# The Incidence, Management, and Outcome of Penetrating Bladder Injuries in Civilians Resultant from Armed Conflict in Baghdad 2005-2006

Authors: Firas G. Petros; Richard A. Santucci; Naimet K. Al-Saigh
Journal: Advances in Urology
 (2009)

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## Abstract

The purpose of this paper is to review the diagnosis, treatment, and outcomes of penetrating bladder injuries suffered by civilians in the Iraqi war zone.Materials and Methods. All civilian trauma cases received alive at Al-Yarmouk Teaching Hospital from January 2005 to August 2006 were reviewed for the presence of bladder injury. Results. 533 cases of penetrating abdominal trauma were identified, of which 177 (33%) involved the genitourinary (GU) system and 64 (12%) involved the bladder. Most (70%) were young males, and most (55%) had grade IV injuries. Associated injuries occurred in 63/64 (98%) of patients. 3 patients had missed bladder injuries, and all of these had complications related to their missed injury. Bladder-related complications occurred in 11% of cases, and mortality in 13%, all due to extravesical injuries.
Conclusions. Penetrating bladder injury among civilians in Baghdad war zone resulted in 64 cases in 18 months. The initial detection rate is very high (98%), and after primary repair, lasting complications are rare. Morbidities from missed injuries were severe hematuria and vesicorectal fistula. However, (3%) of vesicorectal fistulae healed spontaneously with prolonged bladder drainage. Associated injuries are the rule in penetrating bladder injury patients, and must be diligently investigated and treated.


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## Body

## 1. Introduction

The rate of wartime bladder injuries has
stayed remarkably constant, at 15%–20%, over the
last 60 years between World War II and the modern conflicts in the Balkans and
the Gulf (1991) [1–3]. However, in the 21st century,
near-universal use of body armor seems to have decreased the incidence of all
genitourinary (GU)
injuries in US soldiers to a very low percent 2% [4]. Civilians without body armor
still have high rates of abdominal GU injuries and are though more susceptible
than military personnel to bladder injuries. We have endeavored to describe our
significant experience with 64 wartime bladder injuries among a civilian
population in a war
that torn Iraq
during the years 2005-2006.In peacetime, research and writings
completed by civilian surgeons often educate the military surgeons as to the best practices. In
wartime, the large numbers of  the wounded allow military surgeons to advise civilian
practitioners on improvements in the trauma field. It is in this spirit that we
report these data, in order to improve peacetime and wartime understanding of
the best care of penetrating bladder injuries which were obtained in peacetime.


## 2. Materials and Methods

From January 2005
to August 2006, all abdominal trauma cases received alive in the Emergency
Department at Al-Yarmouk Hospital, which is one of the primary sites in Baghdad
for acute
management of civilian trauma, were reviewed for penetrating bladder injury.Injuries were staged using the American
Association for the Surgery of Trauma (AAST) organ injury severity scale [5].  The mechanism of injury as
well as the number and severity of associated injuries were noted.All patients were managed in the
Emergency Department with resuscitation, evaluation of bladder injury when
Foley catheter was installed diagnosing hematuria. Sometimes those patients
have frank wound(s) in the suprapubic areawhile others diagnosed during
abdominal exploration and if time and clinical condition permitted, imaging
studies were done as X-ray of pelvis occasionally cystogram. Urgent surgical
exploration was performed in most cases since we were dealing with multiorgan-injured
trauma victim patients with life-threatening concomitant injuries.When bladder injury was encountered or
looked for during laparotomy (if expected according to injury type and
abdominal wound site), the principle was to repair the bladder with proper
drainage. Through midline exploratory cystostomy, bladder walls, distal
ureters, and bladder neck were all explored, avoiding as possible to interfere
with any pelvic hematoma. Ureters were assessed by retrograde passage of
ureteric catheters, in case of facing difficulties; exploration was done with repair or
reimplantation according to the
site of ureteric injury. Bladder injury site(s) was closed after limited
debridement of any devitalized tissue with two layers of absorbable suture
material. Difficult sites at bladder neck or trigone were managed in some cases
with one-layer suturing from within.In
rectal involvement cases, debridement and selective separation of the organ
walls were performed, to be sutured separately with interposition of omentum or
any other available viable tissue if possible. We always tried to avoid overlapping
suture lines, and together with colostomy, proper drainage of the area was
done. All other injuries
were dealt with accordingly. Transurethral Foley 2 way catheter of size 18–22 Fr was the
routine way of postoperative drainage. Suprapubic cystostomy catheter was added
in severely injured bladder where the repair was thought to be incomplete.
Catheters were kept for 10–14 days according
to injury assessment, and in some cases cystography preceded the removal
especially for those with multiple bladder injuries and difficult bladder neck and/or
trigone closure. Broad
spectrum antibiotic cover was used to all patients starting from the Emergency Department.
There was limited use of anticholinergic medications since in the majority
of cases there was concomitant bowel injury.SPSS version 11.5
(SPSS Inc., Chicago, Ill, USA) was used for data entry and
analysis. Chi-square
test of association was used whenever applicable.P value of less or equal to .05 was
considered significant.


