UROGENITAL TRAUMA

Cystogram Follow-Up in the Management of Traumatic Bladder Disruption
Inaba K, McKenney M, Munera F, de Moya M, Lopez PP, Schulman CI, Habib FA
Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
J Trauma. 2006; 60: 23-8

• Background: The utility of obtaining a routine cystogram after the repair of intraperitoneal bladder disruption before urethral catheter removal is unknown. This study was designed to examine whether follow-up cystogram evaluation after traumatic bladder disruption affected the clinical management of these injuries. We hypothesized that routine cystograms, after operative repair of intraperitoneal bladder disruptions, provide no clinically useful information and may be eliminated in the management of these injuries.
• Methods: Our prospectively collected trauma database was retrospectively reviewed for all ICD-9 867.0 and 867.1 coded bladder injuries over a 6-year period ending in June 2004. Demographics, clinical injury data, detailed operative records, and imaging studies were reviewed for each patient. Bladder injuries were categorized as intraperitoneal (IP) or extraperitoneal (EP) bladder disruptions based on imaging results and operative exploration. Patients with IP injuries were further subdivided into those with “simple” dome disruptions or through-and-through penetrating injuries and “complex” injuries involving the trigone or ureter reimplantation. All patients sustaining isolated ureteric or urethral injury were excluded from further analysis.
• Results: In all, 20,647 trauma patients were screened for bladder injury. Out of this group, there were 50 IP (47 simple, 3 complex) and 37 EP injuries available for analysis. All IP injuries underwent operative repair. Eight of the IP injuries (all simple) had no postoperative cystogram and all were doing well at 1- to 4-week follow-up. The remaining 42 patients underwent a postoperative cystogram at 15.3 +/- 7.3 days (range 7 to 36 days). All simple IP injuries had a negative postoperative cystogram. The only positive study was in one of the three complex IP injuries. In the EP group, 21.6% had positive cystograms requiring further follow-up and intervention.
• Conclusions: Patients sustaining extraperitoneal and complex intraperitoneal bladder disruptions require routine cystogram follow-up. In those patients undergoing repair of a simple intraperitoneal bladder disruption, however, routine follow-up cystograms did not affect clinical management. Further prospective evaluation to determine the optimal timing of catheter removal in this patient population is warranted.
  
  
• Editorial Comment
  When it comes to diagnosing bladder injuries, in the vast majority, the presenting sign is gross hematuria and pelvic fracture (1). For penetrating bladder injuries, up to 50% will only have microscopic hematuria. Accurate methods for diagnosing and staging the bladder injury are a formal cystogram with retrograde filling until at least 300 mL or bladder spasm, as well as a post-drainage film to look for another potential 10-15% of injuries, hidden behind the contrast on filling. Computed tomography (CT) cystogram is also very accurate for bladder injury, and has the advantage that it can be performed at the same time as the abdominal and pelvic imaging CT. The key is that clamping the Foley often produces inadequate bladder distention for injury diagnosis. Retrograde filling is required in order to avoid missed injuries.
  This article nicely illustrates the management and evaluation methods for intraperitoneal (IP) and extraperitoneal (EP) bladder injuries. Inaba et al. divide IP bladder injuries into simple (bladder dome and wall) and complex (involve the trigone and ureteral orifice). Of 39 simple IP bladder injuries closed at the time of celiotomy, 100% were healed by 15 days. They thus effectively argue that after 2 weeks of Foley catheter rest, a cystogram is not required before Foley removal. In contrast, complex bladder injuries (which involve the trigone or ureter) typically also have significant blast injury and require prolonged Foley drainage and thus cystography to confirm healing. For EP bladder injuries, only 10-15% of pelvic fractures have an associated bladder injury, while over 90% of bladder injuries have a pelvic fracture. Inaba et al. show that 88% of EP bladder injuries heal with Foley catheter alone, by 16 days and the remaining 12% by 47 days. This is consistent with prior reports that most EP injuries heal within 2 weeks and the remaining by 4 to 6 weeks. The only EP bladder injury cases that I have seen that not heal with bladder rest were due to bony pelvic spicules penetrating the bladder, and thus required open surgical repair. Such cases are very rare.

Reference
1. Morey AF, Iverson AJ, Swan A, Harmon WJ, Spore SS, Brandes SB: Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma. 2001; 51: 683-6.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA