Trauma to the bladder and ureter: a review of diagnosis, management, and prognosis

Secondary bladder stone caused by delayed penetration of the bladder by a pubic fracture: A case report and literature review

Pelvic fractures sometimes lead to injuries of the urinary bladder, which commonly present as gross hematuria, dysuria and lower abdominal pain. As a type of urinary stone, bladder stones are usually secondary to lower urinary tract obstruction, such as benign prostatic hyperplasia, urethral stricture, and neurogenic bladder. The present case report examines an unusual case of a delayed pubic fracture penetrating the bladder, which caused a secondary bladder stone. A 53-year-old man was first hospitalized at The Second Hospital of Jiaxing (Jiaxing, China) in January 2020 because of trauma-induced bleeding in the scalp and abdominal pain. The patient underwent abdominal exploration and partial bowel resection, and his condition stabilized after surgery. After discharge, the patient had regular outpatient check-ups every 2-3 weeks. However, after 3 months, in April 2020, the patient was readmitted to the hospital because of frequent urination, an urgent need for urination and dysuria. Abdominal computed tomography imaging and cystoscopy revealed a pubic fracture that had penetrated the bladder wall, accompanied by a bladder stone. Subsequently, cystolithotomy was performed, which provided significant relief of symptoms once the catheter was removed after 2 weeks. Since then, the patient has been followed up until January 2023 and had remained asymptomatic. Bladder stones caused by necrotic bone fragmentation are rare. Bladder injuries resulting from pelvic fractures can have delayed onset; therefore, clinicians should be aware of the possibility of urogenital injury in such patients. It is crucial for clinicians to comprehend the potential mechanisms involved, analyze the clinical data of patients, closely monitor their condition and implement appropriate treatment measures when necessary.

An uncommon and easily overlooked case: Delayed intraperitoneal bladder rupture following blunt trauma: A case report and review of the literature

INTRODUCTION

Delayed intraperitoneal bladder rupture is a rare clinical occurrence, frequently overlooked and misdiagnosed due to its nonspecific clinical manifestations. However, literature provides only a limited number of cases reporting delayed intraperitoneal bladder rupture resulting from blunt abdominal injury.

PATIENT CONCERNS

A 72-year-old female pedestrian was struck by a vehicle and experienced sudden, severe abdominal pain on the 8th day following the injury. Abdominal B-ultrasound revealed a significant accumulation of peritoneal effusion. The abdominal puncture retrieved serosanguinous ascites. Then the patient was promptly transferred to our hospital. Upon transfer, the physical examination revealed the patient vital signs to be stable, accompanied by mild abdominal distension, slight tenderness, tension, and an absence of rebound tenderness. Urinalysis detected microscopic hematuria, while contrast-enhanced computed tomography (CT) revealed considerable fluid accumulation in the abdominal cavity, without evidence of solid organ damage, and the bladder was adequately filled.

DIAGNOSIS

The diagnosis of delayed intraperitoneal bladder rupture primarily relied on intraoperative observations.

INTERVENTIONS

An emergency exploratory laparotomy was performed, revealing a linear rupture at the dome of the bladder. Subsequently, the bladder rupture was repaired.

OUTCOMES

Postoperative cystography demonstrated full recovery and the patient was discharged 28 days post-surgery. The postoperative recovery was uneventful without any complications.

CONCLUSIONS

A well-distended bladder observed in CT does not definitively rule out the potential for bladder injury. False negatives may occur due to incomplete bladder filling during CT cystography. Retrograde cystography can identify cases missed by CT cystography. In cases of substantial intra-abdominal free fluid, surgical intervention should be actively considered for patients with blunt abdominal trauma without concurrent solid organ damage.

[Severe combined injury of the rectum and bladder in a child]

Traumatic anorectal injuries are rare in pediatric surgical practice. Only several similar cases are described in the world literature. This causes no generally accepted algorithms and tactics for these patients. We demonstrate successful surgical treatment of combined trauma of the rectum and bladder in a child. A 13-year-old boy was hospitalized after the child sat on the leg of an overturned chair. No evidence of penetrating abdominal injury was revealed. The boy underwent sigmoidoscopy under general anesthesia. We found a lacerated wound of anterior wall of the rectum measuring 1/3 of its diameter with damage to posterior wall of the bladder. Diagnostic laparoscopy revealed intact abdominal cavity. Wall defects were sutured (bladder wound was sutured during traditional cystotomy), and we formed protective separate double-barreled sigmostomy. In 3 months after discharge, the child was hospitalized for cystography and fistulography with subsequent closure of stoma. In long-term postoperative period (6 months), the quality of life is satisfactory. There is no pain and disturbances of urination.

The role of point-of-care ultrasound in the assessment of pelvic urine leakage and diagnosis of urinoma

BACKGROUND

Urinoma, a rare condition resulting from urine leakage due to trauma to the kidney, bladder, or urethra, is typically diagnosed using enhanced computed tomography urogram with delayed imaging. This report presents two cases of urinoma likely caused by overdistention of the renal pelvis following excessive fluid intake and the presence of a ureteral stone.

CASE PRESENTATION

We present two cases of 36-year-old and 38-year-old patients who presented with flank pain. point-of-care ultrasound (POCUS) played a pivotal role in identifying perinephric fluid in Morrison's space and the splenorenal space, respectively. These ultrasound findings guided further investigations, leading to definitive diagnoses via abdominal pelvic CT scans. Treatment involved prophylactic antibiotics and the successful placement of a double J stent into the renal pelvis over the wire under fluoroscopic guidance, which resulted in significant clinical improvement for both patients.

