bladtr [EDocFind.com].ppt
- 1. Bladder Trauma Laura Flath MS4 February 2006
- 2. Introduction Bladder injury is generally associated with blunt trauma and pelvic fracture 10% of urogenital injuries involve the bladder Radiologic examination is of paramount importance to identify and classify bladder injury and plan for treatment and stabilization.
- 3. Considerations when ordering studies in trauma patients 1. IV contrast studies can cause false–positive scan results for blood. 2. The total quantity of contrast required may limit the number of contrast studies, especially with shock. 3. Hypotensive patients are at risk for developing contrast-induced acute renal failure. 4. Abdominal CT reveals more information but requires a hemodynamically stable patient.
- 4. Imaging Techniques Retrograde Cystogram Retrograde cystography was considered the gold standard for detecting bladder rupture. To obtain dependable results, adequate bladder distention is required. This requires 350-400 mL of contrast material to be sufficient. To correctly perform the study, postevacuation images should also be obtained.
- 5. Imaging Techniques cont. Retrograde Cystogram cont. False-negative findings occur, most commonly in association with penetrating injury. With penetrating injury, wound margins may align well and prevent leakage. Other options includes fluoroscopy with the patient in the Trendelenburg position during the examination to increase sensitivity. Contrast material can be instilled until discomfort occurs. Rarely a bladder hematoma also may block the wound orifice and prevent leakage of contrast.
- 6. Imaging Techniques cont. CT Cystography CT is the most recommended study for trauma evaluation of the bladder. It is fast, it can be used to evaluate other urologic organs, and it requires no additional manipulation of the patient beyond what is needed for routine evaluation. Plain abdominopelvic CT may have a high negative predictive value for bladder rupture in a select subset of patients, even without cystography. This makes delaying cystography until after routine abdominopelvic CT even more valuable.
- 7. Imaging Techniques cont. CT Cystography cont. Overall, it is 95% sensitive and 100% specific in detecting bladder rupture. It is slightly less accurate when intraperitoneal rupture is present, with 80% sensitivity and 99% specificity. CT cystography can be used to fully classify bladder injury beyond noting intraperitoneal versus extraperitoneal rupture.
- 8. Classification System for Bladder Injury Based on Findings at CT Cystography Type of Injury Findings 1: Bladder contusion Incomplete or partial tear of the bladder 2: Intraperitoneal rupture Intraperitoneal contrast material around bowel loops, between mesenteric folds, and in the paracolic gutters 3: Interstitial bladder injury Intramural or partial-thickness laceration with intact serosa 4: Extraperitoneal rupture Direct laceration of the bladder by bone fragments from a pelvic fracture
- 9. Classification System cont. Type of Injury Findings 4a: Simple extraperitoneal rupture Extravasation is confined to the perivesical space 4b: Complex extraperitoneal rupture Contrast material extends beyond the perivesical space and may dissect into a variety of fascial planes and spaces 5: Combined bladder injury Extravasation pattern typical for both intraperitoneal injury and extraperitoneal injury
- 10. Intraperitoneal Rupture Intraperitoneal rupture in a 53-year-old man who was involved in a motor vehicle accident. CT cystogram demonstrates the classic appearance of an intraperitoneal rupture, with extravasated contrast material between loops of small bowel (arrows) and the anterior pararenal fascia (arrowheads).
- 11. Interstitial Bladder Injury Interstitial injury in a 41-year- old man who was involved in a motor vehicle accident. CT cystogram demonstrates focal lenticular thickening of the bladder wall due to interstitial hematoma and likely muscular disruption (black arrow), even though no contrast material is seen delineating the injury. Multiple pelvic fractures are also noted (white arrows).
- 12. Extraperitoneal Rupture Extraperitoneal rupture in a 76-year-old woman who was involved in a motor vehicle accident. Initial abdominopelvic CT scan obtained without retrograde bladder filling with contrast material demonstrates inadequate distention of the bladder from antegrade filling. Bladder rupture was not diagnosed from this image, although an intravesical clot (open arrow) and extraperitoneal fascial plane thickening (solid arrow) are seen.
- 13. Extraperitoneal Rupture cont. CT scan obtained 5 hours later with retrograde bladder filling demonstrates extravasated contrast material (arrow), a finding that is diagnostic for extraperitoneal bladder rupture.
- 14. Simple extraperitoneal rupture Simple extraperitoneal rupture in a 47-year-old woman who was involved in a motor vehicle accident. CT cystogram demonstrates extravasated contrast material confined to the perivesical space within the extraperitoneal pelvis (arrows). The extravasated contrast material demonstrates the typical "molar tooth" appearance
- 15. Complex extraperitoneal rupture Complex extraperitoneal rupture in a 23-year-old man who was involved in a motor vehicle accident. CT cystogram demonstrates extraperitoneal perivesicular extravasation with the typical molar tooth appearance (solid arrows). There is extension into the rectus abdominis muscle as well as the superficial fatty layer (fascia of Camper) and deeper membranous layer (Scarpa fascia) of the subcutaneous fascia (open arrow).
- 16. Combined bladder injury Combined intraperitoneal and extraperitoneal rupture in a 23-year-old man who was involved in a motor vehicle accident. CT cystogram demonstrates free contrast material delineating loops of small bowel, a finding that is characteristic of an intraperitoneal rupture.
- 17. Combined bladder injury cont. CT cystogram shows contrast material insinuating itself into the perivesical and perirectal spaces of the extraperitoneal pelvis (straight arrows). Pubic rami fractures are also noted (curved arrow).
- 18. Management CONTUSIONS: catheter placement and observation INCOMPLETE LACERATION: no specific intervention INTRAPERITONEAL RUPTURE: operative intervention EXTRAPERITONEAL RUPTURE: urethral catheter drainage for 10 to 14 days
- 19. Bibliography Beers MH, Berkow R, et al. The Merck Manual of Diagnosis and Therapy – 17th Ed. Merck & Co., Inc. 1999; 17:232. Deck AJ, Shaves S, Talner L, et al. Current experience with computed tomographic cystography and blunt trauma. World J Surgery 2001; 25:1592-1596. Eberhardt SC, Hricak H. Smith’s General Urology – 16th Ed. Lange Medical Books 2004; ch.6. Levy F, Kelen GD. Emergency Medicine: A Comprehensive Study Guide – 6th Ed. McGraw-Hill, Medical Publishing Division 2004; 22:262 Moore EE, Shackford SR, Patchter HL, et al. Organ injury scaling: Spleen, liver, kidney. J Trauma 1989; 29:1664. Vaccaro JP, Brody JM. CT Cystography in the Evaluation of Major Bladder Trauma. Radiographics. 2000; 20:1373-1381. Way LW. Current Surgical Diagnosis & Treatment – 11th Ed. Appleton & Lange 2003; ch.41.