FEATURES OF SURGICAL CARE OF URINARY BLADDER RUPTURE IN CHILDREN WITH POLYTRAUMA

Sherman S.V., Agalaryan A.Kh., Galyatina E.A., Gavrilov A.V., Guseva G.N.

Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia

FEATURES OF SURGICAL CARE OF URINARY BLADDER RUPTURE IN CHILDREN WITH POLYTRAUMA

Car accidents are the most common cause of urinary bladder rupture, which is identified in 90 % of cases [1]. In children, such injuries are caused by car accidents in 97 % of cases [1]. During car accident, the traumatic force impacts the urinary bladder through the seatbelt. Usually, injuries happen in patients with full urinary bladder. The degree of fullness of the urinary bladder determines its shape and amenability to trauma. The full urinary bladder can be injured by a weak hit, whereas the empty bladder is significantly less amenable to injury [1, 2].
Diagnosis and treatment of the urinary bladder injuries are among the most difficult problems in urgent surgery. The incidence of the urinary bladder injuries is 2 % among abdominal injuries requiring for surgical management. Urinary system injuries are more common for children than for adults, since the adjacent anatomical structures are not developed enough and perform the protective function to a lesser degree [2].
Urinary bladder and/or urethra injuries at the background of pelvic fractures are accompanied by high risk of complications in children. Such injuries are rarer in girls and are often missed in emergency units. Urinary bladder and/or urethra injuries are identified in 3 % of girls with fractures of pelvic bones. The risk factors are the pelvic ring fracture, vaginal laceration, multiple fractures of the pelvic bones and injuries to the sacrum [3].
The most common symptoms in patients with serious injuries to the urinary bladder are macrohematuria (82 %) and pain during abdominal palpation (63 %) [2]. Other symptoms include the impossible independent urination, and hematoma in the pubic region.
The radiologic techniques take the leading role in diagnosis of the urinary bladder ruptures: cystography, computer tomography (85-100 % of accuracy), angiography, ultrasonic examination and cystoscopy.
The priority task in treatment of patients with the urinary bladder injuries is stabilization of the patient’s condition and compensation of associated life-threatening injuries.
The management of the urinary bladder trauma is determined by characteristics and anatomical location of an injury in relation to the peritoneum. There are closed and opened injuries according to the injury mechanism [4, 5]. There are intraperitoneal, extraperitoneal and combined injuries according to the anatomical position of the injury in relation to the peritoneum [4]. All intraperitoneal and combined injuries (opened or closed) are treated only by surgical techniques. Both surgical and conservative techniques are used for extraperitoneal injuries to the urinary bladder [6, 7].
Objective – to present the features of diagnosis and surgical care of a girl with multiple pelvic fractures and urinary bladder and vaginal rupture.
The study was conducted in concordance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013 and the Rules for Clinical Practice in the Russian Federation (the Order by Health Ministry of the Russian Federation, June 19, 2003, No.266) with written consent from the girl’s parents and the approval from the local ethical committee (the protocol No.25, April 4, 2017).
The patient B., age of 12, was admitted to Regional Clinical Center of Miners’ Health Protection 9 hours after the injury on January 5, 2017. The patient was transported in the reanimobile by the instant readiness team. Kashtan anti-shock suit was used.
The anamnesis: a road traffic injury. The girl was in a car as a passenger. She was transferred to the nearest medical facility. She was examined by the surgeon and the traumatologist. The examination was conducted. The X-ray images of the pelvis showed a fracture of pubic and ischial bones on both sides, and a fracture of the sacroiliac joint to the right.
Laparotomy was conducted. The bladder wall, the left ovarian laceration and the mesosigmoid were sutured. The retroperitoneal hematoma was revised. The vagina was packed. The abdominal drains were installed. The pelvic bones fractures were not stabilized.
The diagnosis was made: “Polytrauma. A closed unstable fracture of the superior and inferior branches of the pubic bone on both sides, a fracture of the ischial bone to the right, a rupture of the sacroiliac joint to the right. Blunt abdominal trauma. Urinary bladder rupture. Left ovary laceration. Brain concussion. Traumatic shock of degree 3”.
Considering the severity of the patient’s condition, the patient was transported to Regional Clinical Center of Miners’ Health Protection. After admission to the center, the general condition was severe and was determined by severity of the associated injury (abdominal, skeletal and traumatic brain injury). The patient was immobilized in Kashtan anti-shock suit. The level of consciousness – coma 3 at the background of medicamental sedation. The pupils were narrow and equal. The photo response was depressed. Oculocephalic reflexes were negative. The innervation of the face was symmetrical. The range of motions was full in all joints of the upper and lower extremities. There was no evident deformation. The examination of the pelvis showed the positive Larrey's symptom. Skin surfaces and visible mucosa were pale. The intubation tube and ALV device were used for breathing. The chest was active in the respiratory act. During auscultation, the breathing was vesicular, over all parts of the lungs, without stertor. The cardiac tones were rhythmical. The heart rate was 130-140 beats per min. Arterial pressure was 100-120/70 mm Hg. The abdomen was of correct shape and symmetrical. The postsurgical wound was along the middle abdominal line, and it was sutured with the interrupted suture. The silicone drains were in the right and left iliac regions for the serous and hemorrhagic discharge. The abdomen was soft during palpation. There were no pathologic formations. Intestinal motility was not auscultated. The externailia are normally developed, according to female type. A gauze sponge was in the vagina. The sponge was blood-soaked. The blood was discharging after removal of the sponge. The urina did not move through the catheter (blood clots were moving).

