Early cystography after traumatic bladder repair is associated with shorter catheter duration and fewer CAUTIs without increased detection of postoperative leaks

Abstract

BACKGROUND:

Optimal postoperative management after traumatic bladder repair, such as imaging strategies and catheter duration, remains unclear and may affect the rate of catheter-associated urinary tract infections (CAUTIs). We evaluated early (≤7 d) versus late (≥8 d) or no postoperative cystography for traumatic bladder repairs, hypothesizing that early imaging would reduce catheter duration and CAUTI rates without increasing the rate of urinary leak detection.

METHODS:

We retrospectively reviewed trauma registry data from a university-based Level I and II trauma system from 2017 to 2024. Patients with full-thickness bladder injuries undergoing cystorrhaphy were included. Those with in-hospital mortality or concomitant ureteral and/or urethral injuries were excluded. Patients were stratified by timing of initial postoperative cystography: early versus late and early versus none. Primary outcomes included catheter duration, CAUTI rate, and urinary leak rate on initial postoperative imaging.

RESULTS:

One hundred eighteen patients met the inclusion criteria: 62 (52.5%) isolated intraperitoneal, 39 (33.1%) isolated extraperitoneal, and 17 (14.4%) combined injuries. Eighty-six (71.9%) sustained blunt trauma. Twenty-nine (24.6%) patients underwent early, 70 (59.3%) late, and 19 (16.1%) no postoperative imaging. There were more AAST grade 4 bladder injuries (79.3% vs. 45.7%, p<0.01) in the early versus late cystography cohort. Otherwise, there were no differences in patient demographics, mechanism, injury severity, associated injuries or interventions, or management strategies. Early postoperative imaging was associated with reduced catheter duration (7 [6–10] vs. 14 [11–18] d, p<0.01) and CAUTI rates (6.9% vs. 30%, p=0.02) compared with late imaging. Rates of urinary leak (3.5% vs. 8.6%, p=0.67) were similar. Early postoperative cystography was associated with reduced catheter duration (7 [6–10] vs. 10 [9–15] d, p<0.01) compared with no cystography.

CONCLUSIONS:

Despite having more high-grade injuries, early postoperative cystography was associated with reduced catheter duration and CAUTI rates without an increased urinary leak rate. Early imaging facilitates earlier catheter removal and improves outcomes. (J Trauma Acute Care Surg. 2026;101: 810–818.)

LEVEL OF EVIDENCE:

Therapeutic/Care Management; Level IV.

Traumatic bladder injuries are uncommon but carry significant morbidity if not properly managed. Current guidelines provide general recommendations regarding the surgical management of these injuries. Practice patterns vary considerably with respect to postoperative management, specifically the timing and necessity of postoperative cystography and the optimal duration of urinary catheterization. As postoperative practices remain heterogeneous, many clinicians rely on delayed imaging and prolonged catheterization despite limited supporting evidence. Given the morbidity associated with urinary catheters, including infection and impaired mobility, clarification of postoperative management strategies represents an important gap in the care of patients with traumatic bladder injuries.

Currently, professional societies recommend routine postoperative cystography for complex repairs while foregoing imaging for simple repairs based on estimated prevalences of postoperative urinary leak.^1–4 However, these recommendations are derived from a limited number of studies with small sample sizes. Similarly, guidance regarding the timing of postoperative cystography largely reflects expert opinion rather than data-driven analyses.⁴

In addition, the role of adjunctive intraoperative and postoperative measures intended to guide urinary catheter management, including intraoperative leak testing and pelvic drain placement, remains incompletely defined. The predictive value of these strategies for postoperative urinary leak and their ability to safely inform catheter duration have not been well established in trauma populations.

A clearer understanding of how postoperative imaging and adjunct management strategies influence clinical outcomes is needed to inform guideline refinement and reduce practice variability. Accordingly, the objective of this study was to compare clinical outcomes associated with early (≤7 d) versus late (≥8 d) postoperative cystography and early (≤7 d) versus no postoperative cystography following traumatic bladder repair. We hypothesized that early postoperative cystography would be associated with reduced urinary catheter duration, fewer catheter-associated urinary tract infections (CAUTIs), and shorter hospitalizations without an increase in postoperative urinary leak detection or the need for additional imaging.

