Nonoperative treatment of isolated posttraumatic intraperitoneal bladder rupture in children-is it justified?

Open surgical repair has been the standard treatment for intraperitoneal bladder rupture. We sought to explore the possibility of nonoperative treatment of isolated intraperitoneal bladder rupture in children.

Eight children (4 girls and 4 boys) with a mean age of 6.3 +/- 4.6 years (range 1 to 13) presented with isolated posttraumatic intraperitoneal bladder rupture between 1993 and 2003. Retrograde cystogram was performed in all cases. Diagnosis was confirmed by aspiration and chemical analysis of the free intraperitoneal fluid in patients with an equivocal cystogram. Four patients who presented early in the series (group 1) were treated with the classic open repair, whereas the last 4 patients (group 2) were treated nonoperatively with adequate bladder drainage and percutaneous intraperitoneal tube drain. The mechanisms of injury, clinical presentation, management, complication, hospital stay and duration of catheterization were reviewed in both groups.

Six patients had a history of a direct blow to the full bladder, while 2 presented following a motor vehicle accident. All patients presented with vomiting and abdominal distention, and 5 had mild gross hematuria without associated clots or hemodynamic instability. One patient in group 1 had early urinary leakage and wound sepsis, and was treated conservatively. All patients in group 2 demonstrated significant improvement in general condition within a few hours of the bladder and peritoneal drainage. Intraperitoneal tube drains were removed at 1 to 4 days. There were no post-intervention complications in group 2 and surgical treatment was never required. Mean indwelling catheter duration was 9.3 +/- 7.9 and 11.8 +/- 2.6 days (p = 0.24), and mean hospital stay was 10.5 +/- 8.4 and 7.3 +/- 3.9 days (p = 0.56) in groups 1 and 2, respectively.

Nonoperative treatment is a justified initial approach for isolated intraperitoneal bladder rupture in children. Indications for surgical intervention include improper bladder drainage, unduly prolonged urinary drainage through the peritoneal drain and/or lack of clinical improvement.