ACR Appropriateness Criteria Suspected Lower Urinary Tract Trauma EVIDENCE TABLE

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1 1. Dreitlein DA, Suner S, Basler J. Genitourinary trauma. Emerg Med Clin North Am 2001; 19(): Bjurlin MA, Fantus RJ, Mellett MM, Goble SM. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. J Trauma 2009; 67(5): Type 1,80 patients with pelvic fractures; 1, had GUI Objective (Purpose of ) Review diagnosis and management of genitourinary trauma. Retrospective study to compare morbidity, mortality, and health care resource utilization in patients with and without GUI associated with pelvic fractures. Results Diagnosis and treatment of external genitals injures when done promptly results in excellent long-term outcome. Men more commonly sustained pelvic fractures with GUI than women (66.1% vs.86%). The incidence of urogenital, bladder, and urethral injuries for men and women was 5.%,.1%, 1.5%, and.62%,.7%, 0.15%, respectively. Patients with GUI remained hospitalized longer (median 10 vs 6 days, P<0.001), had more intensive care unit stay days (median vs 1 days, P<0.001), were less often discharged home (1.02% vs 2.82%), and had an increased mortality rate (1.99% vs 8.08%, P<0.001) when compared with patients without GUI. Motor vehicle collisions were the most common mechanism of injury for all pelvic fractures. Spleen and liver were the most commonly injured abdominal organs associated with pelvic fractures as a whole. Pelvic fractures with GUI were more likely to result in associated injuries of the bowel, and reproductive organs. Although GUI was not found to be an independent predictor of mortality, age 65 years, initial systolic blood pressure in the emergency department 0 mm Hg to 90 mm Hg, Injury Severity Score 25, Glasgow coma score of 8, and female gender were independent predictors of mortality. Patients sustaining a pelvic fracture with GUI have an increase in morbidity. Although GUI was not an independent predictor of mortality, patients who sustained a pelvic fracture with GUI had a greater number of concomitant injuries resulting in an increase in overall mortality compared with those without an associated GUI. Page 1

2 . Jankowski JT, Spirnak JP. Current recommendations for imaging in the management of urologic traumas. Urol Clin North Am 2006; (): Andrich DE, Day AC, Mundy AR. Proposed mechanisms of lower urinary tract injury in fractures of the pelvic ring. BJU Int 2007; 100(): Corriere JN, Jr., Sandler CM. Diagnosis and management of bladder injuries. Urol Clin North Am 2006; (1):67-71, vi. 6. Cass AS. Diagnostic studies in bladder rupture. Indications and techniques. Urol Clin North Am 1989; 16(2): Sezhian N, Rimal D, Suresh G. Isolated intraperitoneal bladder rupture following minor trauma after alcohol ingestion. South Med J 2005; 98(5): Type 168 patients (108 pelvic ring fractures 60 acetabular fractures) Objective (Purpose of ) Review current recommendations for imaging in urologic traumas. Review case notes and radiographs of patients to examine whether specific pelvic fractures pattern help predict the presence and type of injuries to the lower urinary tract. Review diagnosis and treatment of injuries to the bladder. Review indications and techniques in the diagnosis of bladder rupture. 1 patient To describe a case of intraperitoneal bladder rupture in a 1-year-old male caused by trauma from a fall after alcohol ingestion. Results Choice of modality is based on mechanism of injury and patient presentation. For pelvic injuries and gross hematuria, CT cystography or conventional cystography is recommended. For scrotal trauma when physical exam is inconclusive, US is recommended. For patients with penetrating trauma to the external genitalia, retrograde urethrography is recommended. 27 (25%) of 108 had a lower urinary tract injury documented either radiologically or as an intraoperative finding. Pelvic fracture pattern alone does not predict the presence of a lower urinary tract injury. The pattern of injury to the soft tissue envelope and specifically to the ligaments supporting the lower urinary tract offers the best correlation with the observed lower urinary tract injury. The pelvic fracture pattern alone does not predict the presence of a lower urinary tract injury. When it occurs, the type of lower urinary tract injury appears to be related to the fracture mechanism. The pattern of injury to the soft tissue envelope and specifically to the ligaments supporting the lower urinary tract offers the best correlation with the observed lower urinary tract injury. Diagnosis is made by a retrograde static cystogram performed by filling the bladder with contrast through a urethral catheter. Retrograde cystogram with bladder filling of 00 ml of radiopaque dye followed by a washout film will diagnose intraperitoneal and extraperitoneal ruptures of the bladder. Falsenegative cystograms occur with penetrating injuries of the bladder when only 250 ml or less of contrast medium is used to fill the bladder. Signs of peritonitis appeared the following day, and emergency CT revealed intraperitoneal rupture. Laparotomy revealed a laceration of the bladder in the fundus. Page 2

