Am J Clin Exp Urol 2024;12(5):301-305

[Link] /ISSN:2330-1910/AJCEU0158759

Case Report
Minimally invasive management of extraperitoneal
bladder injury with extension to the trigone of the
bladder with bilateral external ureteral catheterization:
innovative approach instead of open surgical treatment
Reza Kazemi1, Faezeh Sadat Jandaghi2, Farzaneh Montazeri3
1
Department of Urology, Isfahan University of Medical Sciences, Isfahan, Iran; 2Department of Urology, School of
Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran; 3School of Medicine, Isfahan
University of Medical Sciences, Isfahan, Iran
Received June 25, 2024; Accepted October 11, 2024; Epub October 15, 2024; Published October 30, 2024

Abstract: This case study emphasizes the critical role of accurate diagnosis and tailored management strategies in
successfully treating bladder injuries, particularly in complex cases. We present a patient with trigonal involvement
and a Grade V injury that did not respond to conservative treatment, underscoring the need for precise surgical
management. However, considering the patient’s condition and the variability in surgical approaches, a less inva-
sive intervention was chosen, leading to successful management using an external catheter to allow the bladder to
heal without direct contact with urine. This innovative approach resulted in complete recovery without surgery, dem-
onstrating the potential for positive outcomes even in complex cases. The study reiterates the importance of prompt
recognition and appropriate management to prevent adverse outcomes associated with bladder trauma, underscor-
ing the significance of close clinical monitoring and individualized treatment strategies for successful outcomes.

Keywords: Bladder rupture, extraperitoneal bladder injuries, conservative management, minimally invasive man-
agement, bladder

Introduction most common type of bladder injury. Prompt

and precise diagnosis and management are
Bladder rupture, a rare condition, can occur crucial to prevent severe complications like
due to various reasons. It is often a result of septic events, pelvic infections, and urinary fis-
trauma to the abdomen and pelvis, frequently tulas. Intraperitoneal rupture typically involves
in association with pelvic fractures [1]. However, complete disruption of the dome of the bladder,
it can also occur spontaneously or as a compli- posing a significant risk of peritonitis, chemi-
cation of surgical procedures [2]. The most cal ileus, and sepsis [5, 6]. It is important to
common signs of bladder rupture are gross note that retrograde cystography, a reliable and
hematuria and blood in the urine [3]. Other widely accepted method, is the gold standard
symptoms include pain in the suprapubic re- for diagnosing bladder injuries [2, 3]. Abnormal
gion and difficulty or inability to urinate [4]. The laboratory tests such as electrolyte disturbanc-
bladder, an extraperitoneal organ protected by es, increased blood urea nitrogen, and creati-
the pubic bones, is covered by the peritoneum nine are nonspecific findings more common in
above and behind it. This anatomical arrange- intraperitoneal ruptures [3].
ment is crucial in understanding bladder inju-
ries, classified as intraperitoneal, extraperito- Treatment of bladder rupture includes conser-
neal, or a combination of both [5]. vative and surgical approaches [1]. Surgical
treatment is essential for intraperitoneal inju-
Extraperitoneal rupture, often associated with ries due to the risk of sepsis and worsening of
pelvic fractures due to blunt trauma, is the the injury [2, 5]. Extraperitoneal injuries have

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 Minimally invasive management of grade V bladder injury

105/73 mmHg, her heart rate was 99 beats

per minute, her respiratory rate was 18 breaths
per minute, and her temperature was 36.9°C.
On examination, there was tenderness in the
suprapubic region. A hematologic evaluation
revealed a white blood cell count of 7300/μL,
hemoglobin level of 11.8 g/dL, hematocrit of
35.4%, platelet count of 148,000/μL, blood
urea nitrogen (BUN) level of 7 mg/dL, and
serum creatinine level of 0.7 mg/dL.

