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Primary vs delayed repair of bladder neck injuries in children
LETTERS
TO THE EDITOR
PRIMARY VS DELAYED REPAIR OF BLADDER NECK INJURIES IN CHILDREN To the Editor: I read with interest, “Delayed Retropubic Urethroplasty of Completely Transected Female Membranous Urethra,” by Y. T. Lee and J, M. Lee, published in the June issue (vol. 33, pages 499502, 1988) of UROLOGY. As the article infers, there is healthy debate over primary versus delayed repair of injuries to the bladder neck in children, sustained through blunt abdominal trauma. Although the authors report one case managed by suprapubic drainage with delayed urethroplasty, there is a stronger case for immediate repair. In 1984, we* classified these injuries into three specific types of vesicourethral/vesicovaginal injuries after blunt lower abdominal trauma in the child. In our series, pelvic fracture was common but not completely necessary. The mechanism of injury was displacement of the pubic bones directly into the bladder, or by traction on supporting tissues of the bladder neck, resulting in disruption of the vesical neck. The vesicovaginal septum may be a point of minimum resistance, and a sudden increase in intravesical pressure or a severe shearing force may result in traumatic blow-out of the vesicovaginal septum with resultant fistula, as we described in 2 of our 3 female patients. Since the bladder neck is the region of primary continence in the female patient and is of assistance in maintaining continence in the male patient, we believe that it is important to repair the vesicourethral junction primarily rather than simple cystostomy. One exception to this approach might be the patient who has an unstable and massive pelvic hematoma. Thus, early surgical intervention should be aimed at preoperative endoscopic identification of the extent of the injury, early transabdominal suture realignment of the vesicourethral junction under direct vision, and closure of the vagina and bladder transvesically to prevent development of a vesicovaginal fistula (should a traumatic blow-out have occurred). In summary, we identified three types of injuries; type I and type II are anterior vesicoureteral avulsion, and type III is a complex injury of anterior vesicoureteral evulsion of posterior vesicovaginal septal rupture. In our series of four, there were 3 girls who sustained traumatic bladder injuries secondary to lower abdominal trauma. All 3 girls had pelvic fractures. The boy and 2 girls had vesicourethral avulsion at the bladder neck with concomitant vesi-
UROLOGY
/ OCTOBER
1988
/
VOLUME
XxX11, NUMBER
covaginal rupture. Early operation resulted in no complications in 3 children. However, delayed surgery in 1 girl resulted in poor continence, persistent vesicovaginal fistula with pyocolpos. necessitating hysterectomy. It seems that there is a significant argument for early surgical intervention in the child with a traumatic bladder neck injury. M. David Gibbons, M.D. Department of Pediatric Urology Georgetown University Children’s Medical Center Washington, D.C. *Merchant WC, Gibbons MD, and Gonzales the bladder neck, trigone and vagina in children, (1984).