3 8. Schneider RE. Genitourinary trauma. Emerg Med Clin North Am 199; 11(1): Brewer ME, Wilmoth RJ, Enderson BL, Daley BJ. Prospective comparison of microscopic and gross hematuria as predictors of bladder injury in blunt trauma. Urology 2007; 69(6): Fuhrman GM, Simmons GT, Davidson BS, Buerk CA. The single indication for cystography in blunt trauma. Am Surg 199; 59(6):5-7. Type 8,026 patients Objective (Purpose of ) Examine genitourinary trauma and patients at risk for urology injury, review physical findings and describe present radiographic procedures that allow for proper diagnosis and treatment. To prospectively demonstrate that bladder imaging is required for gross hematuria and unnecessary for microscopic hematuria. 26 patients Two studies were completed to define indications for cystography in blunt trauma. 1st study Retrospective study revealed 26 patients with bladder trauma. 2nd study Randomized prospective study of all patients with blunt trauma. Results A retrograde urethrogram is the diagnostic procedure of choice in all cases of suspected urethral injury. Recommends retrograde cystography or retrograde CT cystography for suspected bladder injury. 1 ST arm 21 patients had cystography for microscopic hematuria, and no bladder injuries were identified; 78 patients underwent cystography for gross hematuria, and 21 bladder injuries were identified. 2 ND arm 08 patients presented with microscopic hematuria, none of whom underwent cystography, and 91 patients underwent cystography for gross hematuria, with 15 bladder injuries identified. Presence of gross hematuria demonstrated 100% sensitivity and 98.5% specificity as a screening test for bladder injury. No bladder injuries were missed. results reveal that the presence of gross hematuria warrants evaluation of the bladder. The presence of gross hematuria demonstrated improved sensitivity, specificity, PPV, NPV, and accuracy over the presence of microscopic hematuria in the detection of bladder injury. Using gross hematuria as an indication for bladder imaging will eliminate unnecessary imaging without compromising the quality of patient care. 11 patients had pelvic fractures and no hematuria. 109 patients had microscopic hematuria and a 9% incidence of coexistent pelvic fractures. 1 patients had gross hematuria and a 26% incidence of pelvic fracture. Bladder injuries were seen in this group. Cost analysis of the prospective study revealed a potential savings of $26,22 if gross hematuria had been the sole indication for cystography in blunt trauma. Page

4 11. Hochberg E, Stone NN. Bladder rupture associated with pelvic fracture due to blunt trauma. Urology 199; 1(6): Gomez RG, Ceballos L, Coburn M, et al. Consensus statement on bladder injuries. BJU Int 200; 9(1): Shin SS, Jeong YY, Chung TW, et al. The sentinel clot sign: a useful CT finding for the evaluation of intraperitoneal bladder rupture following blunt trauma. Korean J Radiol 2007; 8(6): Sandler CM, Hall JT, Rodriguez MB, Corriere JN, Jr. Bladder injury in blunt pelvic trauma. Radiology 1986; 158():6-68. Type 10 cases of bladder rupture 7 consecutive trauma patients Objective (Purpose of ) To identify risk fractures with cystography for bladder rupture. Recommendations by an International Consensus panel on bladder injuries. Experts describe blunt, penetrating and iatrogenic injuries and their management. To evaluate the frequency and relevance of the "sentinel clot" sign on CT for patients with traumatic intraperitoneal bladder rupture in a retrospective study. 97 patients Review clinical and radiologic findings in patients with bladder injury secondary to blunt pelvic trauma. Results Since 90% of the patients do not have bladder rupture, cystography may be safely reserved for those patients with pelvic fracture with significant pubic arch involvement, gross hematuria, and hemodynamic instability. Combined intraperitoneal and extraperitoneal ruptures are present in 5%-8% of all bladder ruptures and mainly diagnosed during surgery. Important to have prompt diagnosis and treatment. A static or CT cystogram can be used for diagnosis. 20 of the 7 patients had intraperitoneal bladder rupture. The sentinel clot sign was seen for 16 patients (80%) with intraperitoneal bladder rupture and for four patients (7%) without intraperitoneal bladder rupture (P<0.001). Pelvic fracture was noted in 5 patients (25%) with intraperitoneal bladder rupture and in 9 patients (72%) without intraperitoneal bladder rupture (P<0.001). Intraperitoneal free fluid was found in all patients (100%) with intraperitoneal bladder rupture, irrespective of an associated intraabdominal visceral injury, whereas 19 (5%) of the 5 patients without intraperitoneal bladder rupture had intraperitoneal free fluid (P<0.001). Detection and localization of the sentinel clot sign abutting on the bladder dome may improve the accuracy of CT in the diagnosis of traumatic intraperitoneal bladder rupture, especially when the patients present with gross hematuria. All cases (n=55) of extraperitoneal rupture were demonstrated cryptographically. In 15 cases in this group, the injury was complex, with extravasation of contrast material beyond the confines of the perivesical space. In two additional patients, incomplete bladder injury termed "interstitial bladder rupture" was identified. proposes a classification of bladder injury based on cystographic patterns of extravasations. Page

