Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury

BACKGROUND: There is controversy about the appropriate sequence of urologic investigation in patients with pelvic fracture. Use of retrograde urethrography or cystography may interfere with regular pelvic CT scanning for arterial extravasation. STUDY DESIGN: We performed a retrospective study at a regional trauma center in Toronto, Canada. Included were adult blunt trauma patients with pelvic fractures and concomitant bladder or urethral disruption who underwent initial pelvic CT before operation or hospital admission. Exposure of interest was whether retrograde urethrography (RUG) and cystography were performed before pelvic CT scanning. Main outcomes measures were indeterminate or false negative initial CT examinations for pelvic arterial extravasation. RESULTS: Sixty blunt trauma patients had a pelvic fracture and either a urethral or bladder rupture. Forty-nine of these patients underwent initial CT scanning. Of these 49 patients, 23 had RUG or conventional cystography performed before pelvic CT scanning; 26 had cystography after regular CT examination. Performing cystography before CT was associated with considerably more indeterminate scans (9 patients) and false negatives (2 patients) for pelvic arterial extravasation (11 of 23 versus 0 of 26, p < 0.001) compared with performing urologic investigation after CT. In the presence of pelvic arterial hemorrhage, indeterminate or false negative CT scans for arterial extravasation were associated with a trend toward longer mean times to embolization compared with positive scans (p=0.1). CONCLUSIONS: Extravasating contrast from lower urologic injuries can interfere with the CT assessment for pelvic arterial extravasation, delaying angiographic embolization.     

Computerized tomography cystography for the diagnosis of traumatic bladder rupture

PURPOSE: We present our experience with computerized tomography (CT) cystography for diagnosing bladder rupture in patients with blunt abdominal and pelvic trauma, and compare the results of CT cystography with those of surgical exploration. MATERIALS AND METHODS: We identified all patients with blunt trauma diagnosed with bladder rupture from 1992 to September 1998. We reviewed the radiology computerized information system for all CT cystography performed to evaluate blunt trauma during the same period. We also reviewed the medical records and pertinent radiographic studies of patients with bladder rupture who underwent CT cystography as part of the hospital admission evaluation. Operative and radiographic findings were compared. RESULTS: CT cystography was performed in 316 patients as part of the initial evaluation of blunt trauma. Of the 44 patients with the ultimate diagnosis of bladder rupture CT cystography revealed bladder rupture in 42, while 23 of the 28 (82%) who underwent formal bladder exploration had operative findings that exactly matched the CT cystography interpretation in terms of the presence and type of rupture. In the 316 patients CT cystography detected bladder rupture with an overall sensitivity and specificity of 95% and 100%, respectively. For intraperitoneal rupture sensitivity was 78% and specificity was 99%. CONCLUSIONS: CT cystography provides expedient evaluation of bladder rupture due to blunt trauma and has accuracy comparable to that reported for plain film cystography. We recommend CT cystography over plain film cystography in patients undergoing CT for other injuries associated with blunt trauma.     

Bladder rupture after blunt trauma: guidelines for diagnostic imaging

PURPOSE: The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome. METHODS: We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series. RESULTS: Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. CONCLUSION: The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.     

Diagnosis of blunt bladder injury: A prospective comparative study of computed tomography cystography and conventional retrograde cystography

BACKGROUND: This study was designed to evaluate prospectively the accuracy of computed tomography (CT) cystography for the detection of bladder rupture, performed concurrently with screening abdominal/pelvic CT, in patients at risk for blunt bladder injury. The study also aimed to validate our proposed method of performing CT cystography, which was designed to minimize the time and effort required to image the bladder. METHODS: CT cystography was performed on patients at risk for blunt bladder injury. Retrograde filling of the bladder with dilute iodinated contrast material was performed before routine abdominal/pelvic CT scanning, performed with oral and intravenous contrast. Conventional cystography, when performed, followed CT cystography. RESULTS: CT cystography, followed by conventional cystography, was performed in 212 patients, among whom 19 had bladder rupture. The CT cystography sensitivity and specificity for bladder rupture in these patients was 95% and 100%, respectively; for conventional cystography, sensitivity and specificity were 95% and 100%, respectively. CT cystography was performed without conventional cystography in 283 patients, among whom 27 had bladder rupture. The sensitivity and specificity of CT cystography for bladder rupture in these patients were both 100%. CONCLUSIONS: CT cystography is equivalent to conventional cystography for detecting the presence or absence of blunt bladder injury. CT cystography can be performed as an integral part of the CT screening undergone by many blunt trauma patients and, in the vast majority of these patients, it can alleviate the need for a separate conventional cystogram.     

