Operation for injury of bladder

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Operation for injury of bladder

 

The urinary bladder is well protected since it is located in the deep pelvic cavity. As a result, it is seldom traumatized. However, it is susceptible to injuries that might result in extraperitoneal and intraperitoneal ruptures.

 

Bladder damage is distinguished by severe haematuria. Physicians examining patients with blunt or penetrating lower abdominal trauma must be cautious about urological damage, particularly bladder and urethral injuries.

Etiology

 

Genitourinary trauma affects all sexes and all age groups, however it is more prevalent in men. The kidney is the most often damaged organ in the genitourinary system, accounting for up to 5% of all trauma cases and 10% of all abdominal trauma cases.

 

Because of anatomical issues and more frequent engagement in physical sports, aggression, and war-fighting, males suffer from genital injuries at a significantly higher rate.

 

The bladder is an abdominal organ in young children, especially when full, and is more vulnerable to blunt trauma injuries due to the comparatively weak abdominal muscle that protects most of it.

 

etiology

Brutal trauma (the majority)

In most cases, deceleration injuries result in both bladder damage (perforation) and pelvic fractures.

Road traffic accidents, falls, and assaults are the most prevalent causes of blunt trauma.

The bladder is insulated from most external stresses because it is positioned inside the bony structures of the pelvis.

Approximately 4% of individuals with pelvic fractures develop severe bladder damage.

The chance of bladder damage is proportional to the degree of distention at the moment of trauma.

A blow to the pelvis that is severe enough to shatter the bones and allow bone fragments to infiltrate the bladder wall might result in injury.

In the majority of these instances, the bladder damage is coupled with additional injuries, the most frequent of which are to the spleen and rectum.

Penetrating trauma

Gunshot wounds and stabbings are the most prevalent causes of penetrating trauma.

Penetrating trauma is often more severe and unpredictable than blunt trauma. Bullets have a high kinetic energy and have the ability to do more damage. They are often linked to numerous organ damage.

Penetrating trauma to both the rectum and the urinary system may result in significant morbidity and death.

 

Obstetric trauma

Persistent pressure from the fetal head on the mother’s pubis during protracted labor or a difficult forceps delivery may result in bladder necrosis.

Direct laceration of the urinary bladder may occur in women following cesarean birth on rare occasions.

Previous cesarean delivery adhesions are a risk factor for bladder injuries.

When bladder injuries go unnoticed, they may develop vesicouterine fistulas and other complications.

 

Gynecological trauma

During a vaginal or abdominal hysterectomy, iatrogenic bladder damage may occur. An increased risk of bladder or ureter damage is connected with laparoscopic hysterectomy.

Bladder damage comes from blind dissection in the improper tissue plane between the base of the bladder and the cervical fascia.

Previous surgery, inflammation, and malignancy are the most common risk factors for bladder damage.

 

Urological trauma

 

A bladder perforation may happen during a bladder biopsy, a transurethral resection of the prostate (TURP), or a transurethral resection of a bladder tumor (TURBT).

Orthopedic injury

Orthopedic pins and screws may perforate the urine bladder, especially during pelvic fracture internal fixation.

Thermal bladder wall injuries may develop during the setting of cement compounds used to attach arthroplasty prostheses.

Other types of iatrogenic trauma

In newborns undergoing inguinal canal surgery, the bladder may sometimes become punctured.

Idiopathic bladder trauma

Individuals who are dependent on alcohol or who consume big amounts of fluids on a regular basis are vulnerable to this form of harm.

A history of bladder surgery is a risk factor.

A combination of bladder overdistension and modest exterior trauma, such as a simple fall, might result in this form of injury.

Urethral trauma

Iatrogenic urethral trauma, caused by catheterization, equipment, or surgery, is the most frequent kind of urethral trauma observed in urological practice.

Urethral strictures may occur as a result of radiotherapy.

Iatrogenic urethral injuries may occur as a result of major pelvic surgeries.

Patients with bony pelvic fractures may experience injuries to the posterior urethra or urinary bladder.

Blunt or ‘fall-astride’ trauma is the most prevalent cause of anterior urethral injury.

During sexual intercourse, penile fractures may develop. In around 20% of these instances, the urethra is affected.

Female urethral injuries are relatively uncommon.

highlighting features

Hypovolaemia, hypotension, and shock are all possibilities.

The clinical manifestations of bladder damage are largely unspecific.

The following scenarios are possible:

Haematuria with macroscopic blood. Traumatic bladder rupture is highly associated with a combination of pelvic fracture and considerable haematuria, indicating the need for further imaging.