5 15. Wirth GJ, Peter R, Poletti PA, Iselin CE. Advances in the management of blunt traumatic bladder rupture: experience with 6 cases. BJU Int 2010; 106(9): Vaccaro JP, Brody JM. CT cystography in the evaluation of major bladder trauma. Radiographics 2000; 20(5): Chapple CR. Urethral injury. BJU Int 2000; 86(): Type Objective (Purpose of ) 6 patients To assess how advances in urology, radiology and orthopaedics are changing the current management of bladder ruptures, by reviewing patients treated for bladder ruptures after blunt trauma. To review CT cystographic technique and the characteristic imaging features of types of bladder injury. Review management and diagnosis of urethral injury. Results 6 patients with extraperitoneal (61%) and intraperitoneal (IPR) or combined ruptures (9%) were identified; 81% of them presented pelvic-ring fractures. Diagnosis relied on CT cystography, which has replaced plain-film cystography. The sensitivity of either type of cystography was >90%. However, bladder ruptures (11%) were missed on CT cystography performed with insufficient bladder distension. All 1 patients with intraperitoneal had immediate surgical repair, four of them by laparoscopy. 12/22 extraperitoneals (55%) were sutured during concomitant orthopaedic/visceral surgery or because of the urologist's apprehension of infection. Only 8/22 patients with extraperitoneal (6%) completed conservative treatment. Diagnosis relies increasingly on CT cystography, allowing simultaneous assessment of multiple organ systems. However, only specific CT cystography guarantees an adequate sensitivity. Orthopaedists increasingly use open reductions and fixation of pelvic-ring fractures, prompting urologists to suture extraperitoneals simultaneously. Data indicate that this proactive management reduces infectious complications. Laparoscopic suture is an advantageous treatment of isolated intraperitoneal. CT cystography is highly accurate as an adjunct to routine abdomino-pelvic CT in the trauma setting. CT (preferably spiral CT) is the first choice for evaluating intra-abdominal urinary tract trauma. This provides an accurate evaluation of the kidneys. Page 5

6 18. Hemal AK, Dorairajan LN, Gupta NP. Posttraumatic complete and partial loss of urethra with pelvic fracture in girls: an appraisal of management. J Urol 2000; 16(1): Venn SN, Greenwell TJ, Mundy AR. Pelvic fracture injuries of the female urethra. BJU Int 1999; 8(6): Ingram MD, Watson SG, Skippage PL, Patel U. Urethral injuries after pelvic trauma: evaluation with urethrography. Radiographics 2008; 28(6): Colapinto V, McCallum RW. Injury to the male posterior urethra in fractured pelvis: a new classification. J Urol 1977; 118(): Type Objective (Purpose of ) 5 patients Review literature and analyze cases of posttraumatic urethral injuries and pelvic fracture in girls. 12 patients To review pelvic fracture urethral injuries in women. To review role of urethrography in the evaluation of urethral injuries. 15 patients Propose a new classification of membranous urethral rupture in cases of fractured pelvis. Type 1: The prostate or urogenital diaphragm is dislocated but the membranous urethra is merely stretched and not severed. Type 2: The membranous urethra is ruptured above the urogenital diaphragm at the apex of the prostate. Type : The membranous urethra is ruptured above and below the urogenital diaphragm. Results patients with complete urethral loss had a more severe degree of pelvic fracture. More severely displaced pelvic fracture is associated with greater urethral loss and requires more complex repair. Cases of partial urethral injury without much displacement are better managed by primary repair of the transected urethra. Patients with milder injuries, perhaps damaging just the innervation of the urethra, presented with incontinence; more severe injuries seemed to cause a longitudinal tear in the urethra but again patients presented mainly with incontinence problems. The most severe injuries were associated with complete rupture of the urethra and a distraction defect suggesting an avulsion injury. These problems were difficult to treat both reconstructively and in providing continence. Pelvic fracture urethral injuries occur in females, but less often than in males. The female urethra seems relatively resistant to injury; differing degrees of severity of pelvic trauma cause different types of urethral injury but in general, a more severe injury is needed to damage it than is necessary in males. Although CT is usually used for the initial imaging evaluation of patients with polytrauma, urethral injury is better assessed and classified by using urethrography. recommends a more widespread use of retrograde urethrography in patients with a suspected posterior urethral rupture. Page 6

