Closed injuries and trauma to the bladder

In peacetime, closed injuries and trauma to the urinary bladder are 0.4% of all types of injuries and 15% among people with injuries to the genitourinary organs. In pelvic injuries, they are found in 7.5%, in closed abdominal trauma - 13.4% of victims. Isolated extraperitoneal injuries are found in an average of 26% of observations, intraperitoneal - 12%.

Most often, damage to the bladder is combined with a fracture of the pelvic bones (40-42%), rupture of the intestine (4-10%), other internal organs (8-10%) with simultaneous damage to the pelvic bones (12-36%).

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What causes closed bladder injuries and trauma?

Spontaneous ruptures of the urinary bladder, its damage during instrumental examinations: cystolithotripsy, TUR and hydraulic distension to increase capacity are described.

The mechanism of rupture depends on the nature and strength of the traumatic impact and the degree of filling of the bladder with urine. A sudden increase in intravesical pressure is transmitted with equal force to all walls of the bladder containing urine. In this case, its lateral walls, surrounded by bones, and the base of the bladder adjacent to the pelvic diaphragm, counteract the increased intravesical pressure, while the least protected and most thinned part of the bladder, facing the abdominal cavity, ruptures. Intraperitoneal ruptures of the bladder wall that occur by this mechanism spread from the inside out: first the mucous membrane, then the submucosal and muscular layer, and lastly the peritoneum.

In a number of observations, the peritoneum remained intact, leading to subperitoneal spread of bladder contents. A similar hydrodynamic rupture can result from compression of an overfilled bladder by overlapping fragments of the pelvic ring during its fractures without direct injury to the bladder wall by bone fragments.

An additional influencing factor is the tension of the pubovesical ligaments when the fragments of the pubic bones and the pubic symphysis diverge. In this case, the extraperitoneal part of the bladder is most often subject to rupture. Finally, damage to the bladder near its neck is caused by displaced fragments of the pubic and ischial bones, although they are rarely detected in the bladder wound during surgery.

This fact explains the elasticity of the pelvic ring, as a result of which bone fragments, having injured the bladder at the moment of injury, can subsequently exit the wound channel. Not all fractures of the pelvic bones, even with a violation of the continuity of the pelvic ring, are accompanied by ruptures of the bladder. Apparently, for its injury it is necessary to have a sufficient amount of urine in it, which contributes to the close location of the walls to the pelvic bones and less displacement of the bladder at the moment of injury.

A distinction is made between contusions, incomplete ruptures of the bladder wall (urine does not spill beyond its limits) and complete ruptures with urine leaking into the surrounding tissues or abdominal cavity. An incomplete rupture becomes complete as a result of inflammatory and necrotic changes in the wound, overflow of the bladder with urine and increased intravesical pressure during urination. This mechanism leads to a two-stage rupture.

Symptoms of closed injuries and trauma to the bladder

Closed bladder injuries are characterized by a combination of symptoms of damage to the bladder itself, signs of damage to other organs and pelvic bones, manifestations of early and late complications of the injury. Hematuria, urination disorders, pain in the lower abdomen or suprapubic region during the initial examination of a patient with a history of trauma allow us to suspect damage to the bladder.

Isolated injuries cause pain in the suprapubic region, urinary dysfunction, and hematuria. Urinary dysfunctions associated with bladder injury vary. The nature of the disorder is related to the degree of bladder emptying through the wound opening into the surrounding tissues or into the abdominal cavity. Contusions and incomplete ruptures of the bladder cause frequent, painful urination, and acute urinary retention is possible.

Sometimes, with minor injuries, urination remains normal. Complete ruptures are characterized by the absence of spontaneous urination with frequent and painful urges, but unlike urinary retention, tympanitis is determined above the pubis. With extraperitoneal damage, it soon gives way to increasing dullness that does not have clear boundaries; with intraperitoneal ruptures, tympanitis is combined with the presence of free fluid in the abdominal cavity. With ruptures of the bladder against the background of fruitless urges to urinate, the release of several drops of blood, a long absence of urination and urges to urinate are sometimes possible.