METHODS

This study was designed, conducted, and reported in accordance with the STROBE, Supplemental Digital Content 4, http://links.lww.com/TA/F403 (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cohort studies.⁵

After institutional review board approval, we performed an 8-year retrospective analysis using trauma registry data from a university-based trauma system comprising one Level I and one Level II trauma center. Patients were eligible for inclusion if they sustained a full-thickness bladder injury between January 1, 2017, and December 31, 2024. Patients were excluded if they died during the index hospitalization, underwent suprapubic catheterization or nonoperative management, or sustained concomitant ureteral or urethral injuries to minimize confounding effects.

A retrospective chart review was performed. Variables collected included patient demographics (age, sex, comorbidities), mechanism of injury (blunt, penetrating), injury severity [Injury Severity Score (ISS), abdominal Abbreviated Injury Scale (AIS)], bladder injury characteristics [American Association for the Surgery of Trauma (AAST) grade, size, location], associated injuries (bowel perforation, pelvic hematoma, pelvic fracture), associated interventions (internal iliac embolization, surgical control of pelvic hemorrhage, pelvic fixation), management team and strategies (cystotomy for extraperitoneal repair, number of repairs, intraoperative leak test, pelvic drain, drain creatinine testing), and imaging strategies (modality, timing). Primary outcomes included postoperative urinary leak rate, urinary catheter duration, CAUTI rate, and hospital length of stay (LOS). CAUTI was defined as a urine culture with no more than two species of bacterium or yeast of ≥100,000 CFU/mL. Secondary outcomes included the setting of urinary catheter removal, intensive care unit (ICU) LOS, ventilator days, bladder reoperation, bacteremia, urosepsis, postoperative hematuria, urinary retention requiring catheter reinsertion, and disposition to home. Patients were stratified by early (≤7 d) versus late (≥8 d) postoperative cystography and early (≤7 d) versus no postoperative cystography.

Possible confounders included the mechanism of injury, injury severity, the clinical service performing bladder repair, concomitant injuries, and associated interventions. Rates of these factors were reported for each management cohort.

Statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). Continuous variables were compared using the Wilcoxon rank-sum test, and categorical variables were compared using the χ² or Fisher exact test, as appropriate. Data are presented as medians with interquartile ranges (IQRs).

Multivariate analyses were conducted to identify independent predictors of postoperative cystography timing and clinical outcomes. Variables with clinical relevance or demonstrating an association at p<0.20 on univariable analysis were considered for inclusion, with conceptually overlapping or clinically non-independent variables excluded to minimize multicollinearity. Logistic regression was used for dichotomous outcomes, and linear regression for continuous outcomes. Results are reported as adjusted odds ratios (ORs) or β coefficients (point estimates) with 95% confidence intervals (CIs). Statistical significance was defined as a two-sided p<0.05.

RESULTS

Study Population

Of the 180 patients who sustained full-thickness bladder injuries during the study period, 62 patients were excluded: 15 deaths during the index hospitalization, 16 concomitant ureteral or urethral injuries, and 31 isolated extraperitoneal injuries that were managed nonoperatively with urinary decompression alone. A total of 118 patients who underwent surgical repair of full-thickness traumatic bladder injuries met the inclusion criteria: 62 (52.5%) isolated intraperitoneal, 39 (33.1%) isolated extraperitoneal, and 17 (14.4%) combined injuries (Fig. S1, Supplemental Digital Content 2, http://links.lww.com/TA/F401). Early (≤7 d) postoperative cystography was performed in 29 (25%) patients. Late (≥8 d) postoperative cystography occurred in 70 (59%) patients. Nineteen (16%) patients did not receive postoperative cystography before urinary catheter removal.

Patient Demographics

Most patients were male (74.6%), had comorbidities (83.1%), and sustained blunt trauma (72.9%). Median age was 34.5 [IQR, 27–43] years, and median Injury Severity Score (ISS) was 19 [IQR,14–29]. Most bladder injuries were AAST grade 4 (56.8%) and classified as abdominal AIS 3 (57.6%). Bladder repairs were performed predominantly by trauma surgeons (90.7%), followed by orthopedic surgeons (6.8%) and urologists (2.5%). Associated injuries included bowel perforation (21.2%), pelvic hematoma (31.4%), and pelvic fractures (51.7%).