The patient had a history of multiple traumas

due to a car accident one month prior, resulting
in a left superior pubic ramus and left pubic
body fracture and contrast extravasation in the
left pelvis, according to the MDCT scan of the
Figure 1. A cystography showing contrast extravasa-
abdomen and pelvis. Additionally, she had
tion through the urinary bladder.
gross hematuria. Following a urology consulta-
tion and after CT cystography, a Foley catheter
different treatment approaches depending on was inserted due to the diagnosis of extraperi-
their complexity [7]. Uncomplicated injuries toneal bladder rupture, and conservative man-
are usually managed conservatively and may agement was initiated. She had been advised
resolve within two to three weeks. However, by the urology service and had a Foley cathe-
surgical intervention is recommended if no ter inserted. Surgical and orthopedic consulta-
improvement is seen within four weeks [5, 7]. tions were also obtained, and due to her con-
Complicated extraperitoneal injuries, such as dition and fractures, absolute bed rest was
those associated with stable hematuria, rectal advised.
or vaginal rupture, continuous urinary leakage,
bone fragments inside the bladder, and blad- One month later, the patient presented with
der neck injuries, require surgical intervention the abovementioned complaints. Initially, she
[5, 8]. Appropriate and timely intervention can underwent an abdominopelvic computed tomo-
significantly reduce the complications associ- graphy (CT) scan with contrast and cystogra-
ated with ongoing bladder leakage [6]. Mini- phy, which revealed extraperitoneal bladder
mally invasive treatments offer several advan- wall rupture with contrast extravasation th-
tages over open surgeries, including shorter rough the posteroinferior part of the urinary
hospital stays, faster recovery times, and bladder (Figure 1). Subsequently, the patient
reduced hospital costs. Additionally, minimally underwent cystoscopy, which revealed a 15
invasive methods significantly lower the risks of mm laceration near the left ureteral orifice and
infection and bleeding. Therefore, when feasi- involvement of the trigone. A ureteroscopy was
ble and at the discretion of the medical team, performed, and 5 French external catheters
these approaches should be considered [9]. were placed in the right and left ureters. A 16
French silicone catheter was then fixed to the
In this study, we reported a rare case of com- Foley catheter along with the external cathe-
plex extraperitoneal bladder rupture associat- ters.
ed with pelvic fracture, which, despite the need
for surgical intervention, was successfully man- As the patient did not respond to previous con-
aged using an innovative minimally invasive servative treatment after four weeks and based
treatment approach. on the cystoscopic findings indicating compli-
cated extraperitoneal bladder rupture, surgical
Case presentation intervention was necessary. However, consi-
dering the patient’s life circumstances, it was
A 15-year-old girl presented with complaints of decided not to proceed with open surgery and
severe lower abdominal pain and inability to instead opt for a minimally invasive approach.
urinate for 48 hours. The patient was stable On the second day of hospitalization, due to the
hemodynamically. Her blood pressure was stable clinical condition and routine laboratory

302 Am J Clin Exp Urol 2024;12(5):301-305

 Minimally invasive management of grade V bladder injury

accident suffered a pelvic fracture followed by

a bladder rupture.

Bladder rupture can occur intraperitoneally or

extraperitoneally, depending on the location of
the injury and its relation to the peritoneum.
Intraperitoneal ruptures typically result from
penetrating trauma or direct impact to a dis-
tended bladder. In contrast, extraperitoneal
ruptures are most commonly diagnosed th-
rough extravesical contrast extravasation and
account for approximately 70-90% of bladder
injuries [2, 10]. Extraperitoneal bladder injuries
are typically managed non-surgically through
urinary catheter drainage for two to three
weeks. However, in cases of complex and com-
plicated injuries, such as injury to the bladder
Figure 2. A retrograde cystography revealing no con- neck, concurrent injury to the vagina or rectum,
trast extravasation. presence of bony fragments in the bladder
lumen resulting from pelvic fractures, injury
tests, the patient was discharged with a white from penetrating trauma, and instances where
blood cell count of 8700 cells/mm3, hemoglo- conservative treatment fails to yield improve-
bin level of 12.4 g/dL, blood urea nitrogen level ment after four weeks, surgical intervention is
of 10 mg/dL, and creatinine level of 0.8 mg/dL. warranted.