CONCLUSIONS

This study demonstrates the rare occurrence of urinoma from urolithiasis, the use of POCUS in expediting diagnosis and treatment, and the importance of interpreting sonographic images in the correct clinical setting.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.

Manifestation of Spontaneous Rupture of the Urinary Bladder in Pregnancy: A Systematic Review of the Literature

Spontaneous rupture of the urinary bladder (SRUB) during pregnancy is a potentially fatal event that necessitates immediate surgery. The aim of this systematic review is to determine the symptoms, causes, associated factors, and prognosis of SRUB in pregnancy. We searched the literature from inception until December 2022 using the Cochrane Central Register, PubMed, EMBASE, ProQuest, Scopus, and Google Scholar. Articles not in English and those unrelated to the topic were excluded. The JBI Critical Appraisal Checklist for case reports was employed for the risk of bias assessment. The search strategy yielded 312 citations; 29 full-text articles were evaluated for eligibility after screening. Five case reports were included in this review. The age range of the cases was 27-39 years. Four cases were in their second trimester of pregnancy, and one was in her third. Two cases had undergone previous cesarean sections, and one had an appendectomy and salpingectomy due to an ectopic pregnancy. One case reported a history of alcohol and drug abuse. The most common symptoms were abdominal pain, abdominal distension, oliguria, voiding difficulty, hematuria, fever, and vomiting. The diagnosis of SRUB was primarily made via emergency laparotomy due to the patients' critical conditions. Beyond its diagnostic role, laparotomy was also the treatment method in all cases. Tear repair, antibiotic therapy, and urinary catheterization were all integral parts of the treatment. Four cases resulted in an uneventful pregnancy and a healthy, full-term baby. In one case, a hysterectomy was performed due to a combined uterus and bladder rupture. SRUB often presents with non-specific symptoms, leading to a delayed diagnosis. A high index of suspicion is essential when a pregnant woman exhibits urinary symptoms and severe abdominal pain, especially in those with a history of previous surgery. Early detection and treatment of SRUB are critical for an uneventful recovery.

Emergency Abdominopelvic Injuries

The presentation of traumatic abdominopelvic injuries in sport can range from initially benign appearing to hemorrhagic shock. A high clinical suspicion for injury, knowledge of the red flags for emergent further evaluation, and familiarity with the initial stabilization procedures are necessary for sideline medical providers. The most important traumatic abdominopelvic topics are covered in this article. In addition, the authors outline the evaluation, management, and return-to-play considerations for the most common abdominopelvic injuries, including liver and splenic lacerations, renal contusions, rectus sheath hematomas, and several others.

Comparison of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy in iatrogenic distal ureteral injuries: tertiary care center experience

PURPOSE

In this study, we aimed to compare the results of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy, which are the most commonly used techniques in stage ≥ 3 iatrogenic distal ureteral injuries.

METHODS

The files of patients who were treated for iatrogenic distal ureteral injuries in our clinic between January 2013 and January 2019 were retrospectively reviewed. A total of 60 patients who underwent either intra-vesical split-cuff nipple ureteroneocystostomy (Group A) or extra-vesical modified Lich-Gregoir ureteroneocystostomy (Group B) operations were included in the study. The success of ureteroneocystostomy was defined as no additional surgery requirement, no progression of hydronephrosis on imaging, and normal contrast transition on imaging.

RESULTS

Thirty-four patients underwent split-cuff nipple and 26 patients underwent modified Lich-Gregoir ureteroneocystostomy. The treatment was successful in 53 (88.3%) patients and failed in seven (11.7%). Complications occurred in 19 (31.7%) patients, of whom 14 (23.3%) had minor and five (8.3%) had major complications. The rate of postoperative complications was significantly higher in Group A than in Group B (p = 0.019). There was no significant difference between Group A and Group B in terms of the success ratio (p = 1), rate of major complications (p = 0.372), and postoperative hospitalization times (p = 0.254).

CONCLUSION

In this study, a higher complication rate was found in patients with iatrogenic ureteral injuries who underwent ureteroneocystostomy with the split-cuff ureteral nipple technique compared to those who underwent this operation with the modified Lich-Gregoir technique. However, no significant difference was observed between these two techniques in terms of treatment success and major complications.

Bulbar Artery Injury With Bladder Hematoma and Severe Anemia Due to Traumatic Foley Catheter Removal

This case is described with the aim of informing about the high-level suspicion of bladder or urethral injuries in patients with traumatic Foley removal and their prolonged bleeding that should alert clinicians for a prompt urological intervention. A patient was initially admitted to the ICU with delirium and organ dysfunction due to an overdose of drugs. On the second day of his admission, he unintentionally removed his Foley catheter, which led to a course of gross hematuria. He was managed conservatively. After three weeks of hospitalization and stabilization, his profuse, constant bleeding was finally addressed. CT and ultrasound imaging was performed and revealed that his bladder was at an abnormal size and filled with blood. A cystoscopy and a fulguration of the bulbar artery were completed. Quick relief and recovery were noted after the procedure was finalized.

