19.1.2.1 Clinical Assessment

Rupture of the bladder without fracture of the pelvis is classically seen in the elderly drunk who has been injured (Figure 19.1). The patient seldom remembers the cause and the diagnosis may be difficult because leakage of uninfected hypotonic urine into the peritoneal cavity at first excites little reaction [18, 19]. There is no tenderness on palpation; bowel sounds persist. Only a very astute doctor will suspect a vesical injury, when there is any doubt the patient should be admitted for observation.

Nonetheless, gross haematuria is present in >80% of patients; if this is coupled with a pelvic fracture, then at least 30% of patients will have a bladder rupture and immediate imaging is warranted [2, 3, 8, 9, 20]. Therefore, other signs of injury need to be sought for, such as suprapubic or abdominal tenderness, inability to void, suprapubic bruising, clots in the urine, or signs of peritonitis if intraperitoneal rupture.

Extraperitoneal ruptures causes extravasation of urine which can track down to the scrotum causing it to enlarge or down the thighs or even anterior abdominal wall between the transversalis fascia and the peritoneum [2, 11].

Intraoperative bladder injuries are usually noticed when excessive clear fluid appears in the surgical field, when the laceration or the urinary catheter is seen, or when blood is noted in the urinary catheter bag, while air inflation of the urine bag is seen during laparoscopic or robotic procedures. If there is a high suspicion of a bladder injury, despite absence of overt signs, then the instillation of methylene blue into the bladder might illicit the injury site.

If an injury is missed at the original operation (e.g. hysterectomy), urine can leak from the vagina a few days later, forming a vesicovaginal fistula. However, the patient can slowly develop ileus and peritonitis if the injury was intraperitoneal. If injured extraperitoneally, urine collection with pain and or sepsis can develop.

Endoscopic iatrogenic bladder injuries are diagnosed when seeing extra vesicle fat, a dark gap between the detrusor muscles or bowels [14]. One can also notice that the bladder fails to distend despite adequate irrigation with low return of irrigation fluid and abdominal distention.

If an intraperitoneal injury is not recognised, the patient gradually develops a chemical peritonitis, the abdomen becomes swollen and tender, and bowel sounds disappear. Eventually, there may be fat necrosis and sloughing of omentum and bowel. When in any doubt, it is safer to perform a laparotomy and close the rent in the bladder and drain it because these injuries carry a high mortality (nearly 15%) if left untreated [1].

Patients with an intravesical forging body may present with recurrent infections, dysuria, pelvic pain, frequency, and urgency and can lead to bladder stone formation.

19.1.2.2 Blood Tests

Renal function test: Elevated creatinine and urea levels could be found in patients with intraperitoneal ruptures as a result of the reabsorption of urea, nitrogen, and creatinine.

The fluid leaking from the vagina may be shown to be urine by measuring its creatinine concentration; no other body fluid can have a creatinine concentration greater than that of the plasma postoperatively [21].

19.1.2.3 Imaging

19.1.2.3.1 Cystography

Cystograms are the gold standard for diagnosing bladder injuries and are highly accurate when performed appropriately (>95% accuracy) (Figure 19.3). The absolute indication is visible haematuria associated with pelvic fracture or penetrating injuries. The relative indication for cystogram after blunt trauma is visible haematuria without pelvic fracture or microscopic haematuria with pelvic fracture.

Computed tomography (CT) cystogram is comparable to plain X‐ray cystogram; however, it can diagnose other injuries and is therefore considered more efficient (Figure 19.3) [1, 2].

Whether a CT cystogram or a plane film cystogram is obtained, a stress cystogram should be performed. During a stress cystogram, the bladder is filled with 350–400 ml of diluted contrast and three images obtained: a precontrast plain film, a film when bladder is full, and a postcontrast image for detection of posterior extravasation.

Extraperitoneal bladder injury in a plain cystogram gives a flame‐shaped collection of contrast medium in the pelvis. In intraperitoneal injuries, the contrast medium will freely flow to the abdominal cavity and outline the loops of bowel or other abdominal organs.

Clamping the catheter in an attempt to antegrade fill the bladder and obtaining delayed images is considered to be inadequate [22].