7 22. Goldman SM, Sandler CM, Corriere JN, Jr., McGuire EJ. Blunt urethral trauma: a unified, anatomical mechanical classification. J Urol 1997; 157(1): Sandler CM, Goldman SM, Kawashima A. Lower urinary tract trauma. World J Urol 1998; 16(1): Type Objective (Purpose of ) Review uroradiological, emergency radiological and urological textbooks to propose a simple, anatomically based classification of blunt urethral injury. Review and illustrate bladder and urethral injuries, including their mechanisms of injury, imaging diagnosis, systems for classification, and the accuracy/pitfalls of the diagnostic methods. Emphasis is on lower urinary tract injuries. Results The proposed classification is valid and includes all of the common types of blunt urethral injuries. Lower urinary tract injuries resulting from high speed, wide impact blunt trauma is the most common mechanism of lower urinary tract injury encountered in civilian practice. Page 7

8 2. Mundy AR, Andrich DE. Pelvic fracturerelated injuries of the bladder neck and prostate: their nature, cause and management. BJU Int 2010; 105(9): Corriere JN, Jr., Sandler CM. Management of the ruptured bladder: seven years of experience with 111 cases. J Trauma 1986; 26(9):80-8. Type Objective (Purpose of ) 15 men Article describes authors' experience of pelvic fracture-related injuries of the bladder neck and prostate. 111 patients (95 from blunt trauma 16 from penetrating injuries) Review radiographs of ruptured bladder during a 7-year period to confirm the presence and type of bladder injury and assess posttreatment cystogram. Results In all patients with an anterior midline rupture, the primary injury appeared to be to the prostate and prostatic urethra with secondary involvement of the bladder neck and the subprostatic urethra. The Mitrofanoff procedure was successful. Of the 1 patients with a layered reconstruction one, without an omental wrap, broke down but was successfully repaired on a subsequent occasion. The patients who also had a ruptured urethra had a simultaneous bulboprostatic anastomotic urethroplasty, two of which required further attention. 8/1 reconstructed patients underwent implantation of an artificial urinary sphincter for sphincter weakness incontinence, in 7 of whom this was successful. Two of these had previously undergone implantation of an artificial urinary sphincter with an unsatisfactory outcome and were made continent by bladder neck reconstruction. The other 6 patients had acceptable urinary incontinence by reconstruction of the bladder neck and urethra alone. The primary injury is to the prostate and prostatic urethra. The bladder neck and subprostatic urethra are involved secondarily by extension. These injuries have a particular cause and a particular location with a predictable outcome. They need to be identified and treated promptly as they do not heal spontaneously and otherwise cause considerable morbidity. We also describe two particular types of bladder neck injury that we have not seen described before in adults. 9 patients with extraperitoneal bladder injuries were treated with only catheter drainage. 8 died before institution of therapy. Patients with bladder ruptures may be treated with simple catheter drainage and clinical evaluation. Page 8