An important symptom of bladder trauma is hematuria, the intensity of which depends on the type of injury and its location. In case of contusions, external and internal incomplete, intraperitoneal ruptures, macrohematuria is short-term or even absent, whereas in case of significant ruptures in the neck and bladder triangle, it is pronounced. However, isolated ruptures of the bladder are extremely rarely accompanied by significant blood loss and shock.

In case of intraperitoneal ruptures of the urinary bladder, peritoneal symptoms develop slowly, increase gradually (over 2-3 days), are weakly expressed and inconstant, which is often the reason for late diagnosis of urinary peritonitis.

Initially localized in the suprapubic region, the pain becomes diffuse, accompanied by intestinal paresis, abdominal distension, stool and gas retention, nausea, and vomiting. After a cleansing enema, there is stool and gas is released. The abdomen participates in breathing, abdominal wall muscle tension and pain during abdominal palpation are insignificant or moderately expressed, peritoneal symptoms are weakly expressed, intestinal peristalsis is heard for a long time.

After 24 hours, the patient's condition worsens, signs of intoxication join, leukocytosis and azotemia develop. Infected urine entering the abdominal cavity leads to an earlier appearance of the picture of diffuse peritonitis, but in this case, the clinical picture of dynamic intestinal obstruction comes to the fore, accompanied by a sharp bloating of the intestine. In the absence of anamnestic information about the injury, such a clinical picture is regarded as food poisoning.

In case of extraperitoneal injury, after a few hours after the injury, the intensity of hematuria decreases, but the frequency and pain of the urge to urinate increases. In the suprapubic and inguinal areas, swelling of the skin and subcutaneous tissue appears in the form of a doughy swelling. The condition of the victim gradually worsens due to increasing urinary intoxication and the development of pelvic phlegmon or abscesses, as evidenced by high body temperature, neutrophilic leukocytosis with a shift to the left, hypochromic anemia, an increase in residual nitrogen, urea and creatinine in the blood serum in laboratory tests.

In 50-80% of cases, patients with combined bladder injuries are in a state of collapse and shock, which significantly changes the nature of clinical manifestations and complicates diagnosis. Isolated pelvic bone fractures with a perivesical hematoma may also manifest as pain, dysuria, tension and tenderness during palpation of the anterior abdominal wall, gas, stool and urine retention. These symptoms are probably associated with irritation of the parietal peritoneum by the hematoma, compression of the bladder neck.

Suspected bladder damage is an indication for special studies that allow us to confirm the fact of bladder damage, determine its type and plan treatment tactics.

Complications of closed injuries and trauma of the bladder

Complications of bladder injuries most often arise due to late diagnosis of damage or untimely treatment.

Complications of bladder injuries:

• increasing urohematoma:
• pelvic phlegmon;
• localized abscesses;
• urinary peritonitis;
• adhesive intestinal obstruction;
• sepsis.

If the bladder neck, vagina, and rectum are damaged, without timely elimination, urinary incontinence, urinary fistulas, and strictures develop. Subsequently, plastic surgery may be required.

Extensive trauma to the sacrum, sacral roots, or pelvic nerves results in denervation of the bladder and dysfunction of urination. If the cause of bladder dysfunction is a disorder of innervation, catheterization may be required for some time. In some severe injuries to the sacral plexus, dysfunction of urination may be persistent due to decreased muscle tone of the bladder and its neurogenic dysfunction.

Complications from contusions and incomplete ruptures of the bladder are rare: hematuria, urinary tract infection, decreased bladder volume, and, less commonly, the formation of pseudodiverticula of the bladder.

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Diagnosis of closed injuries and trauma of the bladder

Diagnosis of closed bladder injuries is based on the analysis of the circumstances and mechanism of injury, physical examination data, laboratory and radiological diagnostic methods.

