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Treatment of Rupture of the Bladder
Vol. 116, August Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
TREATMENT OF RUPTURE OF THE BLADDER V. L. ROBARDS, JR.,* R. V. HAGLUND, E. N. LUBIN
AND
J. R. LEACH
From the Sections of Urology, Hillcrest Medical Center and St. John's Hospital, Tulsa, Oklahoma
ABSTRACT
Herein we review our 6-year experience with operative and non-operative treatment of bladder ruptures. Many ruptured bladders with extraperitoneal and intraperitoneal extravasation of urine can be treated without an operation and with less patient morbidity. Surgical exploration with closure of the laceration and drainage of the bladder and paravesical space is the usually accepted therapy for traumatic rupture of the bladder.' The procedure is ordinarily well tolerated in otherwise healthy individuals. However, many patients with a ruptured bladder have multiple injuries and even limited procedures can be a significant threat to their lives. While in the military service a few years ago one of the authors observed several patients with traumatically ruptured
catheters were connected to drainage after the diagnostic studies. If, with close observation, reasonable clearing of the urine occurred and there were no other indications for a surgical procedure the patients were treated without an operation. The causes of bladder perforation were similar to those reported in other series (see table). All but 1 of the patients requiring an operation were injured in automobile accidents. The need to operate was probably because of the associated
Examples of cystograms from patients who did not undergo operations
bladders who had been treated in the field with urethral catheter drainage, analgesics and fluid replacement. He observed that the urine frequently was clear and that the patients were stable when they arrived at the general hospital. It seemed obvious that these patients would not necessarily benefit from an operation to close the bladder. These observations subsequently led to a more varied approach to the treatment of rupture of the bladder in civilian practice. CASE MATERIAL
From July 1969 through June 1975, 34 patients with injuries to the bladder were evaluated with excretory urograms, retrograde cystograms and other studies when indicated. Of these patients 18 were considered to have contusions of the bladder and were treated conservatively. In the remaining 16 patients preforations of the bladder were demonstrated by extravasation of contrast medium: 12 had extraperitoneal extravasation and 4 had intraperitoneal extravasation. In these cases urethral Accepted for publication December 5, 1975. * Requests for reprints: Tulsa Urologic Clinic, Inc., 550 Doctors Bldg., Tulsa, Oklahoma 74104.
178
injuries and not because of the severity of the bladder injury. Eight patients were treated operatively and 8 non-operatively. Of the 8 patients treated without an operation 2 had intraperitoneal and 6 had extraperitoneal extravasation of contrast medium and all did well. Even though all patients were treated with antibiotics at some time during the hospitalization, treatment was not instituted in some cases until the catheters were removed. We used Foley catheters varying in size from 16 to 24F. The urethral catheters were left in place from 7 days to 5 weeks. Some catheters were allowed to remain Causes of rupture of bladder-16 cases Operated
Not Operated
Automobile accident Motorcycle accident Stab wound Gunshot wound Transurethral resection injury Stomped Thrown from horse
7
3
0 1 0 0 0 0
1 0 1 1 1 1
Totals
8
8
179
TREATMENT OF BLADDER RUPTURE
for a prolonged period for nursing convenience in patients with injuries to the head, pelvis or extremities. Examples of cystograms from this group show that the injuries were significant as evidenced by extravasation of contrast medium (see figure). Of the 8 patients explored surgically 2 had intraperitoneal and 6 had extraperitoneal extravasation. In all cases the lacerations were closed and drainage was provided for the bladder and paravesical area. Four patients had ruptured spleens and the need for splenectomy was the primary indication for an operation. In another patient rupture of the spleen was suspected but not confirmed. Another patient was explored because of an abdominal stab wound and the suspicion of a concomitant bowel injury. The bladder injury was the principal indication for an operation in only 2 of the patients. One of these had massive hematuria with extensive lacerations of the bladder in the other patient, the catheter was noted to be outside the bladder when the cystogram was performed. The catheters remained in place from 7 to 8 weeks postoperatively. They were allowed to remain for long periods in some patients for nursing convenience. All patients except the 1 with the stab wound to the bladder received antibiotic treatment. In 2 patients residual urethral strictures have required subsequent treatment. COMMENT
Although it is generally accepted that operative treatment is indicated for traumatic rupture of the bladder some authors have suggested that conservative treatment is sufficient in a limited number of cases. 2 Waterhouse and Gross reviewed cases of trauma to the genitourinary tract in 1969 and suggested that extraperitoneal perforation of the bladder may be managed conservatively if careful clinical assessments are made. 3 In 1972 Lucey and associates stated that drainage with Foley catheters was used occasionally in the treatment of extraperitoneal ruptures but that all intraperitoneal perforations of the bladder must be explored.' Del Villar and associates treated 1 of their 51 patients with ruptured bladders with urethral catheter drainage. 5 In 1974 Mulkey and Witherington reported satisfactory results with conservative (nonoperative) treatment in 8 patients! However, they did not state the percentage of their patients who were managed in this fashion. Richardson and Leadbetter recently reported on 3 patients with ruptured bladders who were treated with urethral catheter drainage only. 6 They related that 4 of 10 patients were treated conservatively with satisfactory results.
