Diagnosis and management of bladder injury by trauma surgeons.

BACKGROUND: Bladder injuries constitute one of the most common urological injuries involving the lower urinary tract. The methods of diagnosis and management of bladder trauma have been well established and accepted. However, bladder injuries are usually associated with other major injuries, and it is our concern here how bladder injuries have been managed as part of multiple trauma.
METHODS: From 1991 to 2000, a total of 51 cases of bladder injury were retrospectively reviewed. The mechanisms of trauma, types of bladder injury, time needed to diagnosis, methods of treatment, and patient outcome, were analyzed. Diagnosis time was defined as the time interval from patient arrival to the establishment of a diagnosis either by image studies or laparotomy. Management followed the general rule that bladder contusions or extraperitoneal ruptures were treated non-operatively, and that those with intraperitoneal rupture or combined rupture underwent operative repair. If bladder injury was noted after the patient left the emergency room (ER), it was defined as a delay diagnosis. The Injury Severity Score (ISS), length of hospital stay, and morbidity were used to evaluate patient outcome.
RESULTS: The mean age of all the patients was 31.4 years old, and most of them had sustained an injury from a motor vehicle accident (40 of 51). All but 3 patients had gross hematuria. Ten of the patients underwent emergency laparotomy, and 2 of them underwent emergency neurosurgical procedures, therefore no image studies were performed for these 12 patients. A total of 33 patients underwent abdominal computed tomography (CT), but only 20 were correctly diagnosed, yielding an accuracy rate of 60.6%. There were 3 delay diagnoses, due to either a lack of gross hematuria on presentation or the patient leaving the ER before any bladder injury study could be performed. A retrograde cystogram was performed in 24 patients, with an accuracy rate of 95.9% (23 of 24). The mean diagnosis time of the 48 bladder injuries presented in the ER was 3.2 hours and the time needed to reach a diagnosis was not related to the severity of bladder injury. Those patients who underwent operation immediately did not seem to have a quicker diagnosis. Those patients with a higher injury score (ISS >16), and those patients who suffered from pelvic fracture, stayed in the hospital longer. However, the severity of the bladder injury was not related to the length of hospital stay. There was no bladder-related mortality in our series.
CONCLUSIONS: We report our results of dealing with bladder injuries from the point of view of trauma surgeons who treat bladder injury as part of multiple injuries. Although known as a procedure of choice for diagnosis of bladder injury, the retrograde cystogram was performed in fewer than half of the patients (24 of 51), which means it is not feasible in many situations. The patient outcome was determined by the severity of injury of the patient but not by the severity of bladder injury.