At the pre-hospital stage, diagnostics of bladder injuries is difficult: only 20-25% of victims are sent to hospitals with a correctly established diagnosis, where recognition of extraperitoneal ruptures does not cause any particular difficulties. The high frequency of combinations of bladder injury with pelvic bone fractures alerts doctors, and in the presence of corresponding complaints, urination disorders, blood in the urine, there is a need for additional ultrasonographic and radiographic studies, which allow for an early correct diagnosis and surgical treatment in the first hours after hospitalization.

The situation is completely different with the diagnosis of intraperitoneal ruptures. The typical picture of intraperitoneal damage occurs in approximately 50% of victims, which is why observation of patients is delayed. Clinical signs of injury (serious general condition; rapid pulse, abdominal distension, presence of free fluid in the abdominal cavity, symptoms of peritoneal irritation, urinary disorders and other signs) are absent or weakly expressed against the background of shock and blood loss.

Abrasions, bruises and other signs of trauma in the abdominal and pelvic area, clarification of the mechanism of injury, assessment of the patient's condition and the degree of filling of the bladder help to suspect its injury. Palpation through the rectum determines the presence of its injury, hematoma and urinary leakage of bone fractures, overhang of the vesicorectal fold.

When examining a patient, it is necessary to pay attention to abrasions and subcutaneous hematomas of the anterior abdominal wall, hematomas on the perineum and inner thighs. It is necessary to visually assess the color of the urine.

The most typical symptoms of bladder injuries are macrohematuria (82%) and abdominal tenderness on palpation (62%). Other symptoms of bladder injury are microhematuria, inability to urinate, hematoma in the suprapubic area, tension of the muscles of the anterior abdominal wall, arterial hypotension, and decreased diuresis.

If the patient is intoxicated, the above symptoms do not appear immediately. If the urogenital diaphragm is intact, urine leaks are limited to the pelvic area. If the upper fascia of the urogenital diaphragm is torn, urine infiltrates the scrotum, perineum, and abdominal wall. If the lower fascia of the pelvic diaphragm is torn, urine infiltrates the penis and/or thigh.

The simplest, most accessible method of diagnosing bladder damage that does not require high qualifications or special equipment is diagnostic catheterization, performed carefully, with a soft catheter, in the absence of signs of damage to the urethra.

Signs that indicate bladder damage:

• absence or a small amount of urine in the bladder in a patient who has not urinated for a long time:
• a large amount of urine, significantly exceeding the physiological capacity of the bladder;
• admixture of blood in urine (it is necessary to exclude renal origin of hematuria);
• discrepancy between the volumes of fluid introduced and removed through the catheter (positive Zeldovich symptom);
• The released fluid (a mixture of urine and exudate) contains up to 70-80 g/l of protein.

In recent years, ultrasound, laparoscopy and laparocentesis (diagnostic puncture of the anterior abdominal wall) have been widely used to detect free blood and urine in the abdominal cavity. A catheter inserted into the abdominal cavity is alternately directed under the hypochondrium, into the iliac regions and the pelvic cavity, removing the contents of the abdominal cavity with a syringe. When blood, fluid with an admixture of bile, intestinal contents or urine are obtained, damage to internal organs is diagnosed and an emergency laparotomy is performed. If the fluid does not enter the abdominal cavity through the catheter, 400-500 ml of physiological sodium chloride solution is introduced, then aspirated and examined for admixture of blood, diastase and urine. A negative result of laparocentesis allows you to refrain from laparotomy.

To detect a small amount of urine in wound discharge and intraperitoneal fluid obtained during laparocentesis or surgery, the presence of substances that selectively concentrate in urine and are its indicators is determined. The most suitable endogenous substance is ammonia, the concentration of which in urine is thousands of times greater than in blood and other biological fluids.