Non-traumatic bladder rupture

Spontaneous bladder rupture, while rare, carries a high risk of morbidity and mortality if left untreated. Here, we describe a case report of spontaneous bladder rupture in a patient initially presenting with foley malfunction. Despite foley replacement, the patient continued to endorse abdominal pain and clinically deteriorate, thus raising our suspicion for possible bladder rupture. Recognizing and understanding the different variations of spontaneous bladder rupture is paramount for timely appropriate intervention.

Nontraumatic Paraureteral Urinoma in a Cat with Urolithiasis

Urinoma is an encapsulated collection of urine due to a disruption in the collection system of the urinary tract. This condition is rarely reported in veterinary medicine. The aim of this study is to describe the clinical and diagnostic findings of a well-encapsulated paraureteral urinoma associated with urinary tract stones in a critical feline patient. The ultrasound examination of the abdomen revealed a well-defined collection of anechoic fluid containing the left kidney in the retroperitoneal space, while the radiographic examination revealed a loss of soft tissue contrast in the lumbar region. Both techniques confirmed the presence of stones in the bladder. Following the ultrasound-guided drainage of the lesion, the nature of the fluid was also confirmed to be urine. Due to the worsening of the cat’s health, to better define the extent and genesis of the lesion, a positive contrast radiographic study was performed by means of an ultrasound-guided percutaneous injection of a contrast medium into the lesion, which highlighted a wide and homogeneous radiopaque area in the left retroperitoneal space. These findings were confirmed with a postmortem examination, corroborating the diagnostic suspicion of urinoma. The percutaneous contrast inoculation performed in this critically ill patient plays a role in the diagnostic process to reach a final diagnosis in cases in which the patient’s clinical condition does not allow for performing an excretory positive contrast study.

Traumatic extraperitoneal bladder rupture in the absence of pelvic fracture in a patient with pelvic organ prolapse: A case report and review of the literature

Introduction and importance

Traumatic bladder rupture is a rare occurrence. It is more likely to occur following blunt injury and is associated with pelvic fractures in patients presenting with hematuria. We present a unique case of an extraperitoneal bladder rupture in a female after sustaining a minor fall in the absence of a pelvic fracture.

Presentation of case

The patient is a morbidly obese female with a history of vaginal vault prolapse who reported profuse vaginal bleeding and lower abdominal and suprapubic pain shortly after falling off of her bed. The patient showed no signs of hemodynamic instability and genital bleeding was ruled out in the emergency department. A Computed Tomography (CT) cystogram confirmed bladder rupture confined to the extraperitoneal space without any evidence of pelvic fractures.

Discussion

Blunt traumatic extraperitoneal bladder rupture is typically associated with concomitant pelvic fracture. These injuries tend to occur as a result of high-impact motor vehicle or motorcycle collisions and are associated with an increased morbidity and mortality.

Conclusion

Dedicated bladder imaging should be considered in blunt abdominopelvic trauma patients presenting with hematuria in the absence of pelvic fracture when the patient's underlying medical conditions or comorbidities increase the risk of bladder rupture. Our patient's history of pelvic organ prolapse placed her at an increased risk of traumatic injury to the bladder.

•

Traumatic bladder rupture is a rare occurrence which is more likely to occur following blunt injury and is associated with pelvic fractures in patients presenting with hematuria.

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Traumatic bladder rupture tends to occur as a result of high-impact motor vehicle or motorcycle collisions and is associated with an increased morbidity and mortality.

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CT cystography is the initial imaging modality of choice in the acute setting for suspected bladder rupture.

Bioengineering solutions for Ureteric disorders: Clinical need, challenges and opportunities

Objectives

To summarise the causes of ureteric damage and the current standard of care, discussing the risks and benefits of available therapeutic options. We then focus on the current and future solutions that can be provided by ureteric bioengineering and provide a description of the ideal characteristics of a bioengineered product.

Methods

We performed a literature search in February 2021 in: Google Scholar, Medline, and Web of Science. Three searches were conducted, investigating: (a) the epidemiology of ureteric pathology, (b) the current standard of care, and (c) the state of the art in ureteric bioengineering.

Results

The most‐common causes of ureteric damage are iatrogenic injury and external trauma. Current approaches to treatment include stent placement or surgical reconstruction. Reconstruction can be done using either urological tissue or segments of the gastrointestinal tract. Limitations include scarring, strictures, and infections. Several bioengineered alternatives have been explored in animal studies, with variations in the choice of scaffold material, cellular seeding populations, and pre‐implantation processing. Natural grafts and hybrid material appear to be associated with superior outcomes. Furthermore, seeding of the scaffold material with stem cells or differentiated urothelial cells allows for better function compared to acellular scaffolds. Some studies have attempted to pre‐implant the graft in the omentum prior to reconstruction, but this has yet to prove any definitive benefits.

Conclusion

There is an unmet clinical need for safer and more effective treatment for ureteric injuries. Urological bioengineering is a promising solution in preclinical studies. However, substantial scientific, logistic, and economic challenges must be addressed to harness its transformative potential in improving outcomes.

