Bladder injuries are a relatively uncommon finding in abdominal trauma. The most common mechanisms are penetrating injury and blunt force injuries that disrupt the anterior pelvic ring. In most cases, repair of a full-thickness injury is straightforward and can be performed by the trauma surgeon during the abdominal exploration. More complicated injuries near the trigone usually require assistance from our urology colleagues.
But what happens after the repair? How long should the urinary catheter be left? Should a cystogram be performed before removing it? Over time, the interval to catheter removal and the number of patients with pre-pull studies have been shrinking. There is a huge amount of variability in how trauma professionals approach this, making it one of those areas that is ripe for a practice guideline! And unfortunately, there are none.
The group at the Medical College of Wisconsin in Milwaukee performed a retrospective review of their experience over 13 years at their Level I trauma center. All adult patients with non-complex, full-thickness bladder injuries that were repaired were included in the study.
Here are the factoids:
- Only 86 patients met the inclusion criteria
- The injuries were intraperitoneal in 43%, extraperitoneal in 31%, and mixed in the remaining 26%
- Trauma managed 41% of patients, and urology managed 59%
- Comparing care by trauma surgery vs urology, there were significant differences in catheter duration (median 11 vs 17 days) and use of pre-pull cystogram (77% vs 100%)
- There was a 4% leak rate in patients treated by each group (1 vs 2)
The authors concluded that the variation in management between urology and trauma resulted in similar leak and complication rates and suggested that a standard practice should be developed.
Bottom line: This is a provocative study, but still falls under the rule “don’t let a single scientific paper change your practice.” It’s small, it’s retrospective, and it essentially examines “how we do it.”
However, it does extend and add to things we already know. Inaba published a paper in 2013 that showed bladder injuries typically healed within 9 days. A urology group noted that there were no complications in their patients who did not undergo cystography before removing the catheter.
This paper should stimulate two things. First, a carefully designed prospective study should be conducted to determine the timing of catheter removal and the need for a cystogram. And in the meantime, some enterprising centers should craft their own practice guideline that adopts a standard discontinuation time (seven days?) and selective or non-use of pre-pull cystography with safeguards built in to ensure patient safety.
References:
- Investigating the timing of catheter removal after traumatic bladder injury: a single-institution 12-year experience: Trauma Surgery & Acute Care Open 2025;10:e001693.
- Prospective evaluation of the utility of routine postoperative cystogram after traumatic bladder injury. J Trauma Acute Care Surg 2013; 75:1019–23.
- Clinical Utility of Routine Follow-up Cystography in the Management of Traumatic Bladder Ruptures. Urology 2018; 113:230–4.