Method for determining urine in the test fluid Add 5 ml of 10% trichloroacetic acid solution to 5 ml of the test fluid (to precipitate protein), mix and filter through a paper filter. Add 3-5 ml of 10% potassium hydroxide (KOH) solution and 0.5 ml of Nessler reagent to the transparent and colorless filtrate for alkalization. If the test fluid contains more than 0.5-1% urine, it turns orange, becomes cloudy and a brown sediment forms, which is considered damage to the urinary organs. If there is no urine in the test fluid, it remains transparent and slightly yellow.

Ultrasound, bladder catheterization and abdominal puncture are the most acceptable methods for diagnosing bladder injuries in emergency care practice.

These same methods are the main diagnostic techniques at the stage of providing qualified surgical care, which does not include X-ray equipment.

The diagnostic value of cystoscopy in case of bladder ruptures is limited by the difficulty of placing the patient in the urological chair (shock, pelvic bone fractures), the impossibility of filling the bladder in case of ruptures, intense hematuria, which prevents examination due to poor visibility. In this regard, there is no need to try to perform cystoscopy if there is a suspicion of bladder damage. It can be used at the final stage if clinical and radiological data do not confirm, but do not exclude with sufficient reliability the presence of damage, and the patient's condition allows cystoscopy.

Laboratory testing of blood is mandatory to assess the severity of blood loss (hemoglobin, hematocrit and red blood cell levels) and urine. High levels of electrolytes, creatinine and urea in the blood serum raise suspicion of intraperitoneal rupture of the bladder (urine enters the abdominal cavity, urinary ascites and is absorbed by the peritoneum).

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Macrohematuria

Macrohematuria is a constant and most important, but not unambiguous symptom accompanying all types of bladder injury. Numerous studies show that macrohematuria in hip fracture strictly correlates with the presence of bladder rupture. During bladder rupture, macrohematuria occurs in 97-100%, and hip fracture - 85-93% of cases. The simultaneous presence of these two conditions is a strict indication for cystography.

Isolated hematuria without any information about lower urinary tract trauma is not an indication for cystography. Additional factors that allow one to suspect bladder injury are arterial hypotension, decreased hematocrit, general severe condition of the patient, and fluid accumulation in the pelvic cavity. If pelvic bone trauma is not accompanied by macrohematuria, then the likelihood of serious bladder injury is reduced.

In case of urethrorrhagia, before performing cystography, it is necessary to perform retrograde urethrography in order to identify possible damage to the urethra.

Microhematuria

The combination of a pelvic ring fracture and microhematuria indicates damage to the urinary tract, but if the general urine analysis shows less than 25 red blood cells per high-power field of view, the likelihood of bladder rupture is low. All patients with bladder rupture have hematuria - more than 50 red blood cells per high-power field of view.

Cystography is advisable if, according to urine analysis at high magnification, the number of red blood cells exceeds 35-50 and even 200 in the field of view.

Caution should be exercised with injuries in childhood, since studies have shown that if 20 red blood cells are detected in the high-magnification field of view, up to 25% of bladder ruptures can be missed without cystography.

Plain radiography can detect bone fractures, free fluid and gas in the abdominal cavity.

Excretory urography with descending cystography in most bladder injuries, especially those complicated by shock, is uninformative due to the fact that the concentration of the contrast agent is insufficient to detect urine leaks. The use of excretory urography in bladder and urethra injuries gives a false-negative result in 64-84% of cases, as a result of which its use for diagnostics is inappropriate. The usual cystographic phase during standard excretory urography does not allow to exclude bladder injury.

Cystography

Retrograde cystography is the "gold standard" for diagnosing bladder injuries, allowing to detect a violation of the integrity of the bladder, to conduct differential diagnostics between intra- and extraperitoneal ruptures, to establish the presence and localization of leaks. In addition to being highly informative, the method is safe, does not aggravate the condition of the victim; does not cause complications from the penetration of a contrast agent into the abdominal cavity or perivesical tissue - if a rupture is detected, cystography is followed by surgical intervention with drainage of the abdominal cavity or drainage of leaks. Retrograde cystography should be combined with the Ya.B. Zeldovich test.