Current Experience with Computed Tomographic Cystography and Blunt Trauma

We present our experience with computed tomographic (CT) cystography for the diagnosis of bladder rupture in patients with blunt abdominal and pelvic trauma and compare the results of CT cystography to operative exploration. We identified all blunt trauma patients diagnosed with bladder rupture from January 1992 to September 1998. We also reviewed the radiology computerized information system (RIS) for all CT cystograms performed for the evaluation of blunt trauma during the same time period. The medical records and pertinent radiographs of the patients with bladder rupture who underwent CT cystography as part of their admission evaluation were reviewed. Operative findings were compared to radiographic findings. Altogether, 316 patients had CT cystograms as part of an initial evaluation for blunt trauma. Of these patients, 44 had an ultimate diagnosis of bladder rupture; 42 patients had CT cystograms indicating bladder rupture. A total of 28 patients underwent formal bladder exploration; 23 (82%) had operative findings that exactly (i.e., presence and type of rupture) matched the CT cystogram interpretation. The overall sensitivity and specificity of CT cystography for detection of bladder rupture were 95% and 100%, respectively. For intraperitoneal rupture, the sensitivity and specificity were 78% and 99%, respectively. CT cystography provides an expedient evaluation for bladder rupture caused by blunt trauma and has an accuracy comparable to that reported for plain film cystography. We recommend CT cystography over plain film cystography for patients undergoing CT evaluation for other blunt trauma-related injuries.     

The incidence,spectrum and outcomes of traumatic bladder injuries within the Pietermaritzburg Metropolitan Trauma Service

IntroductionThe purpose of this study is to provide a comprehensive overview of the incidence, spectrum and outcomes of traumatic bladder injury in Pietermaritzburg, South Africa, and to identify the current optimal investigation and management of patients with traumatic bladder injuries.MethodsThe Pietermaritzburg Metropolitan Trauma Service (PMTS) trauma registry was interrogated retrospectively for all traumatic bladder injuries between 1 January 2012 and 31 October 2014.ResultsOf 8129 patients treated by the PMTS over the study period, 58 patients (0.7% or 6.5 cases per 1,000,000 population per year) had bladder injuries, 65% caused by penetrating trauma and 35% by blunt trauma. The majority (60%) were intraperitoneal bladder ruptures (IBRs), followed by 22% extraperitoneal bladder ruptures (EBRs). There was a high rate of associated injury, with blunt trauma being associated with pelvic fracture and penetrating trauma being associated with rectum and small intestine injuries. The mortality rate was 5%. Most bladder injuries were diagnosed at surgery or by computed tomography (CT) scan. All IBRs were managed operatively, as well as 38% of EBRs; the remaining EBRs were managed by catheter drainage and observation. In the majority of operative repairs, the bladder was closed in two layers, and was drained with only a urethral catheter. Most patients (91%) were managed definitively by the surgeons on the trauma service.ConclusionTraumatic bladder rupture caused by blunt or penetrating trauma is rare and mortality is due to associated injuries. CT scan is the investigative modality of choice. In our environment IBR is more common than EBR and requires operative management. Most EBRs can be managed non-operatively, and then require routine follow-up cystography. Simple traumatic bladder injuries can be managed definitively by trauma surgeons. A dedicated urological surgeon should be consulted for complex injuries.     

Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes

BACKGROUND: Pelvic fractures are often associated with major intraabdominal injuries or severe bleeding from the fracture site. OBJECTIVE: To study the epidemiology of pelvic fractures and identify important risk factors for associated abdominal injuries, bleeding, need for angiographic embolization, and death. METHODS: Trauma registry study on pelvic fractures from blunt trauma. Stepwise logistic regression was used to identify risk factors of severe pelvic fractures, associated abdominal injuries, need for major blood transfusion, therapeutic embolization, and death from pelvic fracture. Adjusted relative risks and 95% confidence intervals were derived. RESULTS: There were 16,630 trauma registry patients with blunt trauma, of whom 1,545 (9.3%) had a pelvic fracture. The incidence of abdominal injuries was 16.5%, and the most common injured organs were the liver (6.1%) and the bladder and urethra (5.8%). In severe pelvic fractures (Abbreviated Injury Scale [AIS] > or =4), the incidence of associated intraabdominal injuries was 30.7%, and the most commonly injured organs were the bladder and urethra (14.6%). Among the risk factors studied, motor vehicle crash is the only notable risk factor negatively associated with severe pelvic fracture. Major risk factors for associated liver injury were motor vehicle crash and pelvis AIS > or = 4. Risk factors of major blood loss were age > 16 years, pelvic AIS > or =4, angiographic embolization, and Injury Severity Score (ISS) > 25. Age> 55 years was the only predictor for associated aortic injury. Factors associated with therapeutic angiographic embolization were pelvic AIS > or =4 and ISS > 25. The overall mortality was 13.5%, but only 0.8% died as a direct result of pelvic fracture. The only pronounced risk factor associated with mortality was ISS>25. CONCLUSIONS: Some epidemiological variables are important risk factors of severity of pelvic fractures, presence of associated abdominal injuries, blood loss, and need of angiography. These risk factors can help in selecting the most appropriate diagnostic and therapeutic interventions.     

