Management of bladder injuries dr aroju


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Management of bladder injuries dr aroju

  2. 2. OUTLINEIntroductionSurgical AnatomyAetiologyPathophysiologyClinical FeaturesInvestigationscomplicationsTreatmentprognosisConclusion05-Jul-12 management of bladder injuries 2
  3. 3. INTRODUCTION• Relatively uncommon• 2% of abdominal injuries• Rarity ► protection in bony pelvis• 83 – 100% are due to blunt injury• 90% are associated with pelvic #05-Jul-12 management of bladder injuries 3
  4. 4. INTRODUCTION… Pelvic # associated with bladder rupture :• Pubic symphysis diastasis• Sacroiliac diastasis,• Sacral, iliac,• Pubic rami #s05-Jul-12 management of bladder injuries 4
  5. 5. INTRODUCTION…• Up to 30% of patients with pelvic fractures will have some degree of bladder injury.• 5 – 10% : major bladder injury05-Jul-12 management of bladder injuries 5
  6. 6. INTRODUCTION…• Previously fatal• prompt diagnosis & intervention ► excellent outcome• The probability of bladder injury α the degree of bladder distention05-Jul-12 management of bladder injuries 6
  7. 7. SURGICAL ANATOMY• Bladder: hollow muscular organ that serves as reservoir for urine.• Empty bladder : protected behind the pubic symphysis• Largely a pelvic organ in adults, abdominal organ in children.05-Jul-12 management of bladder injuries 7
  8. 8. SURGICAL ANATOMY• The bladder enters the greater pelvis by 6yrs & it is not entirely within the lesser pelvis until after puberty.• When empty : tetrahedral in shape & has apex, body, fundus, neck & uvula.05-Jul-12 management of bladder injuries 8
  9. 9. SURGICAL ANATOMY…• Separated from the pubic symphysis by space of retzius.• The posterior surface & Dome of bladder is covered with peritoneum thus related to bowels.05-Jul-12 management of bladder injuries 9
  10. 10. SURGICAL ANATOMY…05-Jul-12 management of bladder injuries 10
  11. 11. SURGICAL ANATOMY…05-Jul-12 management of bladder injuries 11
  12. 12. SURGICAL ANATOMY…• Bladder neck in males is contiguous with the prostate, & attached to the pubis by puboprostatic ligaments.• Body of the bladder receives support from the urogenital diaphragm inferiorly, & the obturator internus Laterally. 05-Jul-12 management of bladder injuries 12
  13. 13. SURGICAL ANATOMY…• The superior fascia of the urogenital diaphragm is continuous and includes the obturator, and endopelvic fasciae.• The inferior fascia of the urogenital diaphragm fuses with the Colles fascia. 05-Jul-12 management of bladder injuries 13
  14. 14. SURGICAL ANATOMY…05-Jul-12 management of bladder injuries 14
  15. 15. SURGICAL ANATOMY…• Injury above the peritoneal reflection ► intraperitoneal extravasation• Injury below the peritoneal reflection ► extraperitoneal extravasation05-Jul-12 management of bladder injuries 15
  16. 16. SURGICAL ANATOMY…• Arterial : superior, middle & inferior vesical arteries, uterine and vaginal arteries.• Venous: internal iliac veins.05-Jul-12 management of bladder injuries 16
  17. 17. SURGICAL ANATOMY…• Lymphatics: vesical, internal iliac, & common iliac nodes.• Sympathetic : Thoraco-lumbar; Parasympathetic : pelvic plexus.05-Jul-12 management of bladder injuries 17
  18. 18. AETIOLOGY• Penetrating trauma(15 – 40%)• Blunt trauma(60 – 85%)• Iatrogenic: from gynecologic, urologic, and orthopedic operations near the urinary bladder. 05-Jul-12 management of bladder injuries 18
  19. 19. AETIOLOGY…Gynaecologic Trauma Urological Trauma• Myomectomy • Cystoscopy +• TAH biopsy(36%),• Vag. Hysterectomy • TURP • Litholapaxy • Idiopathic: chronic alcoholics05-Jul-12 management of bladder injuries 19
  20. 20. AETIOLOGY…Orthopaedic Trauma• Orthopaedic pins : pelvic & hip #• Thermal injury : bone cement used in hip arthroplasty.05-Jul-12 management of bladder injuries 20
  21. 21. PATHOPHYSIOLOGYEXTRAPERITONEAL• Blunt or penetrating trauma.• Associated pelvic # (90-100%)• commonly anterolateral• Due to direct burst injury• Shearing force of the deforming pelvic ring.• Direct perforation by a bony fragment. 05-Jul-12 management of bladder injuries 21
  22. 22. PATHOPHYSIOLOGY...EXTRAPERITONEAL• When the sup. fascia of UD is ruptured, urine can infiltrate the abdominal wall, scrotum & perineum.• When the Inf. fascia of UD is ruptured, urine can infiltrate the thigh or penis. 05-Jul-12 management of bladder injuries 22
  23. 23. PATHOPHYSIOLOGY...INTRAPERITONEAL• Sudden large increase in intravesical pressure in a full bladder.• Full bladder ► widely separated muscle fibres ► thin bladder wall ►no resistance to perforation05-Jul-12 management of bladder injuries 23
  24. 24. PATHOPHYSIOLOGY...INTRAPERITONEAL• Usually involves the dome & posterior part of the bladder.• common in seat-belt & steering wheel injury and in chronic alcoholics, following trivial fall.05-Jul-12 management of bladder injuries 24
  25. 25. Intraperitoneal bladder rupture05-Jul-12 management of bladder injuries 25