Prior to the institution of this study we were confident that surgical closure was not necessary in the treatment of all patients with perforated bladders. However, we were somewhat surprised to learn, in retrospect, that only 50 per cent of our patients had been treated with an operation. Furthermore, we observed that intraperitoneal extravasation did not seem to be a firm indication for a surgical procedure. Finally, we noted that only 2 of the 8 patients who were operated upon required the procedure primarily for treatment of the bladder injury. All patients treated without operations fared well, without prolonged hospitalization and without complications related to the non-operative treatment. This experience, we believe, validates our approach to the management of rupture of the bladder. Surgical procedures are unnecessary and can be avoided in many patients this fact seems particularly in patients with inJuries. Non-operative treatment of bladders is not suggested as an easy way out. To the contrary, considered for conservative management must be evaluated as and promptly as possible with close attention being focused on general and supportive management as well as on the of the urinary tract. It often has seemed that concern for correct judgment regarding appropriate treatment has required more time and effort than would be required for the unquestioned, relatively simple operation for closure of a ruptured bladder. However, the additional concern is worthwhile since the over-all risk is lessened and the results are satisfactory. REFERENCES 1. Prather, G. C.: Injuries of the bladder. In: Urology, 3rd ed. Edited
2. 3. 4.
5.
6.
by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., vol. 1, p. 852, 1970. Mulkey. A. P., Jr. and Witherington, R.: Conservative management of vesical rupture. Urology, 4: 426, 1974. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., llH: 241, 1969. Lucey, D. T., Smith, M. J. V. and Koontz, W. W., Jr.: Modem trends in the management of urologic trauma. J. Urol., Hl7: 641, 1972. Del Villar, R. G., Ireland, G. W. and Cass, A. S.: Management of bladder and urethral injury in conjunction with the immediate surgical treatment of the acute severe trauma patient. J. Urol., Hl8: 581, 1972. Richardson, J. R., Jr. and LeadbEtter, G. W., Jr.: Non-operative treatment of the ruptured bladder. J. Urol., 114: 213, 1975.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
TREATMENT OF RUPTURE OF THE BLADDER V. L. ROBARDS, JR.,* R. V. HAGLUND, E. N. LUBIN
AND
J. R. LEACH
From the Sections of Urology, Hillcrest Medical Center and St. John's Hospital, Tulsa, Oklahoma
ABSTRACT
Herein we review our 6-year experience with operative and non-operative treatment of bladder ruptures. Many ruptured bladders with extraperitoneal and intraperitoneal extravasation of urine can be treated without an operation and with less patient morbidity. Surgical exploration with closure of the laceration and drainage of the bladder and paravesical space is the usually accepted therapy for traumatic rupture of the bladder.' The procedure is ordinarily well tolerated in otherwise healthy individuals. However, many patients with a ruptured bladder have multiple injuries and even limited procedures can be a significant threat to their lives. While in the military service a few years ago one of the authors observed several patients with traumatically ruptured
catheters were connected to drainage after the diagnostic studies. If, with close observation, reasonable clearing of the urine occurred and there were no other indications for a surgical procedure the patients were treated without an operation. The causes of bladder perforation were similar to those reported in other series (see table). All but 1 of the patients requiring an operation were injured in automobile accidents. The need to operate was probably because of the associated
Examples of cystograms from patients who did not undergo operations
bladders who had been treated in the field with urethral catheter drainage, analgesics and fluid replacement. He observed that the urine frequently was clear and that the patients were stable when they arrived at the general hospital. It seemed obvious that these patients would not necessarily benefit from an operation to close the bladder. These observations subsequently led to a more varied approach to the treatment of rupture of the bladder in civilian practice. CASE MATERIAL
From July 1969 through June 1975, 34 patients with injuries to the bladder were evaluated with excretory urograms, retrograde cystograms and other studies when indicated. Of these patients 18 were considered to have contusions of the bladder and were treated conservatively. In the remaining 16 patients preforations of the bladder were demonstrated by extravasation of contrast medium: 12 had extraperitoneal extravasation and 4 had intraperitoneal extravasation. In these cases urethral Accepted for publication December 5, 1975. * Requests for reprints: Tulsa Urologic Clinic, Inc., 550 Doctors Bldg., Tulsa, Oklahoma 74104.