Associated aortic rupture-pelvic fracture: an alert for orthopedic and general surgeons.

Blunt trauma patients with pelvic fractures have been shown to have a two-fold to five-fold increased risk of aortic rupture compared with the overall blunt trauma population. A retrospective review was performed to determine whether the relationship between aortic rupture and pelvic fracture could be further delineated using a pelvic fracture classification based on mechanism of injury. Of 4,157 consecutive blunt trauma patients, 371 (8.9%) had pelvic fractures, 34 (0.8%) had ruptured thoracic aortas and 12 had both injuries. When pelvic fractures were classified according to vector of force, 10 of 12 (83%) aortic ruptures occurred in patients with an anterior-posterior compression fracture pattern, an incidence of aortic rupture eight times greater than that of the overall blunt trauma population. There was no increased incidence of aortic rupture among patients with any other pelvic fracture pattern. We conclude that the previously reported association between aortic rupture and pelvic fracture can be further specified to include, predominantly, those patients with an anterior-posterior compression fracture pattern.     

Computerized tomography in bladder rupture: diagnostic limitations

Because computerized tomography is often the first test performed in patients with blunt abdominal and pelvic trauma we designed a prospective study to determine if it might be as accurate as retrograde cystography in the diagnosis of bladder rupture. Patients who had suffered blunt trauma with gross hematuria or who had pelvic fractures and microhematuria underwent computerized tomography followed by retrograde cystography. A urethral catheter was inserted and clamped during computerized tomography to ensure bladder filling. Of our first 2 patients computerized tomography showed no evidence of opacified urinary extravasation in 1 and only subtle evidence in the other. Cystography revealed gross intraperitoneal extravasation of opacified urine in both patients. Presently, retrograde cystography, including a film of the distended bladder and a drainage film, remains the most reliable test in suspected bladder rupture.     

The utility of clinical examination in screening for pelvic fractures in blunt trauma

BACKGROUND: Current recommendations of the American College of Surgeons Advanced Trauma Life Support course is routine radiographic screening of the pelvis for all patients who suffer blunt torso trauma. The purpose of this study is to evaluate in a prospective manner the sensitivity of clinical examination as a screening modality for pelvic fractures in awake and alert blunt trauma patients. STUDY DESIGN: During a 32-month period, 2,176 consecutive blunt trauma patients who presented with Glasgow Coma Scores of 14 or 15 were evaluated at an urban Level I trauma center. Clinical examination of all patients was prospectively performed by trauma resident housestaff. The clinical examination of each patient was documented in a study form before performance of a standard anterior-posterior (A-P) pelvic x-ray. RESULTS: We evaluated 2,176 blunt trauma patients, 97 (4.5%) of whom were diagnosed with pelvic fracture. There were seven missed injuries on clinical examination (sensitivity 93%). None of the missed injuries on clinical examination required surgical intervention. The sensitivity of A-P pelvic x-ray was 87%, with 13 missed injuries. There were 463 patients who entered with ethanol levels equal or greater than 100 mg/dL (range 100 to 480 mg/dL). There were 20 pelvic fractures diagnosed in this group, with only 1 missed injury on clinical examination (sensitivity 95%). CONCLUSIONS: 1) Clinical examination of the pelvis can reliably rule out significant pelvic fracture in the awake and alert blunt trauma patient. 2) The addition of routine A-P pelvic x-ray does not improve the sensitivity in diagnosis of surgically significant pelvic fractures nor does it have significant impact on outcomes of pelvic fracture patients. 3) Elevated ethanol level is not a contraindication to use of clinical examination as a screening modality for pelvic fractures in the awake and alert blunt trauma patient.