Pseudorenal failure as a delayed presentation of a traumatic urinary bladder rupture

The urinary bladder is less susceptible to traumatic injury than other abdominal organs, due to its anatomical location behind the pubic bone. As a result, intraperitoneal urinary bladder ruptures are a rare consequence of blunt abdominal trauma and most often occur in the context of high energy and multitraumas. However, a distended bladder is more vulnerable to burst rupture even from a minor trauma, and in case of an isolated bladder injury, presentation can be delayed. We describe a case in which a patient presented 4 days after a minor blunt trauma, with an acute abdomen and pseudorenal failure as the main clinical signs of urinary ascites due to a significant bladder rupture. As an intraperitoneal bladder rupture is associated with significant morbidity and mortality and should be treated surgically, it should always be considered in patients presenting with anuria, ascites and increased serum creatinine after abdominal trauma.

Role of Ultrasonography in Intraperitoneal Bladder Rupture With Delayed Presentation

Delayed presentation of intraperitoneal rupture of the urinary bladder in a child after blunt trauma is a rare occurrence. On ultrasonography, diagnosis of bladder injuries has been sparsely reported in the literature. We report a case of intraperitoneal bladder rupture in a four-year-old child and describe the role of ultrasonography in providing a prompt and accurate diagnosis of the entity as mortality increases if surgical repair is delayed. On high-resolution ultrasonography, rent was noted in the urinary bladder dome with fluid collection in the paracolic gutters and between loops of the small bowel. Peritoneocentesis demonstrated urine and the child was taken up for laparoscopic repair of the bladder tear, which was visualized at the bladder dome. Cystogram performed at one week was unremarkable and the post-operative period was uneventful with no complaints at a one-month follow-up.

Treatment of complicated bladder rupture with novel percutaneous interventional treatment technique

Bladder rupture (BR) is very rare and usually occurs after high-energy events. Although high success rates have been reported for surgical intervention, it has not been clearly stated in the literature what could be done in cases where surgery has been unsuccessful. In this case report, we aimed to demonstrate that we provided treatment with the novel interventional technique in our young patient whose urinary leakage and sepsis persisted despite repeated surgeries and prolonged nephrostomy catheter drainage.

Risk Factors for Urologic Injury in Women Undergoing Hysterectomy for Benign Indication

OBJECTIVE

To investigate risk factors associated with urologic injury in women undergoing hysterectomy for benign indication.

METHODS

A retrospective cohort study for the period of 2011-2018 was conducted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Women without urologic injury were compared with women with injury. A pre-specified multivariable logistic regression model, controlling for key patient demographic factors and intraoperative variables, was used to assess for surgical factors associated with urologic injury.

RESULTS

Among 262 117 women who underwent hysterectomy for benign indication, 1539 (0.6%) sustained urologic injury. On average, patients with urologic injury were younger, had lower body mass index (BMI), and more frequently underwent a transabdominal surgical approach. Patients who underwent total hysterectomy had increased odds of urologic injury than those who underwent subtotal hysterectomy (adjusted OR [aOR] 1.49; 95% confidence interval [CI] 1.21-1.84). Patients with class III obesity had lower odds of injury than patients with normal BMI (aOR 0.64; 95% CI 0.51-0.80). For risk of urologic injury, an interaction was observed between surgical approach and surgical indication. Abdominal compared with laparoscopic approach was associated with urologic injury for women with endometriosis (aOR 2.98; 95% CI 1.99-4.47), pelvic pain (aOR 3.51; 95% CI 1.74-7.08), menstrual disorders (aOR 4.33; 95% CI 1.68-11.1), and fibroids (aOR 2.28; 95% CI 1.72-3.03). Vaginal compared with laparoscopic approach was associated with increased odds of injury for women with menstrual disorders (aOR 7.62; 95% CI 1.37-42.5).

CONCLUSION

While the risk of urologic injury during hysterectomy for benign indication is low, the risk is dependent on patient disease factors and surgical approach.

Minimally invasive management versus open surgery in the treatment of penetrating bladder injuries: a retrospective cohort study

Background

While blunt extra-peritoneal bladder injury is typically treated non-operatively or with minimally invasive management, the treatment for penetrating bladder injury is generally open surgery. We identify a group of patients with penetrating bladder injury who were treated with minimally invasive management and compare the results with those who underwent traditional open surgical treatment.

Methods

This retrospective cohort study analyzes penetrating bladder injuries from a single trauma center from 2012 through 2019, and from the National Trauma Data Bank for 2016 and 2017. Mortality, complications, and length of stay were compared for minimally invasive management versus open surgery. We used Chi square to test significance for categorical variables, Mann–Whitney U test for ordinal variables, and T-test for continuous variables. Multivariate analysis was performed with multiple logistic, ordinal, and linear regression.

Results

Local: 117 (0.63%) had a bladder injury; 30 (25.6%) were penetrating. 6 (20.0%) were successfully treated with minimally invasive management with no complication versus 24 complications in 11 patients (45.8%) for open surgery (p = 0.047). Open surgical management was not a significant independent predictor of mortality or hospital length of stay. National Trauma Data Bank: 5330 (0.27%) had a bladder injury; 963 (19.5%) were penetrating. 97 (10.1%) were treated with minimally invasive management. The minimally invasive management group had 12 complications in 5 patients (4.9%) versus 280 complications in 169 patients (19.7%) for open surgery (p =  < 0.001). Open surgery was a significant independent predictor of complications (OR 1.57, p = 0.003) and longer hospital length of stay (B = 5.31, p < 0.001).

Conclusions

Most penetrating bladder injury requires open surgery, however a small proportion can safely be managed with minimally invasive management. Minimally invasive management is associated with lower total complications and shorter hospital length of stay in select patients.