The additional examinations were conducted in the center:
MSCT of the brain: no cerebral contusions or meningeal hemorrhage. No bone pathology of the cranial vault, the base and facial skeleton.
Chest MSCT: no bone injuries. No pneumo- and hydrothorax.
Cervical spine MSCT: no traumatic changes in vertebral bodies and processes.
X-ray examination and MSCT of the pelvis: the pelvic ring was asymmetrical. A transforaminal fracture of the latera mass S1 with posterior displacement up to 0.5 cm to the right. A fragmented fracture of the medial angle of the acetabular roof to the left, and a fracture of the upper branch of the pubic bone to the eft in the place of its connection with the acetabulum. A transverse  fracture of both lower branches of the pubic bones with displacement to the right by the thickness of the cortical layer. The heads of both femoral bones were centred in the acetabulum, without traumatic changes (Fig. 1).

Figure 1. MSCT of chest organs and pelvic bones at admission. MSCT, 3D-modelling of pelvic bones at admission

  

Considering the hemorrhagic discharge from the abdominal cavity, absence of urina in the catheter and vaginal bleeding, the collegial decision for revision of the abdominal cavity and vagina, and for external osteosynthesis for the pelvic bones was made.
Recurrent laparotomy was conducted. The light yellow fluid (urina) was in the abdominal cavity (up to 100 ml). The revision of the intestine, the liver, the gall bladder and the spleen did not show any abnormalities.
The left ovary was 3.0 × 2.0 × 2.5 cm, the datros was not thick. The ovary had some sutures. The sutures were consistent and without ongoing bleeding.
The urine bladder was full. The wound was sutured with the one-row suture. Urina was between the sutures. The sutures of the urinary bladder were removed. The posterior wall of the urinary bladder was dissected (extended). The cavity of the bladder was filled with blood clots (about 200 ml). The clots were removed. The revision of the bladder cavity identified two ruptures. One rupture was along the anterior wall (3 × 2 cm, the depth about 0.5 cm, incorrect shape). The second rupture was along the neck of the urinary bladder, near the posterior wall (4 × 2 cm, the depth of 0.5 cm, incorrect shape). The defects were diffusely bleeding. The ruptures were sutured. The posterior wall of the bladder was sutured with the two-row suture with formation of epicystostoma. The paravesical space was drained according to Buyalski-McWhorter.
The ongoing bleeding was found after removal of the sponge from the vagina. A rupture (3 cm) of the left wall of the vagina was identified. The rupture’s depth reached to the muscular layer, with extensive detachment of the mucosa from the muscular layer along the borders of the rupture. The region of the rupture was bleeding significantly. After preparation, the rupture of the vaginal wall was sutured with two-layer suture VICRYL 4/0. The vagina was packed for hemostasis.
After laparotomy, the surgery was carried out: pelvis osteosynthesis with the external fixing device (Fig. 2).