Early Versus Late Postoperative Cystography

Median time to postoperative cystography was 6 [IQR, 5–7] days in the early cohort and 13 [IQR, 10–16] days in the late cohort. Bladder injury patterns were not equal across the postoperative imaging cohorts. The early cystography group had more isolated intraperitoneal bladder ruptures (70% vs. 42.9%, p=0.02) with more AAST grade 4 bladder injuries (79.3% vs. 45.7%, p<0.01) and a larger median injury size (5 [IQR, 2–9] cm vs. 2 [IQR, 1–5] cm, p=0.02). All bladder repairs in the early cohort were performed by trauma surgeons. Otherwise, no significant differences were observed between cohorts with respect to patient demographics, injury mechanism, overall or abdominal injury severity, associated injuries or interventions, or adjunct management strategies (Table 1).

TABLE 1.

Demographic, Injury, and Management Characteristics by Postoperative Cystography Strategy

Variable	Early Postoperative Cystography (n=29)	Late Postoperative Cystography (n=70)	p	Early Postoperative Cystography (n=29)	No Cystography (n=19)	p
Male	20 (69)	53 (75.7)	0.49	20 (69)	15 (79)	0.52
Age (y)	35 [26–41]	35 [27–46]	0.41	35 [26–41]	34 [30–42]	0.75
Comorbidity	23 (79.3)	59 (84.3)	0.55	23 (79.3)	16 (84.2)	1
Blunt mechanism	23 (79.3)	48 (68.6)	0.28	23 (79.3)	15 (79)	1
Abdominal AIS			0.44			0.32
2	4 (13.8)	19 (27.1)		4 (13.8)	5 (26.3)
3	21 (72.4)	38 (54.3)		21 (72.4)	9 (47.4)
4	3 (10.3)	9 (12.9)		3 (10.3)	3 (15.8)
5	1 (3.5)	4 (5.7)		1 (3.5)	2 (10.5)
High abdominal AIS (≥4)	4 (13.8)	13 (18.6)	0.77	4 (13.8)	5 (26.3)	0.45
ISS	19 [11–27]	19 [14–29]	0.56	19 [11–27]	22 [17–34]	0.22
Bowel perforation	5 (17.2)	17 (24.3)	0.44	5 (17.2)	3 (15.8)	1
Pelvic hematoma	7 (24.1)	23 (32.9)	0.39	7 (24.1)	7 (36.8)	0.34
Internal iliac embolization	0 (0)	4 (5.7)	0.55	0 (0)	2 (10.5)	0.46
Surgical control of hemorrhage	1 (3.5)	7 (10)	0.64	1 (3.5)	3 (15.8)	0.56
Pelvic fracture	15 (51.7)	32 (45.7)	0.59	15 (51.7)	14 (73.7)	0.13
Pelvic fixation	9 (31)	23 (32.9)	0.42	9 (31)	7 (36.8)	0.59
AAST bladder grade			0.01			0.35
2	0 (0)	9 (12.9)	0.05	0 (0)	2 (10.5)	0.15
3	5 (17.2)	18 (25.7)	0.36	5 (17.2)	4 (21.1)	1
4	23 (79.3)	32 (45.7)	<0.01	23 (79.3)	12 (63.2)	0.22
5	1 (3.5)	11 (15.7)	0.17	1 (3.5)	1 (5.3)	1
High AAST bladder grade (≥4)	24 (82.8)	43 (61.4)	0.04	24 (82.8)	13 (68.4)	0.25
Intraperitoneal injury	20 (69)	30 (42.9)	0.02	20 (69)	12 (63.2)	0.68
Extraperitoneal injury	5 (17.2)	29 (41.4)	0.02	5 (17.2)	5 (26.3)	0.45
Combined injuries	4 (13.8)	11 (15.7)	1	4 (13.8)	2 (10.5)	1
Multiple repairs	8 (27.6)	17 (24.3)	0.73	8 (27.6)	2 (10.5)	0.1
Cystostomy for repair	1 (3.5)	6 (8.6)	1	1 (3.5)	1 (5.3)	1
Repair service			0.1			0.4
Trauma surgery	29 (100)	60 (85.7)	0.03	29 (100)	18 (94.7)	0.4
Orthopedic surgery	0 (0)	7 (10)	0.1	0 (0)	1 (5.3)	0.4
Urology	0 (0)	3 (4.3)	0.55	0 (0)	0 (0)	1
Injury size (cm)	5 [2–9]	2 [1–5]	0.02	5 [2–9]	3.5 [1–8]	0.31
Post-repair intraoperative leak evaluation	16 (55.2)	42 (60)	0.66	16 (55.2)	10 (52.6)	0.86
Leak present	4 (13.8)	8 (11.4)	0.72	4 (13.8)	1 (5.3)	0.62
Pelvic drain	19 (65.5)	36 (51.4)	0.2	19 (65.5)	10 (52.6)	0.37
Extended antibiotic prophylaxis (>24 h)	1 (3.5)	19 (27.1)	<0.01	1 (3.5)	4 (21.1)	0.07
Postoperative imaging modality			0.12
Computed tomography	26 (89.7)	60 (85.7)	0.75
Fluoroscopy	1 (3.5)	9 (12.9)	0.27
Plain film	2 (6.9)	1 (1.4)	0.2