## 3. Results

533 cases of
penetrating abdominal trauma were identified, including 482 (89%) males and 51 (11%)
females. Ages ranged from 4 to 60 years (median age 28) (Figure1). 177 (33%) injuries
involved the GU system and 64 (12%) involved the bladder. These 64
patients represented 36% of thepatients with GU injury.Figure 1
Age distribution of patients with penetrating bladder injury.All penetrating bladder injuries
were due to bullets from pistols, rifles, and/or machine guns (78%), or shells
from explosive devices (22%). No knife wounds were seen. 55% of the injuries
were grade IV or higher (Figure2) with equal involvement of the dome (38%) and
lateral wall (36%) (Figure 3). Concomitant injuries occurred in all but 1 of
the injured bladder patients (Figure 4).Figure 2
AAST organ injury severity scale grade of 64 penetrating bladder injuries.Figure 3
Location of 64 penetrating bladder injuries.Figure 4
Concomitant injuries in 64 penetrating bladder injury patients.Of the 64 bladder-injured
patients, the bladder injury was identified and repairedsurgically during
abdominal exploration in 60 (94%). Supravesical drainage was needed only in severe
cases. Four cases (6%) were treated conservatively. Of these 4 patients, 3
had bladder injuries that were missed during surgical exploration. These 3
were grade III extraperitoneal injuries. The only case that was managed
conservatively bychoice was a grade 1 injury proved by cystography and
associated with lower limb injury.Of the 64 bladder-injured
patients, 49 (77%) suffered no significant morbidity.  8/64 (13%) died within 24 hours of injury,
usually due to severe bleeding and grave-associated injuries, rather than from
the bladder injury itself. Major vascular injuries were found in 5 (63%) of the
patients who died.Serious
complications occurred in 7 of 64 (11%)cases (Figure5). Of these 7 cases,
3 had severe hematuria causing drainage problems and requiring blood
transfusions; 2 had vesicorectal fistulae which healed with conservative
management; 2 had urethral strictures, from concomitant urethral trauma. Of the
3 cases of missed bladder injury, 2 had severe hematuria and one had a
vesicorectal fistula.Figure 5
Complications in 64 patients with penetrating bladder injuries.Mortality in this bladder-injured
population was significantly associated with concomitant vascular (P=.0002)
and chest (P=.003) injuries. Increased complications were related to
those cases where injuries were missed compared to operatively repaired cases (P=.0001).


## 4. Discussion

Civil violence in Iraq  has reached epidemic levels during
the last 4 years, and increasing numbers of urological injuries are being seen
among unprotected civilians. In this study, urologic injuries occurred in 33%
(n  =  177) of 533 penetrating abdominal injury patients, a high incidence that
might be expected when dealing with civilians not wearing body armor. Of these
patients with urologic injury, 36% had bladder injury, representing 12% of the
entire population of patients with abdominal penetrating injury.