19.1.2.3.3 Cystoscopy

Cystoscopy can diagnose intraoperative bladder injury by direct visualisation of the defect or failure to distend the bladder during TURBT. Ureterograms are done on both sides to rule out concomitant ureteric injury. Cystoscopy should ideally be performed after suburethral sling insertion to ensure the trocar has not gone through the bladder wall (Figure 19.4).

In noniatrogenic injuries, it is too difficult to see the tear during cystoscopy because of bleeding and is seldom worthwhile to do.

19.1.3.1 Conservative Management

Conservative management is the standard treatment for extraperitoneal bladder injury. The principles include adequate bladder drainage using a wide‐bore catheter, clinical observations, and antibiotics prophylaxis given to prevent the infection of the extravesicle haematoma [4, 7]. Conservative management may also be considered in intraperitoneal injuries that were not recognised at time of TURBT if the patient is stable and in the absence of peritonitis and ileus [6].

The catheter is left on free drainage for 7–14 days, at which point cystography should be carried out to confirm complete healing.

19.1.3.2 Surgical Management

Intraperitoneal injury and all penetrating trauma should be managed by exploration and surgical repair.

For extraperitoneal injury, surgical repair is indicated where there is bladder neck injury, if the patient is having exploratory laparotomy for other injuries (associated rectal or vaginal injuries or if the patient is undergoing internal fixation of pelvic fracture), if the bladder is entrapped between two bone fragments, or a bone spike has penetrated the bladder wall [2].

19.1.3.2.1 Surgical Approach

Exploration is carried out through a lower midline abdominal incision. Any pelvic haematoma should not be disrupted. The anterior bladder wall is opened between stay sutures, and the whole of the bladder wall should be carefully inspected. The ureteric orifices should be identified and inspected for efflux (Figure 19.5). Injuries are often larger than they appear on imaging.

The bladder wall is then closed in two layers. The bowels should be examined to rule out any concomitant injuries. Injuries sustained during laparoscopy could be repaired laparoscopically if the surgeon is experienced in this technique. A large drain is left in situ. Either a suprapubic or urethral catheter is left on free drainage [9, 23]. The catheter could be removed 7–14 days after the repair; cystography should be done before removing the catheter to ensure bladder integrity.

If vaginal or rectal injuries are present, they should be repaired separately, and viable tissue should be interposed between the two repaired organs to reduce the risk of fistula formation.

19.1.4.1 Silent Rupture of the Bladder

After bladder tumours on the dome have been coagulated with diathermy, especially in patients who are elderly, the coagulated part of the thin wall of the bladder may give way and allow urine to escape into the peritoneum. The early physical signs are minimal: the urine gives rise too little irritation and it is only after two or three days that the patient develops abdominal pain and distension. With prompt catheterization, the condition is easily remedied and laparotomy can be avoided.

19.1.4.2 Catheter Trauma

A catheter may be forced through the wall of the bladder, usually one that is already severely contracted. The diagnosis is as difficult to make as in the other groups of ‘silent’ perforation but should always be suspected.

19.1.4.3 Cather Balloon Rupture

A diabolically dangerous method for bursting a Foley catheter balloon used to be to inject ether down the side channel. Before it burst, the balloon could rupture the bladder. Unless great care was taken in every case to wash the bladder out, bits of rubber from the balloon could be left behind on which stones can subsequently form.

19.1.4.4 Gunshot Wounds

It is necessary to distinguish between gunshot injuries caused by high‐ and low‐velocity missiles [2–4]. In both types of injury, if there is any suspicion of trauma to the rectum, a diverting colostomy will avoid the risk of the havoc caused by gas gangrene with its consequent massive loss of tissue [5, 24, 25].

High‐velocity bullets produce an enormous spherical blast injury with devitalization of all lining tissue within its radius. In the few who survive, all devitalized tissue must be excised. Primary repair must not be attempted [25]. Free drainage is provided. Delayed primary or secondary suture can be carried out 5–10 days later.

Low‐velocity missiles, bullets, and shrapnel fragments call for more conservative debridement, but primary closure should not be performed; delayed primary or secondary suture is safer [25]. In bladder injuries, the main requirement is to provide free drainage.