This table summarizes a univariate analysis comparing demographic, injury, and management characteristics of early (≤7 d), late (≥8 d), and no positive imaging cohorts. Continuous variables are expressed as medians with interquartile ranges in brackets. Categorical variables are expressed as counts with percentages in parentheses.

AAST, American Association for the Surgery of Trauma; AIS, Abbreviated Injury Scale; ISS, Injury Severity Score

Early Versus No Postoperative Cystography

Between the early and no postoperative imaging cohorts, there were no significant differences in patient demographics, injury mechanism, overall or abdominal injury severity, bladder injury characteristics, associated injuries or interventions, or adjunct management strategies (Table 1).

Extraperitoneal Bladder Repairs

Whereas traumatic intraperitoneal injuries always require surgical repair, extraperitoneal injuries may be managed nonoperatively with catheter drainage alone. In our study, 39 isolated extraperitoneal bladder injuries underwent repair. Of these, 2 (5.1%) underwent the operation exclusively for bladder repair, while 37 (94.9%) were performed in conjunction with another operative indication, reflecting a “fix it while you’re there” approach. Twenty-two (56.4%) cystorrhaphies were completed through an anterior pelvic fixation incision and 17 (43.6%) via a laparotomy incision. Among patients repaired through an abdominal approach, 8 required an intraperitoneal cystostomy to access and repair the extraperitoneal injury.

Intraoperative Leak Testing

Intraoperative bladder leak testing was documented in 68 (57.6%) of patients using saline (64.7%), methylene blue (33.8%), or air (1.5%). Of these, 58 (85.3%) underwent postoperative cystography, with 3 urinary leaks identified. Rates of postoperative leak were similar between patients who underwent intraoperative leak evaluation and those who did not (4.4% vs. 8%, p=0.46). Thirteen (19.1%) patients demonstrated intraoperative leaks after initial repair, 11 of whom underwent additional cystorrhaphy with documented resolution. Two subsequently demonstrated urinary leaks on postoperative imaging. The 2 patients who did not undergo further repair for intraoperative leak did not have a urinary leak on postoperative imaging. No statistically significant difference in postoperative urinary leak was observed between patients with and without leak on initial intraoperative evaluation (15.4% vs. 1.8%, p=0.09).

Pelvic Drains

Sixty-five (55.1%) patients had a pelvic drain placed at the time of bladder repair. Of these, 55 (84.6%) underwent postoperative cystography, with 4 urinary leaks identified. Drain creatinine was measured in 18 (27.7%) patients and was concordant with serum creatinine in 17. Among 4 patients with pelvic drains and urinary leaks, 1 leak was detected by an elevated drain-to-serum creatinine ratio before cystography. Two leaks occurred in patients with drain creatinine levels equivalent to serum.

Postoperative Cystography

Postoperative cystography was performed predominantly with computed tomography (CT) (85.9%), followed by fluoroscopy (11.1%) and plain radiography (3.0%). All urinary leaks were identified by CT cystography.

Postoperative Urinary Leaks

Postoperative urinary leaks were identified in 7 patients, representing 5.9% of the entire study population and 7.1% of those who underwent postoperative cystography. Leak rates did not differ between the early and late cohorts (3.5% vs. 8.6%, p=0.67). Leaks occurred exclusively in AAST grade 4 and 5 injuries, representing 7.3% and 25% of those injury grades, respectively. On univariate analysis, postoperative urinary leaks were higher among patients with pelvic hematoma (16.7%), penetrating mechanism (17.9%), bowel perforations (18.2%), multiple bladder repairs (20%), extended (>24 hours of postoperative) antibiotic prophylaxis (25%), combined bladder injuries (26.7%), and surgical control of pelvic hemorrhage (62.5%). There was no association with sex, age, comorbidity, overall or abdominal injury severity, injury location, or bladder repair service (Table 2).