The urological complications of vaginal birth after cesarean (VBAC) - a literature review

The appearance of urological complications is a major problem in obstetrics and gynecologic surgery; the bladder is the most common damaged organ. Due to a continuous increase in the rate of cesareans, the incidence of urologic complications will be potentially higher. We reviewed the most important risk factors for urinary tract injury and analyzed the strategies necessary to avoid these situations during vaginal birth after cesarean (VBAC). The risks and benefits of VBAC should be balanced before deciding the mode of delivery.

Appendicitis Mimicking Urinoma: A Challenging Emergency Presentation Secondary to Ureteric Stone

This article describes the case of a 38-year-old male who presented to the ED with three days history of gradually progressing right-sided lower abdominal pain, which had increased in severity two hours prior to his ED visit. The patient was anorexic but denied experiencing any fever, urinary malfunctions, or chills. Blood tests showed an elevated serum creatinine level of 123 umol/L and a high C-reactive protein level of 62 mg/L. Bedside point-of-care ultrasound (POCUS) imaging showed right-sided mild hydroureteronephrosis with surrounding perinephric fluid. Initially, based on the patient’s presentation and clinical findings, appendicitis or ureteric colic was strongly suspected. CT of the abdomen with contrast revealed urinoma measuring 16 cm, and there was a 3.2 mm calculus in the distal part of the right ureter, with perinephric and periureteric fat stranding.

This rare phenomenon requires prompt care. Delayed medical treatment may result in complications like hydronephrosis, abscess, distorted electrolyte levels, and gradual loss of renal function. Small urinomas are usually treated conservatively, while large-sized urinomas often require aggressive medical treatment. A drainage catheter under CT or ultrasound guidance may be done, and additional decompression and drainage may be needed with percutaneous nephrostomy tubes. The fluid and urine culture guide antibiotic treatment.

Bladder perforation with rectal impalement injury: Usefulness of exploratory laparoscopy for excluding intraperitoneal perforation

A 24-year-old man presented with anal bleeding after accidentally falling on a table leg. Computed tomography showed free air in the bladder and around the rectum with a high-density area without intraperitoneal free air. The patient was suspected of having extraperitoneal bladder perforation with rectal impalement, and he underwent transanal rectal repair, colostomy, and urethral catheter placement after intraperitoneal bladder perforation was excluded by exploratory laparoscopy. Postoperative course was uneventful, and the urethral catheter was removed 19 days after surgery. Three months after the operation, colostomy reversal was performed, and the patient did not experience any complications.

The reasons and countermeasures of Bladder Rupture caused by Transurethral Clot Evacuation

Objective

Bladder rupture caused by transurethral clot evacuation is rare in clinic, but an emergency operation is indeed needed in the patient with bladder rupture. We analyzed the reasons of bladder rupture caused by transurethral clot evacuation and provided the countermeasures to guide clinical surgeon to prevent the iatrogenic damage of bladder.

Method

We retrospectively reviewed the records of 287 patients in our hospital, who had bladder tamponade resulting from clots of blood for various reasons and underwent transurethral clot evacuation from January 2007 to January 2019. Six male cases, aged from 28 to 76 years (mean 56.67±17.76) had bladder rupture. Four patients whose bladder ruptured intraperitoneally were changed to open surgery to repair bladder and clear the remanent blood clots. Two patients with extraperitoneal bladder rupture and a small bladder crevasse underwent a conservative therapy.

Results

We observed that the incidence rate of bladder rupture was not associated with bladder tamponade and the age, but may be associated with gender, bladder paracentesis preoperative and urinary retention preoperative. All six cases were male.. They had different period of urinary retention before operation. No supra-pubis bladder paracentesis was made before operation. The bladder crevasses located in the triangle zone and posterior wall of bladder entirely, and the length of the bladder crevasses ranged from 3 to 7cm (mean 4.83cm). The bladder crevasses were all lengthways, and four cases were of' bladders ruptured intraperitoneally while another two presented an extraperitoneal bladder rupture.

Conclusions

The reasons of bladder rupture caused by transurethral clot evacuation may be related to gender, bladder paracentesis preoperative and urinary retention preoperative. We should decide to use expectant treatment or open surgery immediately according to the extent of the rupture when bladder rupture occurs.

Reduced Need for Urinary Bladder Catheterization in the Postanesthesia Care Unit After Implementation of an Evidence-based Protocol: A Prospective Cohort Comparison Study

Background

Postoperative urinary retention (POUR) is a known complication in the postanesthesia care unit (PACU). The variations in catheterization thresholds contribute to unnecessary invasive procedures.

Objective

In the current study, we implemented an algorithm for a sterile intermittent catheterization (SIC) threshold of 800 ml with volume-dependent bladder scan intervals and compared the incidence of SIC with that of a matched patient cohort threshold of 400 ml.

Design, setting, and participants

This comparative study of two prospective historical cohorts represented two thresholds for POUR, set at 400 ml without a standardized bladder scan protocol and 800 ml with a volume-dependent bladder scan protocol.

Outcome measurements and statistical analysis

The primary outcome was the frequency of catheterization during the PACU stay. Secondary outcomes evaluated patient safety aspects in occurrence of thresholds above 400/800 ml. The study was set at the PACU under the Department of Anesthesia, Center for Cancer and Organ Diseases, Rigshospitalet, Denmark.

