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Bladder Trauma
Ervandy Rangganata
Department of Urology
Faculty of Medicine Universitas Indonesia
RSUPN Dr. Cipto Mangunkusumo
Ny. Nunung
Herawati, 40 th, RM
4452294
Keluhan
Utama
• Pasien rujukan dari RS
Persahabatan karena plasenta
previa totalis spektrum akreta
Riwayat
Penyakit
Sekarang
• Pasien mengaku hamil 9 bulan, HPHT sekitar bulan
Agustus 2019 (tidak yakin), ANC di Klinik sampai usia
hamil 4 bulan, lalu di Puskesmas Duren Sawit 4 kali
dan dirujuk ke RS Saidah lalu ke RSUP Persahabatan,
dikatakan plasenta previa dengan spektrum akreta
pada usia 7 bulan.
• Keluhan mulas-mulas disangkal. Keluar darah
berupa flek, keluar air lendir darah tidak ada, gerak
janin aktif, keputihan tidak ada.
• BAK dan BAB normal.
• TS Obgyn konsultasi ke Urologi untuk backup
operasi SC hingga histerektomi total.
Riwayat
Penyakit
Dahulu
• Hipertensi, diabetes, asma, penyakit
jantung, alergi disangkal.
Riwayat Penyakit
Keluarga
Hipertensi, diabetes, asma, penyakit
jantung, alergi disangkal.
Riwayat
Sosial
• Riwayat Menstruasi : Menarche 15 tahun, haid
teratur siklus 28-30 hari, 5-7 hari, ganti pembalut 34x/hari, dismenorea negatif
• Riwayat Menikah : 1 kali, tahun 2007-sekarang
• Riwayat Obstetri : G5P3A1
1.2008, Keguguran usia kehamilan 4 bulan, kuretase
2.2011, perempuan, 2550 gram, SC atas indikasi
plasenta previa, RS Bunda Aliyah
3.2013, laki-laki, 2700 gram, SC atas indikasi bekas
sesar 1 kali, RS Bunda Aliyah
4.2015, perempuan, 2800 gram, SC atas indikasi bekas
sesar 2 kali, RS Bunda Aliyah
5.Hamil ini
Status
Urologi
• Keadaan umum baik, kesadaran kompos
mentis
• TD 109/74 mmHg, FN 82x/m, RR 18x/m, S
35,3oC
• TB 150 cm, BB 51 kg
• Flank: Tidak ada massa, tidak ada bulging
• Suprasimfisis: Buli kesan kosong
• Genitalia eksterna: dalam batas normal
Diagnosis
• G5P3A1 hamil 36-37 minggu, janin
presentasi kepala tunggal hidup, plasenta
previa totalis spektrum akreta, bekas sesar 3
kali
Temuan
IntraOperatif
Discussion
Trauma
• Physical injury or a wound to living tissue caused by an
extrinsic agent
• 10% of all mortalities
• Men > women  motor vehicle accidents (MVAs) and
interpersonal violence
Introduction
(Trauma)
Classification of trauma
• World Health Organization (WHO)
• Intentional
• Unintentional
• Mechanism of injury
• Blunt
• Penetrating
• high-velocity projectiles (e.g. rifle bullets - 800-1,000
m/sec)
• medium-velocity projectiles (e.g. handgun bullets - 200300 m/sec)
• low-velocity items (e.g. knife stab)
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Motor vehicle accidents are
the most common cause of
blunt bladder injury, followed
by falls and other accidents
Bladder
Trauma
Pelvic crush
Blows to lower abdomen
Blunt bladder trauma  associated pelvic fractures
(60-90%) and other intra-abdominal injuries (4468.5%)
Bladder injury is associated with urethral injury in 520% of cases
Classification of bladder trauma
• Location of Injury
• Intraperitoneal
• Sudden rise in intra-vesical pressure of a
distended bladder
• Secondary to a blow to the pelvis or lower
abdomen
• Extraperitoneal
• Almost always associated with pelvic
fractures
• Distortion of the pelvic ring
• Disruption of the pelvic circle with
displacement > 1 cm
• Diastasis of the pubic symphysis > 1 cm
• Pubic rami fractures
• Bladder perforated by a sharp bony
fragment
• Combined intra-extraperitoneal
• Etiology of Injury
• Non-iatrogenic
• Blunt trauma
• Penetrating trauma
• Iatrogenic
• External
• Obstetric and gynecological procedures
• Urological procedures
• General surgical operations
• Internal
• Transurethral resection of the bladder
(TURB)
• Risk factor  Larger tumors, older age,
pre-treated bladders, location at bladder
dome
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Diagnosis of Bladder Trauma
History Taking
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•
•
•
•
Diagnosis of
Bladder
Trauma
Trauma mechanism
Pain in the pelvis or lower abdomen
Hematuria
Urine retention
History of urinary tract surgery or previous obstetric and gynecological
operations
Physical examination
• Primary survey
• Abdomen
• Presence / absence of muscular defans
• Distension and lower abdominal tenderness
• Suprapubic: hematoma, distension, tenderness
• Examination of a suspected pelvic fracture (pelvic instability, lower limb
look feel move)
• Swelling of the scrotum, perineum, thighs
Supporting examination
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
RADIOLOGIC EXAMINATION
•
•
Absolute indications:
• Visible haematuria and pelvic fracture
• Non-visible haematuria combined with high-risk pelvic fracture
• Posterior urethral injury
Relative indications:
• Inability to void or inadequate urine output
• Abdominal tenderness or distention due to urinary ascites, or signs of urinary ascites
• Uremia and elevated creatinine
• Entry or exit wounds at lower abdomen, perineum, or buttocks in penetrating injuries
Kitrey ND, et al. EAU Guidelines on Urologic Trauma. EAU 2020.
