Bladder ruptures: Operative management may be best

Key Points

Salt Lake City-Much of the literature suggests that the majority of extraperitoneal bladder injuries seen in trauma facilities can be managed conservatively, but a recent study from the University of Utah School of Medicine, Salt Lake City calls this approach into question.

"Most literature seems to indicate extraperitoneal injuries can be managed conservatively. Our experience suggests that this might not be the case; that conservative management might lead to more long-term complications than would appear if the case were managed more aggressively up front," said first author Michael Taylor, MD, a urology resident at the University of Utah School of Medicine, working with Jeremy Myers, MD, and colleagues.

"We think that if a patient is already having his or her pelvis exposed for fixation of an anterior pelvic fracture, or if the patient is undergoing surgical exploration for other injuries, it is worthwhile to repair the bladder during the intervention because the patient is already under anesthetic. This is assuming the patient is stable from a cardiopulmonary standpoint and is able to tolerate a longer procedure."

Because the majority of the patients suffered auto accidents, concomitant injuries were common. Among these were pelvic fracture (87.7%), solid organ injury (26%), and urethral injury (13.7%).

Operative approach leads to lower leak rate

The key findings appeared when the researchers compared conservatively managed patients to those managed operatively. Some 20% of those managed conservatively evidenced persistent leak compared to 12.5% of those managed operatively. Among those patients undergoing exploratory surgery for possible injury, none who had bladder injuries repaired during the procedure manifested persistent leak compared to 16.7% who underwent more conservative treatment.

Dr. Taylor hastened to explain that these findings, although highly suggestive, were not proven because the numbers in the study were too small to achieve significance.

"But the numbers definitely pointed toward operative management as the better course. We don't have enough patients in this study to achieve statistical significance, but we feel that if we combine our data with data from other institutions, we should be able to answer the questions definitively. We are planning a multi-institutional review now," Dr. Taylor told Urology Times.

In the interim, the authors suggest that it would be prudent for trauma or orthopedic surgeons performing abdominal exploration or anterior pelvic fixation to investigate the possibility of bladder injury and consider operative management to be the primary management action for both retroperitoneal and intraperitoneal injuries. This appears, according to this study, to decrease the risk of persistent leaks needing resolution by re-operation.