The patient was closely followed up for two In complex cases where surgical management
weeks. A retrograde cystography performed at is necessary to address the intricate nature of
that time showed no contrast extravasation the injury and potential associated complica-
(Figure 2), indicating a successful repair of the tions, timely recognition of the need for surgical
bladder rupture. As a result, the catheters intervention must be addressed. This under-
were removed. Subsequent ultrasonography scores the critical role of early intervention in
revealed a post-void residual volume of less achieving successful outcomes in managing
than 50 mL. These results provided a clear pic- complicated extraperitoneal bladder injuries
ture of the patient’s healthy condition. [5, 7, 8].

Discussion Bladder injuries are classified into five grad-

es based on anatomical disruptions: Grade I:
It is important to note that bladder injury result- Partial thickness laceration or contusion of the
ing from the protection of bony pelvic struc- bladder wall. Grade II: Extraperitoneal injury
tures is a rare occurrence, found in less than less than 2 cm. Grade III: Intraperitoneal injury
two percent of abdominal and pelvic traumas. less than 2 cm and extraperitoneal injury more
This rarity underscores the need to consider than 2 cm. Grade IV: Intraperitoneal injury more
bladder injury in cases of pelvic fractures and than 2 cm. Grade V: Extraperitoneal or intra-
emphasizes the role of a thorough physical peritoneal injuries with bladder neck or trigone
examination for timely diagnosis [1, 6]. Fur- involvement.
thermore, patients with pelvic injuries and
gross hematuria should undergo retrograde Less severe injuries, such as grades I and II,
cystography to identify potential bladder inju- are typically managed with a precise and con-
ries [2]. servative approach involving urinary catheter
drainage, often obviating the need for surgery.
As previously noted in numerous studies, However, more severe injuries, such as Grade
including those by Yashmi Mahat et al. and III and higher, necessitate similarly precise sur-
John Barnard et al., the majority of bladder inju- gical management. This underscores the cru-
ries occur in association with pelvic fractures cial role of accurate diagnosis in determining
[5, 9]. In our study, a patient involved in a car the appropriate management approach for

303 Am J Clin Exp Urol 2024;12(5):301-305

 Minimally invasive management of grade V bladder injury

bladder injuries, a key takeaway from our case ever, our experience demonstrates that innova-
study [5, 11]. tive, less invasive approaches can also lead to
favorable outcomes, even in cases that initially
In our case study, the patient had trigonal indicate the need for surgery. This underscores
involvement and a Grade V injury that did not the significance of close clinical monitoring and
respond to conservative treatment after four individualized treatment plans to achieve suc-
weeks. Although definitive surgical treatment cessful outcomes in patients with bladder trau-
was indicated, considering the patient’s condi- ma. Ultimately, prompt recognition and appro-
tion and the variability in surgical approaches, priate management are paramount in pre-
a less invasive intervention was chosen. The venting adverse outcomes and ensuring opti-
patient was successfully managed using an mal recovery for patients with bladder injuries.
external catheter for two weeks to allow the
bladder to heal without direct contact with Disclosure of conflict of interest
urine. This innovative and successful approach
led to complete recovery without surgery, high- None.
lighting the potential for positive outcomes
even in complex cases. Address correspondence to: Farzaneh Montazeri,
School of Medicine, Isfahan University of Medi-
Given that this treatment represents an in- cal Sciences, Hezar-Jerib Avenue, Isfahan, Iran.
novation in managing complex extraperitoneal ORCID: 0009-0002-0681-0234; E-mail: arezoo.
bladder rupture, we have not identified similar mtzr@[Link]
cases or conducted studies in this area. Con-
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