In order to ensure high information content of the study, at least 300 ml of a 10-15% solution of a water-soluble contrast agent in a 1-2% solution of novocaine with a broad-spectrum antibiotic is slowly introduced into the bladder through a catheter. A series of X-ray images of the bladder are taken in the frontal (anteroposterior) and sagittal (oblique) projections. An image is necessarily taken after emptying the bladder to clarify the localization and nature of the spread of leaks in the perivesical and retroperitoneal tissue, which increases the effectiveness of the study by 13%.

The main radiographic sign of bladder damage is the presence (leakage) of contrast agent beyond its limits, and an indirect sign is its deformation and displacement upward or to the side. Indirect signs are more often observed with extraperitoneal rupture and perivesical hematomas.

Characteristic direct radiographic signs of intraperitoneal rupture are clear lateral borders, concave and uneven upper contour of the urinary bladder due to overlap of the bladder shadow by the spilled contrast. In intraperitoneal ruptures, the intestinal loops are contrasted: the rectovesical (recto-uterine) recess. The shadows of the contrast agent spilled into the abdominal cavity are well outlined due to their location between the loops of the distended intestine.

Signs of extraperitoneal rupture: unclear outline of the urinary bladder, blurriness: leakage of radiopaque substance into the perivesical tissue in the form of separate stripes (tongues of flame, diverging rays) with a small cloud-like shadow - medium; continuous darkening without clear outlines - large ruptures.

All leaks usually lie below the upper edge/ossa acetabulum.

If the above rules are not followed, there is a possibility of obtaining a false result. The classification of bladder injuries according to the protocol of the European Association of Urologists (2006) is based on cystography data.

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Ultrasound examination

The use of ultrasound for the diagnosis of bladder injuries is not recommended as a routine examination method due to the fact that its role in identifying bladder injuries is small.

Ultrasound can detect free fluid in the abdominal cavity, fluid formation (urohematoma) in the pelvic tissue, blood clots in the bladder cavity, or lack of visualization of the bladder when it is filled through a catheter. The use of ultrasound is currently limited due to the fact that patients with multiple injuries are more often given CT, a more informative diagnostic method.

Computer tomography

Although CT is the method of choice for the investigation of blunt and penetrating abdominal and femoral injuries, its routine use even with a full bladder is inappropriate, since it is impossible to differentiate urine from transudate. For this reason, CT in combination with retrograde contrast of the bladder - CT cystography - is used to diagnose bladder injuries.

CT cystography allows diagnosing bladder injuries with an accuracy of up to 95% and a specificity of 100%. In 82% of cases, CT data completely coincide with the data obtained during surgery. In diagnosing intraperitoneal bladder injury, CT cystography is 78% sensitive and 99% specific. When performing CT cystography, performing additional scanning after emptying the bladder does not increase the sensitivity of the method.

Thus, CT with contrast of the bladder and retrograde cystography have the same information content in terms of diagnosing bladder injuries, but the use of CT also provides the opportunity to diagnose combined injuries of the abdominal organs, which undoubtedly increases the diagnostic value of this research method.

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Angiography

During angiography, a hidden source of bleeding is identified and, at the same time, embolization of the damaged vessel is performed during the examination.

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Magnetic resonance imaging

MRI in the diagnosis of bladder injuries is used mainly for the purpose of diagnosing combined injuries of the urethra.

In case of clinical signs of damage to abdominal organs, the final diagnosis of the type of damage to the bladder is often made during its revision during surgery. After revision of all abdominal organs, the integrity of the bladder is checked. Through the bladder wound, if its size is sufficient, all walls are revised to exclude extraperitoneal ruptures as well.

Treatment of closed injuries and trauma of the bladder

Suspected bladder injury is an indication for emergency hospitalization of the patient.

Treatment tactics depend on the nature of the bladder injury and associated injuries to other organs. In case of shock, anti-shock measures are taken before surgery. In case of contusion and incomplete rupture of the bladder, treatment is conservative: bed rest, hemostatic, analgesic, antibacterial and anti-inflammatory drugs are prescribed.

