p.167
 Intra peritoneal rupture, urine flow into the
abdominal cavity  DD : Rupture of the liver,
spleen
 Extra peritoneal rupture, urine flow into the
cavum retzii (prevesical space). Urine
extravasation and blood may spread to
umbilicus SIAS, periprostatic space, apex
prostate gluteus through canalis
nn.ischiadicus femur through foramen
obturation and scrotum/labia mayora through
canalis inguinalis  DD : Total rupture of the
membranous urethral
CLINICAL FINDING
SYMPTOMS
 There is usually a history of lower
abdominal trauma  blunt trauma or
penetrating trauma
 Patient ordinarily are unable to urinate 
about 13% able to urinate  contussion
(30%)
 Most patients complain of pelvic (fracture)
or lower abdominal pain
 Hematuria
SIGN
 Shock may be present :
 low blood pressure Heavy bleeding
from pelvis fracture
 Raising pulse rate
 Wound at the pelvis area from a gunshot
or stab wound
 Lateral compression on the bones pelvis,
since the fracture site will show crepitus
and be painful to the touch
 Symptom and sign total extra peritoneal rupture :
 Urinary retention ; sometimes urinate in less portion 
hematuria
 A palpable mass in the lower abdomen, usually
represents a large pelvic hematoma  may be
accompanied with pelvic fracture  be painful on the
touch
 On rectal examination, landmark may be indistinct
because of a large pelvic hematoma  DD : posterior
urethra rupture
 Symptoms and signs total intraperitoneal
rupture :
 Not filling and unable to urinate
 Supra pubic tenderness with acute abdomen
(diffuses peritonitis & paralytic ileus
 Supra pubic and lower abdominal pain.
 Fluid intra abdominal cavity  like ascites 
DD : Liver or spleen rupture
 On rectal examination  protrusion of pouch
of Douglas
LABORATORY
 Anemia  Hb ↓ and leucocyt ↑
 Hematuria / erythrocyturia

DIAGNOSTIC
1. Clinical finding : this is base on :
 History
 Appearance of shock
 Inability to void
2. Imaging
 Plain film may show a fracture of the pelvis
or the presence of penetrating foreign body
 Excretory urography may show leacage of
dye
3. Catheterization : the presence of blood
(hematuria) is suspected bladder rupture
 DD : renal rupture
4. Cystography : Lateral film may show
extravasation of dye intra or
extraperitoneal
5. Cystoscopy rarely be necessary, since
bleeding and clots obscure visualization
and prevent accurate diagnosis
6. Bladder tests
 Insert catheter to the bladder. Instilled 300-
350 ml. Aquabidest or sol NaCl 0,9%, then
take fluid out from the bladder, if same with
in volume, 300-350 ml  the meaning is the
bladder is probably intact. If less than 300-
350 ml  it might be there are a bladder
rupture
 On occasion, however, this may
afford erroneous information,
omentum or blood clot may
temporarily plug the laceration or
catheter enter into intra peritoneal
cavity through the split of the bladder
wall or the hole of catheter is closed
by blood clots
DIFFERENTIAL DIAGNOSIS
1. Hematuria, DD : a injury to the kidney or
ureter  excretory urography
2. Rupture of the urethra
 Urethrocystography
 Passage of a catheter into bladder
3. Fluid intraperitoneal cavity.
DD : Rupture of the liver / spleen
COMPLICATION
1. In extra peritoneal rupture, the extravasation
of large amount of blood and urine is often
complicated by infection  a pelvic absces 
abdominal or perineal fistula may develop
2. In intra peritoneal rupture : extravasation of
urine into the abdominal cavity  if the urine
becomes infected  generalized peritonitis
occurs.
If these conditions is unrecognized and
untreated  the mortality rate is high
TREATMENT
A. EMERGENCY MEASURES
 Catheter inserted into the bladder
 Treat shock and hemorrhage
 Fluid infusion
If it is needed
 Blood transfusion
B. Conservative treatment
 contusion / partial rupture of the bladder :
 Catheterization for helping the bladder empty and
at rest
 Antibiotic, analgetic and coagulation
 Bed rest
c. SURGERY
 A lower midline abdominal incision should be
made. As the bladder is approached in the
midline
 A pelvic hematoma which is usually lateral,
should be avoid : Entering the pelvic
hematoma can result in increased bleeding
and infection of the hematoma  sub
sequent pelvic absces
 Bladder should be opened in the midline and
carefully inspected
 After repair, a supra pubic cystostomy tube
is usually left in places
1. Extra Peritoneal Rupture
 This rupture should be repaired intra
vesically
 The bladder is opened in the midline, it
should be carefully inspected and ruptured
closed within chromic absorbable suture
 A supra pubic cystostomy and urethral
catheterization usually left in place to ensure
complete urinary drainage and control of
bleeding
 Drain tube is placed at cavum retzii
2. Intra Peritoneal Rupture
 Intra peritoneal bladder ruptures should be repaired
via a trans peritoneal approach after careful trans
vesical inspection and closure of any other
perforations
 The peritoneum must be closed carefully over the
area of injury
 The bladder is closed in separate layers by
absorbable suture
 All extravaseted fluid from peritoneal cavity should
be removed before closure
 A supra pubic cystostomy and drain tube at cavum
retzii
 Drain tube intra peritoneal
3. Bladder rupture by accident of
during difficult pelvic surgery. If it’s
occurred, directly repair should be
done.
4. The patient whose cystogram shows
only laceration or small degree of
extravasation can be managed by
placing a urethral catheter into the
bladder
PROGNOSIS
 With appropriate treatment, the prognosis
is excellent
 Treatment with in 6-12 hours after the
injury morbidity and mortality will be
minimal
 If treatment is delayed for a few days,
perivesical infection or peritonitis may
develops and may not be controllable 
the number of death will be significant