Results and limitations

In total, 741 patients were consecutively included, with 307 in the POUR-400 and 434 in the POUR-800 group, and with comparable group characteristics. Significantly fewer patients fulfilled the SIC/catheter a’ demeure (CAD) criteria in the POUR-800 (5.0%) versus POUR-400 (14.3%) group, equivalent to a 65.0% relative reduction in SIC.

Conclusions

Implementation of a standardized ultrasound-guided protocol with volume-dependent scan intervals and an evidence-based catheterization threshold of 800 ml decreases the need for SIC by >65%, without increasing the need for urinary catheterization at the wards.

Patient summary

In this study, we implemented an algorithm for a sterile intermittent catheterization threshold of 800 ml with volume-dependent bladder scan intervals. A marked reduction was seen in catheterization in the postanesthesia care unit, without increasing catheterization rates at the ward.

Urinary System Iatrogenic Injuries: Problem Review

INTRODUCTION

From May to December 2019, a literature review of the urinary system iatrogenic injury problem was performed. The most cited, representative articles in PubMed, Scopus, and WoS databases dedicated to this problem were selected. Urinary system iatrogenic injuries include ureter, bladder, urethra, and kidney traumas. It is widely thought that the main causes of such injuries are urological, obstetric, gynecological, and surgical operations on the retroperitoneal space, pelvis, or perineum.

METHODS

The purpose of the study is to describe all aspects of the iatrogenic injure problem, under the established scheme and for each of the most damaged organs: the urethra, bladder, kidney, and ureter. The treatment of confirmed iatrogenic injuries largely depends on the period of its detection. Modern medical procedures provide conservative or minimally invasive treatment. An untimely diagnosis worsens the treatment prognosis. "Overlooked" urinary system trauma is a serious threat to society and a particular patient. Thus, incorrect or traumatic catheterization can lead to infection (RR 95%) and urethral stricture (RR ≥11-36%), and percutaneous puncture nephrostomy can cause the risk of functional renal parenchyma loss (median 5%), urinary congestion (7%), or sepsis (0.6-1.5%).

RESULTS

Lost gain, profits, long-term and expensive, possibly multistage treatment, stress and depression, and the risks of suicide put a heavy financial, moral, and ethical burden on a person and society. Also, iatrogenic injury might have legal consequences.

DISCUSSION/CONCLUSION

Thus, the significant problem of urinary tract iatrogenic injuries is still difficult to solve. There is a need to implement mandatory examining algorithms for patients at risk, as well as the multidisciplinary principle for all pelvic surgery.

Imaging spectrum of traumatic urinary bladder and urethral injuries

Urinary bladder and urethral injuries usually occur as part of multiple injuries in polytrauma patients. These injuries are easily overlooked because the initial evaluation is focused on other life-threatening injuries such as traumatic brain injury, hemopneumothorax or hemoperitoneum. Although the urinary bladder and urethral injuries are not life-threatening, they pose the risk of long-term morbidity which can be burdensome. These complications include urinary incontinence, voiding dysfunction, urethrocutaneous fistula, urethral stricture and erectile dysfunction. Computed tomography (CT) findings of urinary bladder and urethral injuries are usually subtle. Retrograde fluoroscopic/CT cystography and urethrography remain the mainstay imaging techniques for complete evaluation, diagnosis, staging, and follow-up of these traumatic injuries. In this review, we discuss the pathophysiology and imaging spectrum of urinary bladder and urethral injuries with an emphasis on the classification schemes. Familiarity with the pelvic anatomy and the injury pattern leads to the prompt diagnosis, accurate classification and appropriate management, which have been associated with better prognosis.

Cesarean Section Complications Followed by Bladder Cystotomy and Gross Hematuria Due to Unknown Dense Scar Tissue

Adhesions formed from previous Cesarean section (C-section) are a significant risk factor for bladder injury. We present a case of a 43-year-old pregnant woman who underwent a C-section and experienced severe complications due to adhesions and incisional dehiscence from a previous Cesarean delivery 11 years earlier. Several surgical and non-surgical interventions as radiologic tests, cystotomy, blood transfusion, cystogram, and others were necessary to resolve the issues followed by the Cesarean delivery. It is important for clinicians caring for women undergoing both primary and subsequent Cesarean sections to consider and mitigate risk factors for adhesion development.

Robot-assisted laparoscopic pyeloureterostomy for ureteropelvic junction rupture sustained in a traffic accident: A case report

BACKGROUND

Ureteral reconstruction is a highly technical type of laparoscopic or open surgery. The incidence of ureteral injury is low; however, ureteral injuries tend to be overtreated. Robotic surgery for urinary reconstructive surgery is growing in popularity, which has made procedures such as pyeloplasty, ureteroureterostomy, and ureteroneocystostomy possible, with minimal damage to the patient. To the best of our knowledge, this is the first report of robot-assisted laparoscopic pyeloureterostomy in Korea, in a 17-year-old female patient with a ureteral injury.