TABLE 2.

Demographic, Injury, and Management Characteristics by Presence of Postoperative Leak

Variable	No Leak (n=92)	Leak (n=7)	p
Male	66 (71.7)	7 (100)	0.18
Age (y)	34.5 [26.5–44.5]	38 [19–49]	0.63
Comorbidity	76 (82.6)	6 (85.7)	1
Penetrating mechanism	23 (25)	5 (71.4)	0.02
Abdominal AIS			0.11
2	22 (23.9)	1 (14.3)
3	56 (60.9)	3 (42.9)
4	9 (9.8)	3 (42.9)
5	5 (5.4)	0 (0)
High abdominal AIS (≥4)	14 (15)	3 (42.9)	0.1
ISS	19 [11–27]	19 [14–29]	0.56
Bowel perforation	18 (19.6)	4 (57.1)	0.04
Pelvic hematoma	25 (27.2)	5 (71.4)	0.03
Internal iliac embolization	3 (3.3)	1 (14.3)	0.54
Surgical control of hemorrhage	3 (3.3)	5 (71.4)	<0.01
Pelvic fracture	46 (50)	1 (14.3)	0.12
Pelvic fixation	31 (33.7)	1 (14.3)	1
AAST bladder grade			0.07
2	9 (9.8)	0 (0)	1
3	23 (25)	0 (0)	0.2
4	51 (55.4)	4 (57.1)	1
5	9 (9.8)	3 (42.9)	0.04
High AAST bladder grade (≥4)	60 (65.2)	7 (100)	0.09
Intraperitoneal injury	48 (52.2)	2 (28.6)	0.27
Extraperitoneal injury	33 (35.9)	1 (14.3)	0.42
Combined injuries	11 (12)	4 (57.1)	0.01
Multiple repairs	20 (21.7)	5 (71.4)	0.01
Cystostomy for repair	7 (7.6)	0 (0)	1
Repair service			1
Trauma surgery	82 (89.1)	7 (100)	1
Orthopedic surgery	7 (7.6)	0 (0)	1
Urology	3 (3.3)	0 (0)	1
Injury size (cm)	5 [2–9]	2 [1–5]	0.24
Post-repair intraoperative leak evaluation	55 (59.8)	3 (42.9)	0.44
Leak present	10 (10.9)	2 (28.6)	0.11
Pelvic drain	51 (55.4)	4 (57.1)	1
Extended antibiotic prophylaxis (>24 h)	15 (16.3)	5 (71.4)	<0.01
Postoperative imaging modality			1
Computed tomography	78 (84.8)	7 (100)
Fluoroscopy	11 (12)	0 (0)
Plain film	3 (3.3)	0 (0)

This table summarizes a univariate analysis comparing demographic, injury, and management characteristics by presence of postoperative leak. Continuous variables are expressed as medians with interquartile ranges in brackets. Categorical variables are expressed as counts with percentages in parentheses.

AAST, American Association for the Surgery of Trauma; AIS, Abbreviated Injury Scale; Extended antibiotic prophylaxis, antibiotic prophylaxis administered >24 hours postoperatively; ISS, Injury Severity Score.

The single early cystography patient with a urinary leak demonstrated radiographic resolution on repeat cystography 7 days later (postoperative day 13). Among the 6 patients in the late imaging cohort with urinary leaks, radiographic resolution occurred at 35, 37, 54, 57, 65, and 80 days following the initial cystorrhaphy. Resolution was confirmed on the second postoperative exam in 1 patient, while 5 patients required at least 3 postoperative studies to confirm resolution. One patient required reoperation of the bladder on postoperative day 47, with subsequent leak resolution at 65 days after the initial cystorrhaphy (18 days following reoperation). No previously unrecognized urinary leaks were identified on later studies following the initial postoperative exam.

Urinary Catheter Duration

The median duration of urinary catheterization for all patients was 12.5 [IQR, 10–16] days. The early cystography cohort had a shorter duration of urinary catheterization (7 [IQR, 6–10] d) compared with the late (14 [IQR, 11–18] d, p<0.01) and no postoperative cystography cohorts (10 [IQR, 9–15] d, p=0.01).