Morey AF, Zhao LC. Genital and Lower Urinary Tract Trauma. In: Campbell-Walsh Urology 11th Ed. Elsevier. 2016
DIAGNOSTIC EVALUATION
INTRA-OPERATIVE SIGNS OF EXTERNAL IBT
•
Extravasation of urine, visible laceration, visible bladder catheter, blood and/or gas in the urine bag during laparoscopy
POST-OPERATIVELY, missed bladder trauma is diagnosed by:
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•
•
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Haematuria, abdominal pain, abdominal distention, ileus, peritonitis
Sepsis, urine leakage from the wound, decreased urinary output
Increased serum creatinine
IBT during hysterectomy or caesarean delivery can result VVF or VUF
RADIOLOGIC EXAMINATION
•
•
•
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Ultrasonography
Cystography
CT Cystography
Cystoscopy
Kitrey ND, et al. EAU Guidelines on Urologic Trauma. EAU 2020.
Morey AF, Zhao LC. Genital and Lower Urinary Tract Trauma. In: Campbell-Walsh Urology 11th Ed. Elsevier. 2016
Supporting
examination
• Laboratory examination
• CBC: Hemoglobin, hematocrit
• Ur/Cr: Uraemia and elevated
creatinine level due to
intraperitoneal reabsorption
• Urinalysis
• Plain X-ray  bone deformity in
the pelvic area
• Cystography
• Cystoscopy
• Ultrasound
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Cystography
• Preferred diagnostic modality for non-iatrogenic
bladder injury & suspected IBT in the postoperative setting
• Both plain and CT cystography  sensitivity (9095%) & specificity (100%)
• CT: superior in the identification of bony
fragments in the bladder, bladder neck injuries,
and concomitant abdominal injuries
• Retrograde filling of the bladder
• Minimum volume of 300-350 mL of dilute
contrast material
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma:
Bladder Trauma. Eur Urol, 2020. p. 17-21.
CYSTOGRAPHY
INDICATIONS:
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•
•
•
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Gross haematuria
Disruption of pelvic circle >1 cm
Diathesis symphysis pubis >1 cm
Posterior urethral injury
Suspected postoperative IBT
INTERPRETATIONS:
• Scout: fracture or not
• Contrast/Cystogram: intra or extraperitoneal
extravasation
• Post-void: residual urine and extravasation to posterior
TECHNIQUES:
• Retrograde filling with min. volume dilute contrast 300-350 mL (Contrast:NaCl 1:3 or 1:6)
• Filling up to opening the bladder neck or 1.5 times of maximum bladder capacity (max. 300 mL)
Intraperitoneal extravasation is contrast in the abdomen outlining bowel loops or viscera
Extraperitoneal extravasation is typically diagnosed by “flame-shaped” area of contrast
Kitrey ND, et al. EAU Guidelines on Urologic Trauma. EAU 2020.
Morey AF, Zhao LC. Genital and Lower Urinary Tract Trauma. In: Campbell-Walsh Urology 11th Ed. Elsevier. 2016
CYSTOGRAPHY
Intraperitoneal Bladder Injury
Scout
Post-void
Extraperitoneal Bladder Injury
CT CYSTOGRAPHY
• Advantages:
• Patient cannot be positioned, e.g. pelvic fracture
• Superior to identification of bone fragments
• Damage on the bladder neck
• Concomitant abdominal injuries
CT UROGRAPHY
Joshi G, Kim EY, Hanna TN, Siegel CL, Menias CO. CT Cystography for Suspicion of Traumatic Urinary Bladder
Injury: Indications, Technique, Findings, and Pitfalls in Diagnosis. RadioGraphics. 2018;38-92-3
Cystography
• Intraperitoneal extravasation:
• Free contrast medium in the abdomen outlining bowel loops or abdominal viscera
• Extraperitoneal bladder injury:
• Typically diagnosed by flame-shaped areas of contrast extravasation in the perivesical soft tissues
• Contrast medium in the vagina is a sign of vesico-vaginal fistula
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Cystoscopy
• Preferred method for detection of
intra-operative bladder injuries:
• Directly visualize the laceration
• Localization the lesion in relation to the
position of the trigone and ureteral
orifices
• Minimal bladder distension during
cystoscopy  large perforation
• Recommended to detect perforation
of the bladder or urethra following
retropubic sub-urethral sling
operations
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Ultrasound
• Ultrasound alone is insufficient in the diagnosis of bladder trauma
• Visualisation of intraperitoneal fluid or an extraperitoneal collection
of fluid
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
AAST GRADING OF BLADDER INJURY
Santucci RA. McAninch JW. Bladder injuries: evaluation and management. Braz J Urol. 2000;26:408-14
Moore EE, et al. Scaling system for organ specific injuries. AAST Guidelines 2019.