CASE SUMMARY

The patient, a 17-year-old girl without previous medical history, was presented at the emergency room and complained of abdominal and back pain. Tenderness in the right upper quadrant was observed on physical examination. Hemorrhage in the right perirenal space was observed without abdominal organ injuries on the initial enhanced abdomen computed tomography (CT) scan. Ureteral injury was not suspected at this time. The patient was stabilized via conservative treatment, but complained of right flank pain 3 wk later and revisited the emergency room. An enhanced abdominal CT scan revealed a huge urinoma in the right perirenal space with hydronephrosis of the right kidney. Retrograde and antegrade pyelography were performed. Extravasation and discontinuity of the ureter were found. A rupture of the ureteropelvic junction was diagnosed and reconstructive surgery was performed. After 3 mo, the patient did not complain of any symptoms without any abnormal radiologic findings.

CONCLUSION

This case report discusses the safety and effectiveness of this minimal invasive procedure as an alternative to conventional open or laparoscopic surgery.

Two Cases of Isolated Ureteral Injury Secondary to Blunt Force Trauma

Ureteral injuries although rare can cause serious issues. The mechanism of injury is most commonly penetrating but in some rare cases blunt forces can contribute. It is important to diagnose ureteral injuries as soon as possible because they can have significant morbidity and mortality. Here we present two cases of isolated ureteral injury secondary to blunt force trauma. Both patients had the ureteral injury diagnosed by computed tomography (CT) scan and confirmed by a ureterogram with extravasation of contrast. Both patients also had peripelvic cyst, which could have been a contributing risk factor for injury. In both cases, the ureteral injury was repaired using a stent and both patients had no complications. We present these cases along with presentation, diagnostic work-up, and treatment.

Recent advances of near infrared inorganic fluorescent probes for biomedical applications

Near infrared (NIR)-excitable and NIR-emitting probes have fuelled advances in biomedical applications owing to their power in enabling deep tissue imaging, offering high image contrast and reducing phototoxicity. There are essentially three NIR biological windows, i.e., 700-950 nm (NIR I), 1000-1350 nm (NIR II) and 1550-1870 nm (NIR III). Recently emerging optical probes that can be excited by an 800 nm laser and emit in the NIR II or III windows, denoted as NIR I-to-NIR II/III, are particularly attractive. That is because the longer wavelengths in the NIR II and NIR III windows offer deeper penetration and higher signal to noise ratio than those in the NIR I window. NIR imaging has indeed become a quickly evolving field and, simultaneously, stimulated the further development of new classes of NIR I-to-NIR II/III inorganic fluorescent probes, which include PbS, Ag₂S-based quantum dots (QDs) and rare earth (RE) doped NPs (RENPs) that possess quite diverse optical properties and follow different emission mechanisms. This review summarizes the recent progress on material merits, synthetic routes, the rational choice of excitation in the NIR I window, NIR II/III emission optimization, and surface modification of aforementioned fluorescent probes. We also introduce the latest notable accomplishments enabled by these probes in fluorescence imaging, lifetime-based multiplexed imaging and photothermal therapy (PTT), together with a critical discussion of forthcoming challenges and perspectives for clinic use.

A Near-Infrared Fluorescent Probe Coated with β-Cyclodextrin Molecules for Real-Time Imaging-Guided Intraoperative Ureteral Identification and Diagnosis

Although iatrogenic ureteral injury and its lack of recognition due to ureteral invisibility are serious incidents in open and laparoscopic abdominal surgeries, there are currently no safe and effective methods for intraoperative ureteral identification (IUI) and diagnosis (IUD). In this study, I designed and chemically synthesized a near-infrared fluorescence (NIRF) imaging probe (CD-NIR-1) and evaluated its clearance and ability for IUI and IUD in animal models. CD-NIR-1 demonstrated high specificity and ultrarapid clearance by rat kidneys to the urinary bladder following intravenous administration of a single dose (25 nmol/kg of body weight), with 96% of the dose ultimately excreted at the first urination with no chemical modification. Furthermore, urine containing CD-NIR-1 in ureters showed strong NIRF, thereby enabling IUI and IUD via NIRF imaging. These results demonstrated the efficacy of CD-NIR-1 for clinical use.

[Initial experience of renal autotransplantation in a child with ureteric rupture secondary to abdominal blunt trauma]

A 8-year-old child with multiple skeletal injuries after car accident is presented in the article. Extensive right-sided urohematoma with impaired kidney function was diagnosed after 15 days. External drainage of urohematoma, ureteroscopy and examination of the right kidney were consecutively performed within 1.5 months. A complete rupture of the right ureter at the level of pyeloureterostomy was diagnosed. Right kidney autotransplantation with ureteral resection and pyeloureteral anastomosis were performed in 2 months after injury. Duration of surgery was 7.5 hours, cold ischemia - 55 min. Postoperative examination confirmed satisfactory function of the right kidney. This observation is relatively rare and the first in Russia.

Computed tomography (CT) in the evaluation of bladder and ureteral trauma: indications, technique, and diagnosis

INTRODUCTION

Trauma to the genitourinary system includes blunt and penetrating injuries to bladder and ureters. These are rare injuries and are overlooked as other abdominal and pelvic injuries often take priority. Delayed diagnosis can lead to significant morbidity and mortality. Computed tomography has taken a central role in the imaging of the ureters and bladder.

METHODS

This article reviews the anatomic relationships, mechanisms of injury, and clinical presentation to help physicians determine when bladder and ureteral injuries should be suspected and further imaging should be pursued. Radiologic evaluation of bladder and ureteral injury with CT cystography and CT urography, respectively, will be reviewed.