### 4.1. Comparison to Civilian and Wartime Series

The incidence of GU tract injuries reported
in civilians is generally lower or comparable to that seen here. Civilian
penetrating injuries to the bladder occurred in 11% of 155 victims with
penetrating abdominal wounds seen in one US study [6], while during unrest in Belfast
over a 10-year period, only 76 of such injuries were reported [7]. Some civilian series report
bladder injuries in less than 5% of gunshot victims [6, 8].Older series describing wartime bladder
injury rates are also comparable to that seen in our civilian population here. In
Vietnam and Croatia, bladder injuries occurred in 15% of those with GU injury [4, 8] and among 92 reported abdominal wounds in the Korean conflict; the bladder was
involved in 11% of cases [8]. Bladder injury cases in
Kuwait during the first Gulf War (1991) were 11% of all GU injuries among Iraqi wounded and 17%
among US wounded [9, 10]. However, in modern conflicts
in which body armor is universally used, the rate of bladder injuries is well
below 2% [4].The majority of the affected victims in
our study were males (89%), reflecting the same male predominance in civilian
penetrating abdominal injuries series (reported to be between 81% and 87%) [6, 10, 11].In our study, 78% of the cases were caused
by high velocity bullets, with only 22% from shells and explosives. Among US
soldiers in the Iraq war, just the opposite was found, with 83% of the GU
injuries due to fragmentation injuries and mines [9, 12].


### 4.2. Associated Injuries

In our series, all penetrating bladder
cases were associated with injuries to other organs, which coincide with result
reported widely in literature [4–6, 8–11, 13].
Bullets caused injury to a greater number of intra-abdominal organs compared to
explosive fragment wounds (2.05 versus 1.56 organs per patient), which also
coincided with what has been reported in literature [14].Bladder injuries
commonly co-occur with colon/rectal injuries. In one series, bladder injuries occurred
in 13% of penetrating rectal injuries [15],
and in another, 1/3 of patients with extraperitoneal rectosigmoid gunshot
wounds had bladder involvement [10]. In our series, the colon was
injured in 33% and the rectum injured in 22% of the bladder trauma cases. In
general, they were successfully managed, as no significant increase in mortality
was found. In this study and others, small and large bowels were also commonly injured, with
rates reaching 34% and 33% for small and large bowels, respectively [6, 8, 9].
Urethral injury was found in 3% of the cases.Major vascular injuries accompanied 9% of
our bladder cases. It was found to be statistically a significant cause of death in 63% of the
dead cases. This factor represents the major impact on mortality rates in
different studies [6, 16].We had ureteric involvement in 4 (6%)
cases, while it is usually found in 4%–6% of all urological
injuries [9]. Three of our cases were
discovered during surgery and treated with immediate reimplantation, while the
fourth one was missed, and reimplantation was done successfully later.


### 4.3. Surgical Technique

Our surgical technique reflects what is routinely done in many studies [5, 6, 9, 10, 13, 17],
except that we used only suprapubic drainage in more severe and massive bladder
injuries, and no damage control principles were required. Complications
occurred in 7 out of the 64 bladder injuries (11%), representing 5% of the
surgically repaired cases, and appeared lower than rates described elsewhere
which can range as high as 33% [6, 9].  Complications occurred in all 4 missed and
conservatively treated injuries. Of the 3 cases of missed bladder injury, 2 had
severe hematuria and one had a vesicorectal fistula while the only case of
conservative management was accompanied by severe hematuria.
Higher complication rates in cases treated conservatively have been described
previously [5]. The complication of
hematuria and rectal fistula healed spontaneously, and this coincides with
other studies [5, 6, 9, 10].One of the vesicorectal fistulae
resulted from partial dehiscence of repair of concomitant bladder and rectal
injuries which was evident clinically and radiographically at end of the first postoperative week,
while the other one resulted from missed bladder and rectal injuries diagnosed
at the fifth postoperative day by the same way. Healing of vesicorectal fistula was achieved by
prolonged bladder drainage by transurethral catheterization formore than
2 weeks (up to 1 month) depending on the size of the fistula, nothing by
mouth, IV fluid;  antibiotic cover and follow up cystography.We did not see in
our study chronic complications like bladder neck stenosis, erectile
dysfunction, and overactive bladder symptoms such as what have been described elsewhere and can
involve between 5% and 21% of cases [5].Mortality rate after isolated bladder
injury has plummeted over the last century.
Mortality rates dropped from 35% in the 1930s [11] to 16% during 1940s [6], then to 10% in the Korean War [8], reaching 1.3% in civilian
abdominal injuries in the sixties [6]. However, mortality rate in bladder
injuries patients with other associated severe injuries can still reach high
levels between 12% and 22% [5, 18]. This reflects the severity
of the associated injuries rather than the bladder injury itself. Most of this
mortality is due to vascular injury, and death rates are reportedly much higher
in those with longer evacuation times, reflecting the risk of exsanguinations
after these types of injury [4, 7–9, 16, 18].In our study, mortality rate was 13%, death
occurred in all cases within 24 hours of injury, and major vascular injuries
were found in 63% of these victims. Both vascular and associated chest injuries
were statistically associated with higher mortality rate in our series. The grade
of bladder injury was not found statistically related to mortality rate,
reflecting the fact that
death is related to other organs injured rather than the bladder itself.
Bullets were responsible for 75% of injuries, indicating the higher incidence
of major vascular injuries with bullet wounds (20% versus 9%) which ultimately
ended with greater mortality rates (7% versus 2%) [14].


