Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma

Abstract

BACKGROUND The diagnostic evaluation and clinical management of bladder injuries caused by blunt force trauma are variable. We aim to formulate a practice management guideline using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. METHODS The working group, patient, intervention, comparator, outcome (PICO), formulated four questions regarding the following topics: (1) diagnostic evaluation based on patient baseline risk of bladder injury (computed tomography cystography vs. no imaging); (2) management of intraperitoneal bladder injuries (operative versus nonoperative); (3) management of extraperitoneal bladder injuries based on complexity of injury (operative vs. nonoperative); and (4) diagnostic follow-up of bladder injuries based on complexity of repair (cystography vs. no cystography). A systematic review of the MEDLINE database for English language articles with adult patients was undertaken. RevMan 5 (Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) and GRADEpro (GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. McMaster University, 2015) software were used. Recommendations were voted on by working group members. Consensus was obtained for each recommendation. RESULTS Three hundred ninety-three articles were screened, resulting in a full-text review of 64 articles. Seventeen articles were used to formulate the recommendations of this guideline. Several recommendations are made. The need for initial computed tomography cystography after trauma depends on characteristics of the trauma itself, but it is not recommended in patients without gross hematuria. In general, patients with intraperitoneal bladder ruptures should undergo operative repair. This is not routinely necessary in those with extraperitoneal ruptures unless the injury is complex. The need for follow-up cystography after bladder repair depends on the risk of urine leak. Those with low risk of urine leak do not require a follow-up study. CONCLUSION Using the GRADE process, the panel made nine recommendations based on four PICO questions concerning the evaluation and management of blunt force bladder injuries.

Alt Üriner Sistem ve Penis Travmaları Deneyimlerimiz

“…Konservatif takip veya opere edilen hastaların en az 7-10 gün sondalarının tutulması önerilmektedir. Bizim çalışmamızda da ekstraperitoneal yaralanması olan tüm hastalar konservatif takip edilmiş olup intraperitoneal yaralanması olan hastalar opere edilmiştir (5,13,16,17).…”

Extraperitoneal Bladder Injuries Associated With Pelvic Fracture Requiring Internal Fixation: What Is the Evidence?

“…3,16 Although definitive criteria are lacking, complex EBIs are usually defined as follows: concurrent rectal or vaginal injuries, open pelvic injuries, bladder neck injuries, and presence of bony spicules in the bladder lumen. 3,17…”

“…18,19,21,22 These recommendations mainly root in the concern for pelvic hardware contamination with urine and potential infectious complications when the EBI is not fixed. However, there are no prospective trials investigating this matter, and the evidence behind these recommendations are weak 3,17,18 and based upon low-quality data from small series. 23,24 Very few studies have directly looked at pelvic hardware infection after EBI, and although still controversial and subject to major selection biases, recent studies have shown mixed results comparing orthopedic complications in EBI patients who were managed nonoperatively compared to those who underwent surgical repair.…”

“…At the same time, concern for pelvic hardware contamination was among the leading reasons for surgical repair of EBIs in both cohorts. 10,13 Although under ideal circumstances bladder repair can be a reasonable approach when concomitant surgeries such as ORIF are planned, 17,30 current evidence does not support avoiding ORIF if bladder repair is not possible, for example, when lack of access to a surgeon with experience in repairing the bladder or if other injuries make bladder repair complicated. Additionally, many patients with pelvic fractures have concomitant injuries and will be assigned high injury severity scores, and according to damage control orthopedics principles, open interventions might be delayed usually to after day 4.…”

“…3,16 Although definitive criteria are lacking, complex EBIs are usually defined as follows: concurrent rectal or vaginal injuries, open pelvic injuries, bladder neck injuries, and presence of bony spicules in the bladder lumen. 3,17 Extraperitoneal bladder injuries are more commonly associated with pelvic ring fractures, some of them needing anterior pelvic ring stabilization. This is usually achieved with open reduction and internal fixation (ORIF), by plate and screws or screws only, or alternatively with external fixation of the pelvis.…”