CONCLUSION

CT cystography and CT urography are effective tools in identifying potentially serious injuries to the genitourinary system. Timely recognition of these injuries can be crucial for the overall management and prognosis.

Prognostic imaging of iatrogenic and traumatic ureteral injury by near-infrared fluorescence

Background

Iatrogenic or traumatic ureteral injuries are life-threatening but difficult to diagnose early. Ureteral visualization is essential for both the prevention and diagnosis of iatrogenic or traumatic ureter injuries. In the present study, we evaluated the feasibility of near-infrared (NIR) with ZW800-1C as a diagnostic tool of iatrogenic or traumatic ureteral injury in addition to ureter visualization, compared to methylene blue.

Methods

With mice model, we compared the image quality of ZW800-1C with methylene blue for ureter visualization. We also made ureter perforation, obstruction, crushing injury, and transection model with mice and evaluated the feasibility of ZW800-1C for diagnostic tool for ureteral injuries.

Results

We could confirm the ureter in the ZW800-1C images in maximally 30 minutes after injection, and the ureter was visible until NIR imaging concluded at 180 minutes after injection. However, methylene blue failed to provide clear ureter imaging during the same period. ZW800-1C imaging successfully visualized ureters subjected to obstruction, transection, perforation, and crush injuries, although urinary leakage was not visible by eye.

Conclusions

Our results indicate ZW800-1C is better suited for ureter visualization than methylene blue and that ZW800-1C has considerable potential for the early diagnosis of various ureteral injuries.

A contemporary review of adult bladder trauma

Injuries to the bladder are infrequent and commonly result from blunt, penetrating, or iatrogenic trauma. Bladder injuries may be missed as they often present concomitantly with other abdominal and pelvic injuries; however, early detection and treatment are essential as morbidity and mortality may be significant. Gross hematuria, especially in the setting of pelvic fractures, may be indicative of a bladder injury which can be confirmed with cystography. Extraperitoneal injuries are commonly managed conservatively with catheter drainage while intraperitoneal ruptures traditionally required surgical exploration and closure. Presented is a contemporary review which encapsulates the etiology, presentation, assessment, and management of bladder injuries.

[Management of ureteral injuries]

Ureteral injuries account for less than 3% of genitourinary injuries. Most of them are caused iatrogenically during abdominal surgery. The symptoms are often non-specific and do not aid in diagnosis. The later the injury is detected, the more often complications occur. Therefore, in such situations it is important to consider the possibility of ureteral injury and initiate further diagnostic steps as soon as possible. A variety of diagnostic tests are available. In addition to the direct inspection of the ureters and retrograde ureteropyelography, computed tomography (CT) urography is routinely used. Based on the time of diagnosis as well as the extent and the localization of the injury, the further procedure can be determined. For minor injuries, the insertion of a ureteral splint is usually the treatment of choice. In the case of higher grade damage, operative reconstruction by one of several possible surgical procedures is indicated.

Management of blunt intraperitoneal bladder rupture: Case report and literature review

INTRODUCTION

Urinary bladder ruptures are an uncommon injury, occurring in less than 1% of all blunt abdominal trauma. Extraperitoneal bladder ruptures are generally associated with pelvic fractures and usually managed nonoperatively. Conversely, intraperitoneal injuries are often caused by large compressive and shear forces produced during seatbelt injuries and almost invariably require surgical intervention.

PRESENTATION OF CASE

A 29-year-old woman presented as a trauma alert after a motor vehicle collision with abdominal/flank pain and gross hematuria. Free intraperitoneal fluid was found on ultrasound and CT imaging. Exploratory laparotomy located an intraperitoneal rupture across the bladder dome. The patient recovered without complications, was discharged on postoperative day three, and continued bladder catheter care at home for an additional week until outpatient follow up and catheter removal.

DISCUSSION

As evidence for surgical management of bladder trauma continues to grow, clinical practice guidelines have been developed for trauma surgeons. Recent recommendations from the Eastern Association for the Surgery of Trauma appraise the evidence for cystography in the perioperative setting. Postoperative care is focused on preventing catheter-associated urinary tract infections in patients recovering from urotrauma in the critical care setting.

CONCLUSION

We present a case of intraperitoneal bladder rupture in the setting of a blunt traumatic seatbelt injury. Our patient recovered uneventfully after surgical repair, a three-day hospitalization, and ten days with an indwelling bladder catheter.

Urinoma: Prompt Diagnosis and Treatment Can Prevent Abscess Formation, Hydronephrosis, and a Progressive Loss of Renal Function

This case describes a 70-year-old female who presented with right flank pain around the site where a stent had been placed in her right kidney at an outside hospital several months earlier. The patient arrived tachycardic with a leukocytosis and a lactic acidosis. Further imaging revealed a very hydronephrotic right kidney and an extremely large fluid collection in the right retroperitoneum extending into the right flank consistent with leakage of urine from the obstructed right kidney. Prompt treatment of this rare phenomenon is crucial for delay in medical care can lead to abscess, hydronephrosis, electrolyte instability, and a progressive loss of renal function. Treatment for small urinomas is usually conservative as the collection will most often be reabsorbed. Larger urinomas even without systemic signs often necessitate more aggressive medical treatment. A drainage catheter can be placed with ultrasound or CT guidance. Percutaneous nephrostomy tubes are often used as well for additional drainage and decompression. Fluid culture is recommended to guide antibiotic treatment.