### 5. Conclusion

The incidence of urological
injury is high in unprotected civilian victims of wartime injuries in modern Baghdad. The majority of penetrating
bladder injuries were associated with concomitant organ injury, and severe
blood loss and death were not uncommon. Management of bladder or indeed any GU
injury should emphasize investigation for concomitant injury.Complications are
generally uncommon, and most often resolve spontaneously.  Even some severe complications such as
vesicorectal fistula heal with prolonged urinary drainage. Missed injuries have
a higher complication rate, so it is important to accurately screen for bladder
injuries in a penetrating trauma population. Suprapubic tubes are occasionally
required after primary bladder repair of severe and massive bladder
injury. Wartime series such as this can help to
advise civilian trauma surgeons as to the best practices through the vast experience
when dealing with such multiorgan-injured
patients especially in the unique challenges of Iraq’s situation in which there
is deficiency of experienced trauma surgeons, and a lot of the difficult work
is dealt with by junior residents, in addition to deficiency in equipments.
Yet, one can only salute the great job which is done every day, by unknown
soldiers; those are the Iraqi doctors and medical personals on the line of fire
in Baghdad
hospitals.


## 4.1. Comparison to Civilian and Wartime Series

The incidence of GU tract injuries reported
in civilians is generally lower or comparable to that seen here. Civilian
penetrating injuries to the bladder occurred in 11% of 155 victims with
penetrating abdominal wounds seen in one US study [6], while during unrest in Belfast
over a 10-year period, only 76 of such injuries were reported [7]. Some civilian series report
bladder injuries in less than 5% of gunshot victims [6, 8].Older series describing wartime bladder
injury rates are also comparable to that seen in our civilian population here. In
Vietnam and Croatia, bladder injuries occurred in 15% of those with GU injury [4, 8] and among 92 reported abdominal wounds in the Korean conflict; the bladder was
involved in 11% of cases [8]. Bladder injury cases in
Kuwait during the first Gulf War (1991) were 11% of all GU injuries among Iraqi wounded and 17%
among US wounded [9, 10]. However, in modern conflicts
in which body armor is universally used, the rate of bladder injuries is well
below 2% [4].The majority of the affected victims in
our study were males (89%), reflecting the same male predominance in civilian
penetrating abdominal injuries series (reported to be between 81% and 87%) [6, 10, 11].In our study, 78% of the cases were caused
by high velocity bullets, with only 22% from shells and explosives. Among US
soldiers in the Iraq war, just the opposite was found, with 83% of the GU
injuries due to fragmentation injuries and mines [9, 12].


## 4.2. Associated Injuries

In our series, all penetrating bladder
cases were associated with injuries to other organs, which coincide with result
reported widely in literature [4–6, 8–11, 13].
Bullets caused injury to a greater number of intra-abdominal organs compared to
explosive fragment wounds (2.05 versus 1.56 organs per patient), which also
coincided with what has been reported in literature [14].Bladder injuries
commonly co-occur with colon/rectal injuries. In one series, bladder injuries occurred
in 13% of penetrating rectal injuries [15],
and in another, 1/3 of patients with extraperitoneal rectosigmoid gunshot
wounds had bladder involvement [10]. In our series, the colon was
injured in 33% and the rectum injured in 22% of the bladder trauma cases. In
general, they were successfully managed, as no significant increase in mortality
was found. In this study and others, small and large bowels were also commonly injured, with
rates reaching 34% and 33% for small and large bowels, respectively [6, 8, 9].
Urethral injury was found in 3% of the cases.Major vascular injuries accompanied 9% of
our bladder cases. It was found to be statistically a significant cause of death in 63% of the
dead cases. This factor represents the major impact on mortality rates in
different studies [6, 16].We had ureteric involvement in 4 (6%)
cases, while it is usually found in 4%–6% of all urological
injuries [9]. Three of our cases were
discovered during surgery and treated with immediate reimplantation, while the
fourth one was missed, and reimplantation was done successfully later.