9 26. Sandler CM, McCallum RW. Injuries of the urethra. In: Clinical Urology. Pollack HW, ed. Philadelphia, Pa: Saunders Company. Volume 2: Stine RJ, Avila JA, Lemons MF, Sickorez GJ. Diagnostic and therapeutic urologic procedures. Emerg Med Clin North Am 1988; 6(): Baniel J, Schein M. The management of penetrating trauma to the urinary tract. J Am Coll Surg 199; 178(): Corriere JN, Jr., Sandler CM. Management of extraperitoneal bladder rupture. Urol Clin North Am 1989; 16(2): Rehm CG, Mure AJ, O'Malley KF, Ross SE. Blunt traumatic bladder rupture: the role of retrograde cystogram. Ann Emerg Med 1991; 20(8): Type Objective Results (Purpose of ) Book chapter. Review urologic procedures useful for the diagnosis and management of urinary tract disorders. Examine urinalysis, diagnostic radiologic modalities and urologic procedures. Review management of penetrating trauma to the urinary tract. 1 patients To describe the management of extraperitoneal bladder rupture. 21 patients Retrospective review to evaluate importance of microscopic and gross hematuria and the role of retrograde cystography and CT in the diagnosis of blunt traumatic bladder rupture. Retrograde cystourethrography is recommended for evaluation of the lower urinary tract. It should be performed whenever urethral or bladder injury is suspected. US is not usually recommended on an emergency basis despite its many advantages. IVP correctly diagnosed 16% of the cases while retrograde cystography demonstrated all perforations. Retrograde cystography is recommended in the assessment of injury to the bladder. Static cystogram is the only way to diagnose the lesion definitely. 1 patients were treated successfully with catheter drainage alone despite extensive urinary extravasation. 87% of the ruptures will be healed in 10 days, and virtually all will be healed in weeks. All 21 had hematuria with more than 50 RBCs/high-power field, 17 gross and microscopic. 20 patients underwent retrograde cystography, which accurately identified bladder rupture, and one was found at laparotomy for other injuries. 7 patients had CT of the abdomen and pelvis, which failed to demonstrate bladder rupture. There were no associated urethral injuries in any of the patients with bladder rupture. Significant (more than 50 RBCs/high-power field) hematuria is the principal indication for evaluation for blunt bladder injury, and retrograde cystography is the diagnostic procedure of choice. CT is neither sensitive nor specific enough as primary diagnostic modality. Page 9

10 1. Morey AF, Iverson AJ, Swan A, et al. Bladder rupture after blunt trauma: guidelines for diagnostic imaging. J Trauma 2001; 51(): Carroll PR, McAninch JW. Major bladder trauma: the accuracy of cystography. J Urol 198; 10(5): Bigongiari LR, Zarnow H. Traumatic, inflammatory, neoplastic and miscellaneous lesions of the bladder. In: Medical radiology of the lower urinary tract. Lang EK ed. Berlin: Springer- Verlag. 199: Type Objective (Purpose of ) 5 patients To establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries. 51 patients To study accuracy of retrograde cystography in diagnosing traumatic bladder rupture. Results Of 5 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation. Extravasation was observed in 2 cases for which retrograde cystograms were available, including (9%) in which additional infusion of contrast medium was required to demonstrate extravasation. Of the 2 cystograms, (1%) showed rupture on the drainage film only. If drainage radiographs and adequate distension of the bladder with contrast medium had been omitted, the rate of diagnostic accuracy of the cystogram would have been reduced to 79%. If attention is paid to adequate distension of the bladder with contrast material and to obtaining drainage films, diagnostic retrograde cystography for trauma should be almost totally accurate and delays or errors in diagnosis should be rare. Book chapter. Page 10

11 . Festini G, Gregorutti S, Reina G, Bellis GB. Isolated intraperitoneal bladder rupture in patients with alcohol intoxication and minor abdominal trauma. Ann Emerg Med 1991; 20(12): MacMahon R, Hosking D, Ramsey EW. Management of blunt injury to the lower urinary tract. Can J Surg 198; 26(5): Bonavita JA, Pollack HM. Trauma of the adult bladder and urethra. Semin Roentgenol 198; 18(): Werkman HA, Jansen C, Klein JP, Ten Duis HJ. Urinary tract injuries in multiply-injured patients: a rational guideline for the initial assessment. Injury 1991; 22(6): Goletti O, Ghiselli G, Lippolis PV, et al. The role of ultrasonography in blunt abdominal trauma: results in 250 consecutive cases. J Trauma 199; 6(2): Type Objective (Purpose of ) 2 patients Present cases of bladder rupture in intoxicated patient after minor abdominal trauma and without evidence of associated injuries. patients Review cases of bladder rupture seen at a health center over a 10-year period to examine problems in the management of blunt injury to the lower urinary tract. 866 patients (72 with urinary tract injuries) To review diagnosis of trauma of the adult bladder and urethra. To evaluate the initial assessment of urinary tract injuries in multiply-injured patients. 250 patients Prospective study to determine accuracy of US in detecting abdominal lesions and free fluid collections in patients with blunt abdominal trauma. Results When a bladder rupture is clinically suspected, retrograde urethrography is recommended before retrograde cystography. IVP has a low accuracy rate (15%-25%), although specificity is high. Abdominal US is recommended in patients with suspected bladder rupture to exclude associated visceral lesions and/or peritoneal blood or urine. Cystography was performed in 2 of the patients and indicated a ruptured urinary bladder in 2 instances. 2 patients underwent intravenous pyelography and in only 5 (22%) was the diagnosis of a urinary bladder rupture made by this investigation. Cystography found to be reliable. Retrograde urethrography is the only safe and reliable method of diagnosing posterior urethral injury. More than 5 RBC/high-power field in the sediment or macroscopic hematuria were found in patients with serious lesions of the urinary tract. All major injuries were demonstrated by the emergency intravenous urogram. US showed contusions of the kidney or bladder and rupture of the kidneys, but were not reliable in diagnosing ruptures of the bladder. 1 (8%) of 155 patients with a pelvic fracture had lower urinary tract injuries. All urethral lesions were detected with a retrograde urethrogram. Propose a rational guideline, which guarantees diagnostic accuracy of serious injuries of the urinary tract after blunt trauma, with little interference with the resuscitative and diagnostic procedures in severely injured patients. For spleen injuries, sensitivity was 9%, specificity 99 %, PPV 9%. For liver injuries, sensitivity was 80%, specificity 100%, PPV 100%. For kidney lesions, sensitivity was 100%, specificity 100%, PPV 100%. US is recommended in patients with blunt abdominal trauma. Page 11