178
injuries and not because of the severity of the bladder injury. Eight patients were treated operatively and 8 non-operatively. Of the 8 patients treated without an operation 2 had intraperitoneal and 6 had extraperitoneal extravasation of contrast medium and all did well. Even though all patients were treated with antibiotics at some time during the hospitalization, treatment was not instituted in some cases until the catheters were removed. We used Foley catheters varying in size from 16 to 24F. The urethral catheters were left in place from 7 days to 5 weeks. Some catheters were allowed to remain Causes of rupture of bladder-16 cases Operated
Not Operated
Automobile accident Motorcycle accident Stab wound Gunshot wound Transurethral resection injury Stomped Thrown from horse
7
3
0 1 0 0 0 0
1 0 1 1 1 1
Totals
8
8
179
TREATMENT OF BLADDER RUPTURE
for a prolonged period for nursing convenience in patients with injuries to the head, pelvis or extremities. Examples of cystograms from this group show that the injuries were significant as evidenced by extravasation of contrast medium (see figure). Of the 8 patients explored surgically 2 had intraperitoneal and 6 had extraperitoneal extravasation. In all cases the lacerations were closed and drainage was provided for the bladder and paravesical area. Four patients had ruptured spleens and the need for splenectomy was the primary indication for an operation. In another patient rupture of the spleen was suspected but not confirmed. Another patient was explored because of an abdominal stab wound and the suspicion of a concomitant bowel injury. The bladder injury was the principal indication for an operation in only 2 of the patients. One of these had massive hematuria with extensive lacerations of the bladder in the other patient, the catheter was noted to be outside the bladder when the cystogram was performed. The catheters remained in place from 7 to 8 weeks postoperatively. They were allowed to remain for long periods in some patients for nursing convenience. All patients except the 1 with the stab wound to the bladder received antibiotic treatment. In 2 patients residual urethral strictures have required subsequent treatment. COMMENT
Although it is generally accepted that operative treatment is indicated for traumatic rupture of the bladder some authors have suggested that conservative treatment is sufficient in a limited number of cases. 2 Waterhouse and Gross reviewed cases of trauma to the genitourinary tract in 1969 and suggested that extraperitoneal perforation of the bladder may be managed conservatively if careful clinical assessments are made. 3 In 1972 Lucey and associates stated that drainage with Foley catheters was used occasionally in the treatment of extraperitoneal ruptures but that all intraperitoneal perforations of the bladder must be explored.' Del Villar and associates treated 1 of their 51 patients with ruptured bladders with urethral catheter drainage. 5 In 1974 Mulkey and Witherington reported satisfactory results with conservative (nonoperative) treatment in 8 patients! However, they did not state the percentage of their patients who were managed in this fashion. Richardson and Leadbetter recently reported on 3 patients with ruptured bladders who were treated with urethral catheter drainage only. 6 They related that 4 of 10 patients were treated conservatively with satisfactory results.
Prior to the institution of this study we were confident that surgical closure was not necessary in the treatment of all patients with perforated bladders. However, we were somewhat surprised to learn, in retrospect, that only 50 per cent of our patients had been treated with an operation. Furthermore, we observed that intraperitoneal extravasation did not seem to be a firm indication for a surgical procedure. Finally, we noted that only 2 of the 8 patients who were operated upon required the procedure primarily for treatment of the bladder injury. All patients treated without operations fared well, without prolonged hospitalization and without complications related to the non-operative treatment. This experience, we believe, validates our approach to the management of rupture of the bladder. Surgical procedures are unnecessary and can be avoided in many patients this fact seems particularly in patients with inJuries. Non-operative treatment of bladders is not suggested as an easy way out. To the contrary, considered for conservative management must be evaluated as and promptly as possible with close attention being focused on general and supportive management as well as on the of the urinary tract. It often has seemed that concern for correct judgment regarding appropriate treatment has required more time and effort than would be required for the unquestioned, relatively simple operation for closure of a ruptured bladder. However, the additional concern is worthwhile since the over-all risk is lessened and the results are satisfactory. REFERENCES 1. Prather, G. C.: Injuries of the bladder. In: Urology, 3rd ed. Edited
2. 3. 4.
5.
6.
by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., vol. 1, p. 852, 1970. Mulkey. A. P., Jr. and Witherington, R.: Conservative management of vesical rupture. Urology, 4: 426, 1974. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., llH: 241, 1969. Lucey, D. T., Smith, M. J. V. and Koontz, W. W., Jr.: Modem trends in the management of urologic trauma. J. Urol., Hl7: 641, 1972. Del Villar, R. G., Ireland, G. W. and Cass, A. S.: Management of bladder and urethral injury in conjunction with the immediate surgical treatment of the acute severe trauma patient. J. Urol., Hl8: 581, 1972. Richardson, J. R., Jr. and LeadbEtter, G. W., Jr.: Non-operative treatment of the ruptured bladder. J. Urol., 114: 213, 1975.