Figure 2. X-ray examination of pelvic bones after application of external fixing device

The diagnosis was made on the basis of the examinations and the surgical management: “Polytrauma. A closed injury to the abdominal organs: a combined rupture of the urinary bladder. A laceration of the lateral vaginal wall. A rupture of the mesosigmoid, a rupture of serous layer of the rectosigmoid. A rupture of the left ovary.
Skeletal injury: a closed unstable fracture of the superior and inferior branches of the pubic bone on both sides, a fracture of the ischial bone to the right, a rupture of the sacroiliac junction to the right.
Traumatic brain injury: brain concussion. Traumatic shock of degree 3”.
On January 7, 2017, the high amount of urina started to discharge from the drain from the paravesical space, and pastosity of the anterior abdominal wall   above the pubis, and suture inconsistency appeared on the second postsurgical day. Therefore, the surgery was conducted: bladder revision. Recurrent laparotomy showed the light yellow fluid (urina, about 100 ml). Fluid leakage was noted during pumping of saline through the epicystostoma into the urinary bladder. The revision of the urinary bladder and the paravesical space was conducted. Some saline and the color contrast were discharging. The bladder was opened. The revision of its cavity identified a defect of the wall (1.5 × 1 cm) in the region of the neck near the previously applied sutures. The defect was sutured with the interrupted stitches. The epicystostoma was removed. Fokey catheter was not removed. The bladder wound was sutured with the two-row suture. The leak test did not show any leak of the color contrast. The draining of the paravesical space was according to Buyalski-McWhorter.
The control cystography was conducted on January 16, 2017. The urinary bladder was filled, of pear-shaped form, with clear contours. The leakage of the contrast media into the small pelvis cavity to the left, and the formation of the depot of the contrast media of incorrect shape (1 × 0.2 cm) were identified. The contrast media did not enter the ureters. During bladder emptying, the depot of the contrast media in the small pelvis cavity to the left persisted (Fig. 3).

Figure 3. Cystography on 11th day after admission

    

On January 19, 2017, the amount of urina passing through the catheter from the bladder decreased, and urina was discharging from the vagina.
On January 19, 2017, cystostomy, revision, transvaginal suturing of the bladder injury, sanitation and draining of the paravesical space (Buyalski-McWhorter.) were conducted.
The revision showed the paravesical adhesive process. The examination of the bladder did not show any injuries or urina leak. The sutures were removed from the wall of the bladder. During the examination, the bladder edema was edematous, hyperemic, with contact bleeding. The ureteral openings were symmetrical and fissured. Urina was light and clear.
The subsequent revision identified a defect in the region of the opening of the urethra along the posterior semicircle. The length of the defect was about 4 cm, diastasis of the borders – 3 cm. The borders were not clearly differentiated because of the evident inflammatory process. The wall of the bladder was rigid. It was impossible to suture the defect through the bladder.
The anterior wall of the vagina was dissected with the transvaginal approach. The defect of the bladder wall was separated in acute and blunt form. With some technical difficulties, the defect was sutured with the interrupted sutures on the catheter (MONOCRYL 4/0). The cystotomic wound was sutured with two rows of the interrupted sutures (MONOCRYL 4/0, VICRYL 2/0). The contrast leak was not found during the leakage test. The paravesical space was drained according to Buyalski-McWorther). The laparotomy wound was sutured in layer by layer manner. The wound of the anterior vaginal wall was sutured. The ointment sponge was placed.
However two days later, on January 21, 2017, the recurrent discharge of urina through the vesicovaginal fistula appeared (about 50 ml per day).
The treatment in ICU lasted up to January 30, 2017 (25 days). ALV, infusion therapy, transfusion of blood components, antibacterial therapy, analgesia and dressings were conducted. From January 30 to February 10, 2017, the treatment was conducted in the traumatology unit. The patent was discharged from the center on the 36th day. At the moment of discharge, the urina was discharging from the vesicovaginal fistula.

CONCLUSION

Therefore, polytrauma with multiple fractures of the pelvic bones can be accompanied by the urinary bladder rupture. It should be considered in primary diagnostics of all types of injuries.
The urinary bladder rupture is a rare pathology in girls. One should consider that patients with multiple fractures of the pelvic bones have the highest risk of injuries to the urinary bladder and urethra.
A location of a rupture in the region of the neck of the bladder causes some additional difficulties for diagnosis and surgical treatment, resulting in recurrent surgery within different time intervals and increase in hospital management duration. As result, the algorithm of the measures for polytrauma with multiple fractures of the pelvic bones and suspicious injury to the urinary bladder and/or urethra should include the ultrasonic examination, cystography, cystoscopy and MSCT, making possible the targeted identification of the urinary bladder injuries.
The outcome of treatment of the urinary bladder rupture in children depends on the severity of injury to the pelvic structures and organs. One of the postsurgical complications of such pathology is development of a vesicovaginal urinary fistula. The surgical management of this pathology is a difficult surgical task.

Information about financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.

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