12 9. Farahmand N, Sirlin CB, Brown MA, et al. Hypotensive patients with blunt abdominal trauma: performance of screening US. Radiology 2005; 25(2): Shenfeld OZ, Gnessin E. Management of urogenital trauma: state of the art. Curr Opin Urol 2011; 21(6):9-5. Type Objective (Purpose of ) 128 patients To determine retrospectively the accuracy of screening US in patients with hypotension (systolic blood pressure 90 mm Hg) after blunt abdominal trauma. To summarize the most relevant studies published within the last years on the management of urogenital trauma. Results Sensitivity was 85% (/52) for detection of any injuries, 97% (0/1) for surgical injuries (ie, injuries requiring surgery), and 100% (10/10) for fatal injuries. Specificity was 96% (7/76), 82% (80/97), and 69% (81/118), and accuracy was 91% (117/128), 86% (110/128), and 71% (91/128), for respective injury categories. One nonfatal surgical injury was missed in a high-risk patient. For each injury category, frequency of injury in patients with a fluid score of 2 or more was nine times that in patients with a score of 0 (P<.001 for all comparisons). Frequency of false-negative US findings in high-risk patients was eight times that in low-risk patients (P<.01). In patients who are hypotensive after blunt abdominal trauma and not hemodynamically stable enough to undergo diagnostic CT, negative US findings virtually exclude surgical injury, while positive US findings indicate surgical injury in 6% of cases. CT grading of renal trauma is an excellent predictor of the need for surgery and the final renal outcome in these patients, as most patients can be treated conservatively. CT cystography has become the standard for the diagnosis of bladder rupture in which the indications for surgical intervention may be changing. The most common urethral trauma is posterior urethral injury due to pelvic fracture. The best results in adults and children are achieved by urethroplasty. The diagnosis and treatment of genitourinary trauma is still evolving. The long-term sequels of these injuries may best be treated by urologists expert in urogenital reconstruction. In the future, tissue engineering may have an important place in the treatment of these patients. Page 12

