Traumatic bladder injury may require up-front, aggressive management

Much of the literature suggests that the majority of extraperitoneal bladder injuries seen in trauma facilities can be managed conservatively. A study from the University of Utah greets that position with a degree of skepticism.

"Our experience suggests 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, of the University of Utah School of Medicine, Salt Lake City.

"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."

To explore this observation, Dr. Taylor, working with Jeremy Myers, MD, and colleagues, conducted a retrospective study of 259 patients with suspected lower urinary tract injury and identified 73 who presented with definitive extraperitoneal bladder injuries. These were young patients, mean age 38.4, the majority of whom suffered from blunt trauma injury (93.2%) resulting from auto accidents. Only 6.6% suffered penetrating injuries. Most (60.3%) were men and the mean injury severity score was 24.3.

Because the majority of the patients suffered auto accidents, concomitant injuries were common. Among these were pelvic fracture (87.7%), solid organ injury (26.0%), and urethral injury (13.7%).

The key findings appeared when the researchers compared conservatively managed patients to those managed operatively. Twenty percent 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, whereas 16.7% who underwent more conservative treatment experienced persistent leak.

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," Dr. Taylor said.