To prevent a two-stage rupture, a permanent urinary catheter is inserted into the bladder. The duration of bladder drainage is individual and depends on the severity of the injury, the patient's condition, the nature of the injury, the duration of hematuria, the duration of pelvic hematoma resorption (on average 7-10 days). Before removing the urethral catheter, it is necessary to perform cystography and make sure there are no leaks of contrast agent.

Treatment of complete closed injuries is always surgical. The best results are observed in the early stages of surgical intervention. Before surgical intervention for bladder injuries, the primary task is to stabilize the patient's general condition.

In many patients with closed extraperitoneal bladder rupture, bladder catheterization is effective, even if there is extravasation of urine beyond the peritoneum or into the external genital area.

According to the studies by Corriere and Sandler, 39 patients with bladder rupture were cured solely by drainage and good results were noted in all cases. Cass, having cured 18 patients with extraperitoneal bladder rupture solely by drainage, observed complications in only 4 cases.

According to some authors, transurethral drainage of the bladder is preferable, leading to a lower level of complications. The urethral catheter, left for a period of 10 days to 3 weeks, is removed after cystography.

In case of small extraperitoneal bladder injuries that occurred during endourological operations, conservative treatment is possible against the background of bladder drainage for 10 days. By this time, in 85% of cases, bladder injuries will heal on their own.

Indications for surgical treatment of extraperitoneal blunt trauma:

• damage to the neck of the bladder;
• bone fragments in the thickness of the bladder and infringement of the bladder wall between bone fragments;
• inability to adequately drain the bladder with a urethral catheter (clot formation, ongoing bleeding);
• associated injury to the vagina or rectum.

Experience shows that the earlier surgical intervention is performed for such intra- and extraperitoneal injuries of the bladder, the better the results.

The purpose of the operation is to revise the urinary bladder, to suture its defects with a single-row suture using absorbable suture material, to divert urine by placing an epicystostomy and to drain paravesical urinary leaks and urohematomas of the pelvic tissue.

In case of intraperitoneal damage, a median laparotomy is performed. The abdominal cavity is thoroughly dried. The bladder wound is sutured with single- or double-row sutures made of catgut or synthetic absorbable threads. After suturing the bladder wall defect, the tightness of the suture is checked. A thin polyvinyl chloride drain is left in the abdominal cavity.

To administer antibiotics, the abdominal cavity is sutured to the site of the installed drainage. If there is difficulty in detecting a bladder wall defect during surgery and to check the tightness of the suture at the end of the bladder operation, a 1% methylene blue solution or a 0.4% indigo carmine solution is injected into the bladder via a catheter, monitoring the site of the dye entering the abdominal cavity. If suturing of the bladder wound is difficult, its extraperitonization is performed.

Extraperitoneal, easily accessible ruptures of the urinary bladder are sutured with absorbable material using a two- or single-row suture. When localizing damage in the area of the bottom and neck of the urinary bladder, due to their inaccessibility, it is possible to apply immersion sutures from the side of its cavity. Drains are brought to the wound opening from the outside, which are brought out, depending on the location of the wound, through the suprapubic approach: however, it is preferable through the perineum according to Kupriyanov or the obturator opening according to Buyalsky-McWarger. Then the catheter is fixed to the thigh with tension for 24 hours and removed no earlier than 7 days later.

When the bladder neck is torn from the urethra, suturing the separated parts is practically impossible due to the technical difficulties of suturing in this area and the urinary infiltration that has developed by the time of surgery. To restore the patency of the urethra and prevent the formation of long strictures after evacuation of the urohematoma, a catheter is inserted into the bladder through the urethra.

Then, stepping back 0.5-1.5 cm from the edge of the bladder neck wound, 1-2 catgut ligatures are applied on the right and left, while the detrusor of the bladder and the prostate capsule are stitched near the opening of the urethra. The ligatures are tied in stages, the bladder is brought together and the diastasis between the bladder neck and the proximal end of the urethra is eliminated. The bladder is fixed in its anatomical bed. The bladder and perivesical space are drained with silicone (vinyl chloride) tubes.