BLADDER IRRIGATION CHLORHEXIDINE
ET: Trauma to J Urol 131: 747
WITH
To the Editor: Our previous study showed that intermittent bladder irrigation with 0.02 percent chlorhexidine digluconate in distilled water significantly reduced the incidence of postoperative bacteriuria in patients whose urine was sterile before operation. Our preliminary trial suggested that continuous irrigation using a 3-way catheter gave as good results, with the advantages of being easier for the nursing staff to perform and more effective in preventing catheter blockage. l A further trial, to compare results of continuous irrigation with chlorhexidine and with sterile saline, was terminated because 5 of the 41 patients in the chlorhexidine group complained of severe urgency and frequency of micturition after their catheters were removed postoperatively. These symptoms resolved quickly. None of the 42 patients continuously irrigated with saline had these symptoms. In our previous study, no side effects were caused by intermittent exposure of the bladder to chlorhexidine. Bastable et aL2 reported no side effects following short periods of continuous irrigation. Evidently, the longer exposure to chlorhexidine during continuous irrigation in our patients sometimes caused bladder irritation or chemical cystitis. Hence, continued use of this method is not justified. Pearmar? previously reported evidence that prolonged exposure
4
387
TO THE EDITOR
PRIMARY VS DELAYED REPAIR OF BLADDER NECK INJURIES IN CHILDREN To the Editor: I read with interest, “Delayed Retropubic Urethroplasty of Completely Transected Female Membranous Urethra,” by Y. T. Lee and J, M. Lee, published in the June issue (vol. 33, pages 499502, 1988) of UROLOGY. As the article infers, there is healthy debate over primary versus delayed repair of injuries to the bladder neck in children, sustained through blunt abdominal trauma. Although the authors report one case managed by suprapubic drainage with delayed urethroplasty, there is a stronger case for immediate repair. In 1984, we* classified these injuries into three specific types of vesicourethral/vesicovaginal injuries after blunt lower abdominal trauma in the child. In our series, pelvic fracture was common but not completely necessary. The mechanism of injury was displacement of the pubic bones directly into the bladder, or by traction on supporting tissues of the bladder neck, resulting in disruption of the vesical neck. The vesicovaginal septum may be a point of minimum resistance, and a sudden increase in intravesical pressure or a severe shearing force may result in traumatic blow-out of the vesicovaginal septum with resultant fistula, as we described in 2 of our 3 female patients. Since the bladder neck is the region of primary continence in the female patient and is of assistance in maintaining continence in the male patient, we believe that it is important to repair the vesicourethral junction primarily rather than simple cystostomy. One exception to this approach might be the patient who has an unstable and massive pelvic hematoma. Thus, early surgical intervention should be aimed at preoperative endoscopic identification of the extent of the injury, early transabdominal suture realignment of the vesicourethral junction under direct vision, and closure of the vagina and bladder transvesically to prevent development of a vesicovaginal fistula (should a traumatic blow-out have occurred). In summary, we identified three types of injuries; type I and type II are anterior vesicoureteral avulsion, and type III is a complex injury of anterior vesicoureteral evulsion of posterior vesicovaginal septal rupture. In our series of four, there were 3 girls who sustained traumatic bladder injuries secondary to lower abdominal trauma. All 3 girls had pelvic fractures. The boy and 2 girls had vesicourethral avulsion at the bladder neck with concomitant vesi-
UROLOGY
/ OCTOBER
1988
/
VOLUME
XxX11, NUMBER
covaginal rupture. Early operation resulted in no complications in 3 children. However, delayed surgery in 1 girl resulted in poor continence, persistent vesicovaginal fistula with pyocolpos. necessitating hysterectomy. It seems that there is a significant argument for early surgical intervention in the child with a traumatic bladder neck injury. M. David Gibbons, M.D. Department of Pediatric Urology Georgetown University Children’s Medical Center Washington, D.C. *Merchant WC, Gibbons MD, and Gonzales the bladder neck, trigone and vagina in children, (1984).
BLADDER IRRIGATION CHLORHEXIDINE
ET: Trauma to J Urol 131: 747
WITH
To the Editor: Our previous study showed that intermittent bladder irrigation with 0.02 percent chlorhexidine digluconate in distilled water significantly reduced the incidence of postoperative bacteriuria in patients whose urine was sterile before operation. Our preliminary trial suggested that continuous irrigation using a 3-way catheter gave as good results, with the advantages of being easier for the nursing staff to perform and more effective in preventing catheter blockage. l A further trial, to compare results of continuous irrigation with chlorhexidine and with sterile saline, was terminated because 5 of the 41 patients in the chlorhexidine group complained of severe urgency and frequency of micturition after their catheters were removed postoperatively. These symptoms resolved quickly. None of the 42 patients continuously irrigated with saline had these symptoms. In our previous study, no side effects were caused by intermittent exposure of the bladder to chlorhexidine. Bastable et aL2 reported no side effects following short periods of continuous irrigation. Evidently, the longer exposure to chlorhexidine during continuous irrigation in our patients sometimes caused bladder irritation or chemical cystitis. Hence, continued use of this method is not justified. Pearmar? previously reported evidence that prolonged exposure
4
387