13 1. Power N, Ryan S, Hamilton P. Computed tomographic cystography in bladder trauma: pictorial essay. Can Assoc Radiol J 200; 55(5): Chan DP, Abujudeh HH, Cushing GL, Jr., Novelline RA. CT cystography with multiplanar reformation for suspected bladder rupture: experience in 2 cases. AJR 2006; 187(5): Deck AJ, Shaves S, Talner L, Porter JR. Computerized tomography cystography for the diagnosis of traumatic bladder rupture. J Urol 2000; 16(1):-6. Type Objective (Purpose of ) Review use of CT cystography in the classification of bladder trauma. 2 patients Retrospective review was performed to determine the accuracy of CT cystography and the role of multiplanar reformation in the diagnosis of bladder injury. 16 patients Retrospective review to determine accuracy of CT cystography for diagnosis of bladder rupture. Surgical exploration was used as gold standard. Results CT cystography is recommended for polytraumatised patient. It is quicker, more convenient and involves a lower radiation dose to the patient if performed as part of the initial CT than conventional cystography. From the total of 2 examinations, 216 (92.%) were interpreted as negative and 18 examinations (7.7%) were interpreted as positive. On the 18 positive examinations, 11 were extraperitoneal bladder rupture, five were intraperitoneal bladder rupture, and two were combined intraperitoneal and extraperitoneal bladder rupture. Surgical bladder exploration and repair were performed in 9/18 cases. Seven (77.8%) of the nine cases had operative findings consistent with the CT cystogram findings. The overall sensitivity and specificity of CT cystography in diagnosing bladder rupture were each 100%. For extraperitoneal bladder rupture, the sensitivity and specificity were 92.8% and 100%, respectively. For intraperitoneal rupture, the sensitivity and specificity were 100% and 99%, respectively. CT cystography is accurate for diagnosing bladder rupture. Sagittal and coronal multiplanar reformations may be helpful in identifying most sites of bladder rupture. had diagnosis of bladder rupture; 2 had CT cystograms indicating bladder rupture. 28 had formal bladder exploration; 2 (82%) had operative findings that exactly matched the CT cystogram interpretation. CT cystography for bladder rupture: sensitivity 95%, specificity 100%, CT cystography for intraperitoneal rupture: sensitivity 78% specificity 99%. Recommends CT cystography over plain film cystography in patients having CT for other injuries associated with blunt trauma. Page 1

14 . Deck AJ, Shaves S, Talner L, Porter JR. Current experience with computed tomographic cystography and blunt trauma. World J Surg 2001; 25(12): Mee SL, McAninch JW, Federle MP. Computerized tomography in bladder rupture: diagnostic limitations. J Urol 1987; 17(2): Type Objective (Purpose of ) 16 patients Retrospective review to establish sensitivity and specificity of CT cystography for the diagnosis of bladder rupture in patients with blunt abdominal and pelvic trauma using operative findings as gold standard. 2 patients Prospective study to determine if CT is as accurate as retrograde cystography in the diagnosis of bladder rupture. Results had an ultimate diagnosis of bladder rupture; 2 patients had CT cystograms indicating bladder rupture. 28 patients underwent formal bladder exploration; 2 (82%) had operative findings that exactly (i.e., presence and type of rupture) matched the CT cystogram interpretation. Sensitivity and specificity of CT cystography for detection of bladder rupture were 95% and 100%, respectively. Sensitivity and specificity for intraperitoneal rupture were 78% and 99% respectively. Recommends CT cystography over plain film cystography for patients undergoing CT evaluation for other blunt trauma-related injuries. CT showed no evidence of opacified urinary extravasation in one patient and only subtle evidence in the other. Cystography revealed gross intraperitoneal extravasation of opacified urine in both patients. Recommends retrograde cystography as test in suspected bladder rupture. Page 1

15 6. Pao DM, Ellis JH, Cohan RH, Korobkin M. Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol 2000; 7(5): Hsieh CH, Chen RJ, Fang JF, et al. Diagnosis and management of bladder injury by trauma surgeons. Am J Surg 2002; 18(2): Horstman WG, McClennan BL, Heiken JP. Comparison of computed tomography and conventional cystography for detection of traumatic bladder rupture. Urol Radiol 1991; 12(): Lis LE, Cohen AJ. CT cystography in the evaluation of bladder trauma. J Comput Assist Tomogr 1990; 1(): Type Objective (Purpose of ) 5 patients Retrospective blinded review to determine the frequency with which CT fails to depict bladder rupture, the potential utility of delayed CT scans, and whether these findings might be useful in determining which patients may require subsequent cystography. Cystograms were used as the standard. 51 patients Retrospective review to analyze how bladder injuries have been managed as part of multiple traumas. 25 patients To compare conventional cystograms and CT examinations for detection of traumatic bladder rupture. 10 cases of ruptured bladder To evaluate CT cystography with at least 50 cc distention. Results Cystograms depicted bladder rupture in 10 patients. On CT scans, extravesical fluid was depicted in all patients with intraperitoneal bladder rupture (although only a small amount of pelvic intraperitoneal fluid was present in two of these patients), in all 7 patients with extraperitoneal bladder rupture, and in 2/ patients without bladder injury. Contrast material had been excreted into the bladder at the time of the initial or delayed CT in 8 patients with bladder rupture; however, extravasation was identified in only /8. In 2/ patients without extravasation, the bladder was distended at the time of CT. No bladder injuries were found in the 12 patients in whom pelvic fluid was not identified on CT scans. The absence of pelvic fluid on a trauma CT scan indicates that bladder rupture is unlikely. Even when a partially opacified bladder is passively distended, bladder injury may be present despite the absence of contrast material extravasation. patients had abdominal CT, but only 20 were correctly diagnosed with accuracy of 60.6%. 2 patients had retrograde cystogram, with accuracy of 95.9% (2/2). Retrograde cystogram was performed in fewer than half of the patients (2/51), which means it is not feasible in many situations. 5/25 had bladder ruptures. All 5 were detected by both CT and conventional cystogram. If properly performed, CT is as sensitive for detection of bladder injuries as conventional cystography. CT cystography is at least as accurate as plain film cystography in assessing bladder trauma. 2 Page 15