  26. 26. PATHOPHYSIOLOGY...• Continuous urine drainage into the abdomen ► hyperkalemia, hypernatremia, uremia & acidosis.• Such patients may appear anuric, and have urinary ascites.05-Jul-12 management of bladder injuries 26
  27. 27. CLINICAL FEATURES relatively nonspecific• Triad of symptoms is often present (1) gross haematuria (90%), (2) suprapubic pain or tenderness, (3) difficulty or inability to void. 05-Jul-12 management of bladder injuries 27
  28. 28. CLINICAL FEATURES…• Swelling in perineum, scrotum or Anterior abdominal wall.• Evidence of pelvic # (>90%), symphysial / sacro- iliac diasthesis, pubic rami #.• Posterior urethral injuries (10%) & renal injuries in (~2%)05-Jul-12 management of bladder injuries 28
  29. 29. CLINICAL FEATURES…• Mortality (~50%) ► severe pelvic #s, haemorrhage, & MODS• Late presentations are due mild intraperitoneal rupture ► azotemia, hyperchloremia, hypernatremia hyperkalemia & metabolic acidosis. 05-Jul-12 management of bladder injuries 29
  30. 30. INVESTIGATIONSCystography• Very accurate (>90%)• By gravity filling of contrast into bladder.• At least 3 films must be taken ► Plain, Filled,& post drainage.• Severity of injury can be graded• Distinguishes intraperitoneal from extraperitoneal rupture. 05-Jul-12 management of bladder injuries 30
  31. 31. Cystogram05-Jul-12 management of bladder injuries 31
  32. 32. INVESTIGATIONS…CT Cystography• Has approx. 100% sensitivity.• Has advantage of being able to correctly assess other visceral injuries in a polytraumatized pt.• Expensive05-Jul-12 management of bladder injuries 32
  33. 33. CT cystogram05-Jul-12 management of bladder injuries 33
  34. 34. INVESTIGATIONS…USS• Not routinely used• Show injury to other structures• Peritoneal fluid + normal viscera OR failure to visualize bladder after the transurethral intro of saline ► highly suggestive of bladder rupture05-Jul-12 management of bladder injuries 34
  35. 35. INVESTIGATIONS…• Haematocrit• E/U/Cr• RBS• CXR05-Jul-12 management of bladder injuries 35
  36. 36. STAGING…• Cystoscopy & cystogram findings• Adapted by AAST & used by EUAStage I : Hematoma Contusion, intramural hematoma, Laceration Partial thickness.05-Jul-12 management of bladder injuries 36
  37. 37. STAGING…Stage II : Laceration Extraperitoneal bladder wall laceration < 2 cmStage III : Laceration Extraperitoneal (2cm) or intraperitoneal (< 2cm) bladder wall laceration05-Jul-12 management of bladder injuries 37
  38. 38. STAGING…Stage IV :• Laceration Intraperitoneal bladder wall laceration 2cm• Stage V : Laceration Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral orifice05-Jul-12 management of bladder injuries 38
  39. 39. COMPLICATIONS• Urinary extravasation• Sepsis & MODS• Haemorrhage• Pelvic infection• Small-capacity bladder• Urinary incontinence• Obstructive uropathy05-Jul-12 management of bladder injuries 39
  40. 40. MANAGEMENT• Multidisciplinary approach Trauma surgeon, Urologist, anaesthesiologist, Orthopaedic surgeon• The first priority: stabilization of the patient and treatment of associated life-threatening injuries.05-Jul-12 management of bladder injuries 40
  41. 41. MANAGEMENT…• High velocity : urgent exploration• Isolated bladder injury: definitive treatment depends on grade of injury.05-Jul-12 management of bladder injuries 41
  42. 42. MANAGEMENT…Grades 1&2Nonsurgical management• Adequate analgesics• Indwelling catheter is passed• Observe pt. for Increasing pains or changes in vital signs.• Repeat Cystogram at 10-14 days.• If normal, discharge pt home. 05-Jul-12 management of bladder injuries 42
  43. 43. MANAGEMENT…Grades 1&2Nonsurgical management• Obstruction of the catheter by clots or tissue debris must be prevented.• 87% of cases heal in 10days and virtually all heal in 3weeks. 05-Jul-12 management of bladder injuries 43
  44. 44. MANAGEMENT…Grades 3, 4 & 5 Surgical management• Pre-op analgesic, antibiotics• Midline approach, bladder & any bowel injury inspected & severity assessed.• Bladder bivalved at dome, & UO inspected.05-Jul-12 management of bladder injuries 44
  45. 45. MANAGEMENT…Grades 3, 4 & 5 Surgical management• Repair in at least two layers,• Leave SPT in situ via a diff. Stoma• Leave drain in situ.05-Jul-12 management of bladder injuries 45
  46. 46. MANAGEMENT…Post-Op• IV antibiotics & analgesics• Drain out when it not functioning• Do x-ray cystogram at 14th day.• If normal, remove SPC, the urethral catheter & discharge.• For those with pelvic #s, invite orthopaedics05-Jul-12 management of bladder injuries 46
  47. 47. PROGNOSIS Appropriate Rx Excellent outcome Bladder neck involvement Temporary incontinence05-Jul-12 management of bladder injuries 47
  48. 48. CONCLUSION• Traumatic bladder injuries was previously fatal, BUT currently managed quite successfully.• Adequate evaluation, application of modern imaging techniques, & prompt surgical intervention are conditions for optimal outcome.05-Jul-12 management of bladder injuries 48
  49. 49. Thank you for your patience05-Jul-12 management of bladder injuries 49