## 4.3. Surgical Technique

Our surgical technique reflects what is routinely done in many studies [5, 6, 9, 10, 13, 17],
except that we used only suprapubic drainage in more severe and massive bladder
injuries, and no damage control principles were required. Complications
occurred in 7 out of the 64 bladder injuries (11%), representing 5% of the
surgically repaired cases, and appeared lower than rates described elsewhere
which can range as high as 33% [6, 9].  Complications occurred in all 4 missed and
conservatively treated injuries. Of the 3 cases of missed bladder injury, 2 had
severe hematuria and one had a vesicorectal fistula while the only case of
conservative management was accompanied by severe hematuria.
Higher complication rates in cases treated conservatively have been described
previously [5]. The complication of
hematuria and rectal fistula healed spontaneously, and this coincides with
other studies [5, 6, 9, 10].One of the vesicorectal fistulae
resulted from partial dehiscence of repair of concomitant bladder and rectal
injuries which was evident clinically and radiographically at end of the first postoperative week,
while the other one resulted from missed bladder and rectal injuries diagnosed
at the fifth postoperative day by the same way. Healing of vesicorectal fistula was achieved by
prolonged bladder drainage by transurethral catheterization formore than
2 weeks (up to 1 month) depending on the size of the fistula, nothing by
mouth, IV fluid;  antibiotic cover and follow up cystography.We did not see in
our study chronic complications like bladder neck stenosis, erectile
dysfunction, and overactive bladder symptoms such as what have been described elsewhere and can
involve between 5% and 21% of cases [5].Mortality rate after isolated bladder
injury has plummeted over the last century.
Mortality rates dropped from 35% in the 1930s [11] to 16% during 1940s [6], then to 10% in the Korean War [8], reaching 1.3% in civilian
abdominal injuries in the sixties [6]. However, mortality rate in bladder
injuries patients with other associated severe injuries can still reach high
levels between 12% and 22% [5, 18]. This reflects the severity
of the associated injuries rather than the bladder injury itself. Most of this
mortality is due to vascular injury, and death rates are reportedly much higher
in those with longer evacuation times, reflecting the risk of exsanguinations
after these types of injury [4, 7–9, 16, 18].In our study, mortality rate was 13%, death
occurred in all cases within 24 hours of injury, and major vascular injuries
were found in 63% of these victims. Both vascular and associated chest injuries
were statistically associated with higher mortality rate in our series. The grade
of bladder injury was not found statistically related to mortality rate,
reflecting the fact that
death is related to other organs injured rather than the bladder itself.
Bullets were responsible for 75% of injuries, indicating the higher incidence
of major vascular injuries with bullet wounds (20% versus 9%) which ultimately
ended with greater mortality rates (7% versus 2%) [14].


## 5. Conclusion

The incidence of urological
injury is high in unprotected civilian victims of wartime injuries in modern Baghdad. The majority of penetrating
bladder injuries were associated with concomitant organ injury, and severe
blood loss and death were not uncommon. Management of bladder or indeed any GU
injury should emphasize investigation for concomitant injury.Complications are
generally uncommon, and most often resolve spontaneously.  Even some severe complications such as
vesicorectal fistula heal with prolonged urinary drainage. Missed injuries have
a higher complication rate, so it is important to accurately screen for bladder
injuries in a penetrating trauma population. Suprapubic tubes are occasionally
required after primary bladder repair of severe and massive bladder
injury. Wartime series such as this can help to
advise civilian trauma surgeons as to the best practices through the vast experience
when dealing with such multiorgan-injured
patients especially in the unique challenges of Iraq’s situation in which there
is deficiency of experienced trauma surgeons, and a lot of the difficult work
is dealt with by junior residents, in addition to deficiency in equipments.
Yet, one can only salute the great job which is done every day, by unknown
soldiers; those are the Iraqi doctors and medical personals on the line of fire
in Baghdad
hospitals.



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*Source: 275634-2009-04-05.xml*