The urethral catheter is kept for 4-6 days. If it is impossible to apply converging, fixing ligatures, a Foley catheter is used, the balloon of which is filled with liquid and the neck of the bladder is brought closer to the prostate by tension on the catheter, sutures are placed between them in easily accessible places and the catheter is fixed to the thigh with tension. In case of a serious condition of the patient and a protracted intervention, matching the neck of the bladder with the urethra is postponed to a later date, and the operation is completed with cystostomy and drainage of the perivesical space.

The urinary bladder is drained in case of any rupture, using mainly an epicystostomy, and it is better to install the drainage tube as close to the top of the bladder as possible.

The tube is fixed to the wall of the urinary bladder with catgut, after suturing the bladder wound below the tube, the stromal area is sutured to the aponeurosis of the rectus muscles. The high position of the drainage tube prevents the development of osteomyelitis of the pubic bones. Only in isolated cases, with isolated small damage to the bladder in women, the absence of peritonitis and urinary leaks, and the tightness of the suture of the bladder wound, drainage with a permanent catheter for 7-10 days is permissible.

In the postoperative period, it is advisable to actively remove urine using a siphon drainage, a UDR-500 drainage device, a vibroaspirator. Stationary vacuum suction devices. If necessary, flow-through lavage of the bladder with antibacterial solutions is carried out, supplied through an intradrainage irrigator of a double-lumen drainage or an additional capillary tube installed through a suprapubic approach. Improvement of the outcomes of closed bladder injuries is determined by early diagnosis and timely surgical intervention. Mortality in a number of institutions was reduced to 3-14%. The cause of death of victims is
Multiple severe injuries, shock, blood loss, diffuse peritonitis and urosepsis.

In extremely severe cases, a cystostomy is performed and the perivesical tissue is drained. Reconstructive surgery is performed after the patient's condition has stabilized.

In patients with pelvic fracture, bladder reconstruction surgery should be performed prior to intramedullary fixation of the fragments.

In the postoperative period, broad-spectrum antibiotics, hemostatic drugs, and analgesics are prescribed. In the vast majority of cases, when using this method of treating damage, complete healing occurs within a period not exceeding 3 weeks.

Intraperitoneal rupture of the urinary bladder is an absolute indication for emergency surgery; the only contraindication is the patient's agonal state. If combined damage to the abdominal organs is suspected, it is advisable to include an abdominal surgeon in the operating team.

Surgical access is lower midline laparotomy. After opening the abdominal cavity, a thorough revision of the organs is performed in order to exclude their combined injuries. If such injuries are present, the abdominal stage of the operation is performed first.

A rupture of the urinary bladder is usually observed in the area of the transitional fold of the peritoneum. If it is difficult to detect the site of the rupture of the bladder, it is advisable to use intravenous administration of 0.4% indigo carmine or 1% methylene blue, which color the urine blue and thus facilitate the detection of damage to the urinary bladder.

After detecting damage to the bladder wall, an epicystostomy is performed, and the rupture is sutured with a two-row suture using absorbable material. Sometimes the bladder is additionally drained with a urethral catheter, and constant lavage of the bladder with antiseptic solutions is established for 1-2 days.

In the absence of combined damage to the abdominal organs, the operation is completed with sanitation and drainage. Drainage tubes are installed through counter-opening incisions into the pelvic cavity and along the right and left lateral canals of the abdominal cavity. In case of diffuse peritonitis, nasogastrointestinal intubation of the intestine is performed.

In the postoperative period, antibacterial, hemostatic, anti-inflammatory, infusion therapy, intestinal stimulation and correction of homeostasis disorders are carried out.

The duration of abdominal cavity and bladder drainage is determined individually depending on the characteristics of the postoperative period. In this case, they are guided by intoxication indicators, the duration of hematuria, and the presence of infectious and inflammatory complications.