Multivariate linear regression analysis of urinary catheter duration found associations with time to postoperative imaging (adjusted β: 0.9 additional catheter days per day to postoperative cystography, 95% CI: 0.7–1.1, p<0.01) and presence of a postoperative urinary leak (adjusted β: 40.4 additional catheter days, 95% CI: 35.7–45.0, p<0.01). Overall, bladder-specific injury severity and pelvic fracture were not independently associated with length of urinary catheterization (Table 3).

TABLE 3.

Analysis of Factors Associated With Urinary Catheter Duration

Variable	Point Estimate (95% Confidence Interval)	p
ISS	-0.07 (-0.20-0.06)	0.31
Time to postoperative imaging (d)	0.92 (0.73-1.12)	<0.01
High abdominal AIS (≥4)	-1.66 (-5.08-1.75)	0.34
High AAST bladder grade (≥4)	-0.43 (3.18-2.32)	0.76
Postoperative urinary leak	40.37 (35.69-45.04)	<0.01
Pelvic fracture	0.24 (-2.83-3.31)	0.88

This table presents the results of a multivariate linear regression evaluating independent predictors of urinary catheter duration.

AAST, American Association for the Surgery of Trauma; AIS, Abbreviated Injury Scale; High AAST bladder grade, grade ≥4; High abdominal AIS, AIS ≥4; ISS, Injury Severity Score.

Catheter-Associated Urinary Tract Infections

The overall CAUTI rate was 23.7%. Patients undergoing early postoperative imaging experienced lower rates of CAUTI (6.9% vs. 30.0%, p=0.02), corresponding to a higher risk of CAUTI among the late cystography cohort (RR, 4.35; 95% CI, 1.1–17.4). There was no significant difference in CAUTI between early and no postoperative cystography cohorts (6.9% vs. 26.3%, p=0.1).

On multivariate logistic regression, longer duration of urinary catheterization was associated with increased odds of CAUTI (OR, 1.06; 95% CI: 1.01–1.11; p=0.01). Conversely, high-grade bladder injury (AAST grade ≥4) was associated with lower odds of CAUTI (OR, 0.23; 95% CI: 0.08–0.69; p=0.01). Sex, ISS, comorbidities, and utilization of extended antibiotic prophylaxis were not predictive of CAUTI (Table 4).

TABLE 4.

Analysis of Factors Associated With Catheter-Associated Urinary Tract Infection

Variable	Odds Ratio (95% Confidence Interval)	p
ISS	1.03 (0.98–1.08)	0.25
Urinary catheter duration (d)	1.06 (1.01–1.11)	0.01
Male	0.54 (0.17–1.79)	0.32
Comorbidity	3.66 (0.54–24.98)	0.19
High AAST bladder grade (≥4)	0.23 (0.08–0.69)	0.01
Extended antibiotic prophylaxis (>24 h)	1.41 (0.38–5.17)	0.61

This table presents the results of a multivariate logistic regression evaluating independent predictors of catheter-associated urinary tract infection.

AAST, American Association for the Surgery of Trauma; Extended antibiotic prophylaxis, antibiotic prophylaxis administered >24 hours postoperatively; High AAST bladder grade, grade ≥4; ISS, Injury Severity Score.

The following urinary tract pathogens were identified: Escherichia coli (8), Klebsiella (6), yeast (5), Serratia (3), Pseudomonas (3), Enterococcus (2), and Enterobacter (1). One patient with E. coli CAUTI developed bacteremia with the same pathogen.

Hospital Length of Stay

The median length of hospitalization for all patients was 11 [IQR, 7–19] days. The early cystography cohort had shorter hospitalizations than the late cohort (9 [IQR, 7–13] d vs. 12 [IQR, 8–23] d, p=0.03). No statistical difference was found between the early and no cystography cohorts (9 [IQR, 7–13] d vs. 12 [IQR, 7–30] d, p=0.15).

On multivariate linear regression, ISS (adjusted β: 0.3 additional hospital days per point increase, 95% CI: 0.1–0.6, p=0.04) and high abdominal AIS (AIS ≥4) (adjusted β: 10 additional hospital days, 95% CI: 2.9–17.1, p<0.01) were independently associated with longer hospitalization. Time to postoperative cystography, bladder-specific injury severity, and specialty of surgeon were not associated with length of hospitalization (Table 5).