However, 5-15 percent of individuals with bladder rupture have just non-visible haematuria.

Suprapubic discomfort or pain The majority of bladder rupture patients report of suprapubic or abdominal discomfort.

Having difficulty or being unable to avoid it. Many people can still urinate, although this does not rule out bladder damage or perforation.

Always assume a urethral injury if there is blood near the urethral meatus.

Approximately 10-20% of men with a posterior urethral injury also have bladder damage.

An abdominal examination may show the following:

 

Tenderness as a result of distention, guarding, or rebound tenderness

Absence of bowel sounds and perineal discomfort, suggesting an intraperitoneal bladder rupture.

Bruising in the suprapubic region.

The scrotum, perineum, abdominal wall, and/or thighs may swell.

 

Investigations

 

The clinical findings and the cause of damage are used to make the choice on radiographic imaging

Cystography

 

For individuals with non-iatrogenic bladder damage, cystography is the examination of choice. The sensitivities and specificities of plain and CT cystography are comparable. The primary diagnostic study for the acute examination of a male urethral injury is a retrograde urethrography.

Cystoscopy

 

Cystoscopy is the recommended approach for detecting intraoperative bladder injuries since it allows for direct visualization of the laceration. After a hysterectomy and any significant gynecological treatment, a regular cystoscopy is suggested. A flexible cystoscopy may also be used to identify and treat urethral injuries.

A CT scan

 

This is the most accurate test for assessing stable patients. CT scans are more sensitive and specific than IVP, ultrasonography, or angiography. For renal assessment, intravenous contrast may be administered.

Ultrasound examination

 

An ultrasound scan alone is insufficient for determining bladder injuries. In an emergency situation, an ultrasound scan may help guide the exact insertion of a catheter.

Retrograde urethrography is a kind of urethrography that looks backward

This is an excellent inquiry for evaluating the urethra. However, it is not done in an emergency situation.

Management

 

Guidelines for the effective therapy of genitourinary trauma were issued by the European Association of Urology.

Any potentially fatal injuries should be treated first.

 

Medical treatment

 

The majority of small bladder injuries may be safely handled with simple catheter drainage (either urethral or suprapubic), bed rest, and surveillance. The catheter should be kept in place for 7-10 days before a cystogram is conducted. The laceration is sealed around 75-85% of the time, and the catheter is withdrawn for a voiding trial. The majority of extraperitoneal bladder injuries recover in three weeks. Extraperitoneal ruptures may be treated concurrently with surgery for related injuries if the patient is stable.

surgical treatment

Surgical treatment

Rupture of the intraperitoneal bladder

 

Intraperitoneal ruptures are more likely to result in sepsis and have a greater death rate than extraperitoneal injuries. They are typically big and located near the bladder’s dome. All of these injuries should be addressed as soon as possible with surgical exploration. Urine may continue to flow into the abdominal cavity, causing urine ascites, abdominal distention, and electrolyte imbalances.

All gunshot wounds to the lower abdomen must be investigated. Patients who have suffered high-velocity missile injuries should be transported to the operating room as soon as possible. In this facility, bladder injuries may be healed alongside any visceral damage.

Stab wounds to the suprapubic region affecting the urinary bladder are treated on a case-by-case basis. Surgical correction of obvious intraperitoneal damage is recommended.

Conservative therapy may be used for individuals who have simple intraperitoneal damage following TURB or who were not recognised during surgery, but only in the absence of peritonitis and ileus.

Extraperitoneal laceration

 

Extraperitoneal injuries may be effectively handled with a cautious approach.

Catheter drainage followed by a cystogram after 10 days is effective in the vast majority of instances, with almost all ruptures healing within three weeks.

Large or complicated injuries may be healed at the same time in trauma patients who need an emergency laparotomy.

Injury to the urethra

 

The kind of urethral damage determines how it is treated. Catheterization, either urethral or suprapubic, should be performed.  The goal of urethral trauma therapy is to preserve continence and potency while reducing the incidence of strictures. In many circumstances, a urethroplasty is performed after a stricture has developed.

Follow-up

 

Patients who have had extraperitoneal or complicated intraperitoneal bladder disturbances should have regular cystograms.

Routine follow-up cystograms, on the other hand, had little effect on clinical care in patients following repair of a minor intraperitoneal bladder rupture.

The patient will need to return in 7-10 days for staple removal and a wound check.

The cystogram should be performed within 7-14 days after the injury.

The urethral catheter may be withdrawn if the cystogram results are normal.

Inform the patient that they may resume regular activities 4-6 weeks following surgery.

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