Prevention of Bladder Injury
• Emptying the bladder by urethral catheterization in every procedure
where the bladder is at risk
• Obturator nerve block or general anesthesia with adequate muscle
relaxation
• Reducing the incidence of internal IBT during TURB for tumors at the lateral
wall
• The use of combat pelvic protection systems reduces the risk of
bladder and other genitourinary injuries due to the blast mechanism
of improvised explosive devices
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Management of Bladder
Trauma
Blunt
trauma:
Management
• Extraperitoneal blunt trauma:
conservative treatment
• Intraperitoneal blunt trauma:
laparotomy bladder repair
Penetrating
trauma
• Extraperitoneal bladder and
intraperitoneal bladder exploration
is carried out
Monitoring:
• Maintain catheter 1-2 weeks
• On the 14th day a cystography was
performed if there was a need for a
catheter removal
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
MANAGEMENT
BLUNT NON-IATROGENIC TRAUMA
• Extraperitoneal ruptures ⟶ conservative
• Intraperitoneal ruptures ⟶ surgical
PENETRATING NON-IATROGENIC TRAUMA
• Emergency exploration, debridement of devitalised bladder, primary bladder repair ⟶ midline exploratory
cystostomy
• Gunshot wounds: 2 transmural injuries; usually requiring faecal diversion; antibiotic treatment
IATROGENIC TRAUMA
• Recognised intraoperative ⟶ primary closed
• Intraperitoneal injuries ⟶ surgical exploration and repair
• Extraperitoneal injuries ⟶ exploration; drainage of the collection w/wo closure perforation
Kitrey ND, et al. EAU Guidelines on Urologic Trauma. EAU 2020.
Morey AF, Zhao LC. Genital and Lower Urinary Tract Trauma. In: Campbell-Walsh Urology 11th Ed. Elsevier. 2016
MANAGEMENT
CONSERVATIVE INDICATIONS
• Uncomplicated extraperitoneal injuries
SURGICAL INDICATIONS
• All penetrating trauma
• Complicated blunt intraperitoneal injury
• Concomitant rectal and vaginal injury
• Bone fragments in the bladder
• During surgical exploration and/or ORIF
• Intraoperative consultation
• Entrapment of bladder wall
Kitrey ND, et al. EAU Guidelines on Urologic Trauma. EAU 2020.
Morey AF, Zhao LC. Genital and Lower Urinary Tract Trauma. In: Campbell-Walsh Urology 11th Ed. Elsevier. 2016
Santucci RA. McAninch JW. Bladder injuries: evaluation and management. Braz J Urol. 2000;26:408-14
Uncomplicated extra peritoneal injury:
Conservative
Treatment
• Clinical observation
• Airway, breathing, circulation stabilization
• Secondary survey management
• Continuous bladder drainage  urinary catheterization
• Antibiotic prophylaxis
Conservative treatment also indicated in
uncomplicated intraperitoneal injury with the
absence of peritonitis and ileus
Penetrating extraperitoneal bladder injuries (only
if minor and isolated)
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Bladder closure is performed with absorbable sutures
There is no evidence that two-layer is superior to
watertight single-layer closure
Surgical
Management
Intraperitoneal ruptures
should always be managed
by surgical repair
Urine extravasation  peritonitis 
intra-abdominal sepsis  death
Emergency exploration
Penetrating bladder injury:
debridement of devitalized bladder
wall and primary bladder repair
Midline exploratory cystotomy is advised to inspect
the bladder wall and the distal ureters
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Follow-up
• Continuous bladder drainage  prevent elevated intravesical pressure and to allow
the bladder to heal
• Conservatively treated bladder injuries (traumatic or external IBT):
• Cystography
• to rule out extravasation and ensure proper bladder healing
• The first cystography is planned approximately ten days after injury
• In case of ongoing leakage  cystoscopy  2nd cystoscopy 1 week later
• To rule out bony fragments in the bladder
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Kitrey ND, Djakovic N, Hallschiedt P, kuehhas FE, et al. EAU Guidelines on Urologic Trauma: Bladder Trauma. Eur Urol, 2020. p. 17-21.
Summary
• Bladder trauma classified base on location (intra, extra) and etiology of Injury
(iatrogenic and non)
• History taking of trauma mechanism, pain in the pelvis or lower abdomen,
hematuria, urine retention, and history of surgery is essential
• Laboratory exam, cystography, cystoscopy, and USG are several important
supporting examination for bladder trauma
• Management of bladder trauma is divided into conservative and surgical
management
• Continuous bladder drainage is one of the most important follow-up after
treatment
THANK YOU