16 50. Quagliano PV, Delair SM, Malhotra AK. Diagnosis of blunt bladder injury: A prospective comparative study of computed tomography cystography and conventional retrograde cystography. J Trauma 2006; 61(2):10-21; discussion Ali M, Safriel Y, Sclafani SJ, Schulze R. CT signs of urethral injury. Radiographics 200; 2():951-96; discussion Chou CP, Huang JS, Wu MT, et al. CT voiding urethrography and virtual urethroscopy: preliminary study with 16- MDCT. AJR 2005; 18(6): Kim B, Kawashima A, LeRoy AJ. Imaging of the male urethra. Semin Ultrasound CT MR 2007; 28(): Koraitim MM, Reda IS. Role of magnetic resonance imaging in assessment of posterior urethral distraction defects. Urology 2007; 70():0-06. Type CT with conventional cystography (212 patients, 19 had bladder rupture) CT without conventional cystography (28 patients, 27 had bladder rupture) Objective (Purpose of ) To prospectively assess accuracy of CT cystography by comparing it with conventional retrograde cystography for the diagnosis of blunt bladder injury. To evaluate CT scans of patients with pelvic fractures and urethrographically proved posterior urethral injuries and CT scans of patients with similar pelvic fractures who did not have urethral injuries. 1 men CT voiding urethrography exams were prospectively performed with 16- multidetector CT to demonstrate CT voiding urethrography and CT virtual urethroscopy. To describe imaging techniques, anatomy, and findings of various urethral and periurethral pathology in the male. 21 men To determine value of MRI in the assessment of posterior urethral distraction defects. Compared MRI and urethrographic findings and correlated with operative findings. MRI findings were also correlated with the incidence of posttraumatic impotence. Results For CT with conventional cystography, CT cystography sensitivity and specificity was 95% and 100%, respectively; for conventional cystography, sensitivity and specificity were 95% and 100%, respectively. For CT without conventional cystography, sensitivity and specificity of CT cystography for bladder rupture in these patients were both 100%. Authors conclude that CT cystography is equivalent to conventional cystography for detecting the presence or absence of blunt bladder injury. CT is the accepted frontline imaging modality for blunt abdomino-pelvic trauma. The full urethral structure was clearly shown by CT voiding urethrography and virtual urethroscopy in all patients. The results of CT voiding urethrography and conventional methods correlated closely with the urethral diseases being imaged. Cross-sectional imaging techniques of US, CT and MRI have been increasingly used for urethral and periurethral abnormalities in recent times. These studies are useful as an adjunctive tool in patients with the complex anatomical derangements. On MRI, the length of urethral defect and type of prostatic displacement could be correctly determined in 86% and 89% of the patients, respectively. MRI precisely delineated the extent of scar tissue and revealed the presence of paraurethral false tracks in patients. MRI also showed avulsion of the corpus cavernosum, as well as lateral prostatic displacement in all 6 patients with posttraumatic impotence. Page 16

17 Evidence Table Key Category Definitions Category 1 The study is well-designed and accounts for common biases. Category 2 The study is moderately well-designed and accounts for most common biases. Category There are important study design limitations. Category The study is not useful as primary evidence. The article may not be a clinical study or the study design is invalid, or conclusions are based on expert consensus. For example: a) the study does not meet the criteria for or is not a hypothesis-based clinical study (e.g., a book chapter or case report or case series description); b) the study may synthesize and draw conclusions about several studies such as a literature review article or book chapter but is not primary evidence; c) the study is an expert opinion or consensus document. Abbreviations Key CT = Computed tomography GUI = Genitourinary injuries MRI = Magnetic resonance imaging NPV = Negative predictive value PPV = Positive predictive value RBC = Red blood cell US = Ultrasound = Diagnostic Tx = Treatment ACR Appropriateness Criteria Evidence Table Key