■ If imaging, such as a CT scan, has demonstrated a bone spike protruding into the bladder, the bladder should be opened, the bone removed, and the defect in the bladder sutured.
■ Rectal perforation in association with a bladder rupture is uncommon, but again where there is a rectal injury, an extraperitoneal bladder rupture should be repaired because of the high risk of severe pelvic sepsis.
106 J. REYNARD
■ Occasionally, where conservative management of an extraperitoneal bladder rupture with catheter drainage is started, there may be persistent bleeding from the edges of the bladder injury. This can cause troublesome clot retention and is another indication for formal open repair of such injuries.
■ Finally, where the patient is undergoing open fixation of a pelvic fracture, urine leaking from the bladder while the bladder rupture heals spontaneously can potentially cause infection of the metal plate. Simultaneous repair of an extraperitoneal rupture may reduce the likelihood of this occurring.
Surgical repair of an extraperitoneal bladder rupture also allows an accurate assessment to be made of the integrity of the bladder neck. Similarly, vaginal injuries can also be repaired at the same time. The easiest way to repair an extraperitoneal bladder injury is by opening the bladder at the dome, and performing the repair from inside the bladder. This is the most 'direct' approach and it avoids the need to mobilise the posterior wall of the bladder. An associated bladder neck or vaginal injury can also be repaired via such an approach. Attempting such a repair by a vaginal approach is technically difficult because of associated labial oedema or haematoma formation, which makes access to the vagina very difficult.
The key thing with operative management of extraperitoneal bladder ruptures is to inspect the entire surface of the bladder, first to look for other perforations and second to remove any bone fragments that might be poking into the lumen of the bladder. Inspection of the bladder is most easily done by formally opening it between stay sutures and inspecting its interior. Make your incision at the dome, i.e., as far away from the pelvic haematoma as you possibly can so as not to disturb it and precipitate uncontrollable haemorrhage. A urethral or supra-pubic catheter (through a separate stab wound) should be inserted for subsequent bladder drainage over the course of the next 2 weeks or so. Some surgeons are happy with a single-layer closure with absorbable sutures, while others feel that a two-layer closure is more secure. In the case of an extraperitoneal tear, a drain runs the potential risk of allowing a site of access for infection of the pelvic haematoma, and many surgeons prefer not to place a drain after repair of an extraperitoneal rupture, as long as adequate bladder drainage with a catheter has been obtained.