TABLE 5.

Analysis of Factors Associated With Hospital Length of Stay

Variable	Point Estimate (95% Confidence Interval)	p
ISS	0.29 (0.01-0.56)	0.04
Time to postoperative cystography (d)	0.002 (-0.41-0.41)	0.99
High abdominal AIS (≥4)	10.04 (2.94-17.13)	0.01
High AAST bladder grade (≥4)	-2.47 (-8.25-3.22)	0.4
Bladder repair by trauma surgeon	2.22 (-4.06-8.49)	0.49

This table presents the results of a multivariate linear regression evaluating independent predictors of hospital length of stay.

AAST, American Association for the Surgery of Trauma; AIS, Abbreviated Injury Scale; High AAST bladder grade, grade ≥4; High abdominal AIS, AIS ≥4; ISS, Injury Severity Score.

Secondary Outcomes

There were no differences between cystography cohorts regarding outpatient urinary catheter removal, ICU LOS, ventilator days, bladder reoperation, bacteremia, urosepsis, postoperative hematuria, urinary retention requiring recatheterization, or discharge disposition (Table 6).

TABLE 6.

Outcomes by Postoperative Cystography Strategy

Outcome	Early Postoperative Cystography (n=29)	Late Postoperative Cystography (n=70)	RR (95% CI)	p	Early Postoperative Cystography (n=29)	No Cystography (n=19)	RR (95% CI)	p
Urinary catheter duration (d)	7 [6–10]	14 [11–18]		<0.01	7 [6–10]	10 [9–15]		<0.01
Outpatient catheter removal	7 (24.1)	32 (45.7)	0.53 (0.26-1.06)	0.07	7 (24.1)	6 (31.6)	1.76 (0.30-1.93)	0.57
Postoperative leak on cystography	1 (3.5)	6 (8.6)	0.40 (0.05-3.20)	0.67
Length of stay (d)	9 [7-13]	12 [8–23]		0.03	9 [7–13]	12 [7–30]		0.15
ICU length of stay (d)	0 [0-3]	4 [0–12]		<0.01	0 [0–3]	4 [0–18]		<0.01
Ventilator days (d)	0 [0-1]	2 [0–4]		0.05	0 [0–1]	2 [0–15]		<0.01
Bladder reoperation	0 (0)	1 (1.4)		1	0 (0)	0 (0)		1
CAUTI	2 (6.9)	21 (30)	0.23 (0.06-0.92)	0.02	2 (6.9)	5 (26.3)	0.26 (0.06-1.22)	0.1
Bacteremia	1 (3.5)	9 (12.9)	0.27 (0.04-2.02)	0.27	1 (3.5)	1 (5.3)	0.66 (0.04-9.85)	1
Urosepsis	0 (0)	0 (0)		1	0 (0)	0 (0)		1
Postoperative hematuria	6 (20.7)	7 (10)	2.07 ((0.76-5.63)	0.15	6 (20.7)	2 (10.5)	1.97 (0.44-8.74)	0.45
Urinary retention requiring catheter reinsertion	0 (0)	3 (4.3)		0.55	0 (0)	2 (10.5)		0.15
Disposition to home	20 (69)	39 (55.7)	1.24 (0.90-1.71)	0.22	20 (69)	8 (42.1)	1.64 (0.92-2.93)	0.06

This table summarizes a univariate analysis comparing outcomes of early (≤7 d) versus late (≥8 d) and no postoperative cystography cohorts. Continuous variables are expressed as medians with interquartile ranges in brackets. Categorical variables are expressed as counts with percentages in parentheses.

CAUTI, catheter-associated urinary tract infection; CI, confidence interval; ICU, intensive care unit; RR, relative risk ratio.

DISCUSSION

Although current guidelines provide recommendations for the surgical management of traumatic bladder injuries, postoperative care remains highly variable, particularly with respect to the timing and necessity of postoperative cystography and the duration of urinary catheterization. In the absence of data-driven guidance, practice patterns are largely influenced by institutional norms and individual surgeon preference, often resulting in prolonged catheterization and delayed imaging. Given the well-established morbidity associated with urinary catheters, including infection, impaired mobility, and patient discomfort, there is a need to better define postoperative management.

Current societal guidance on postoperative cystography following traumatic bladder repair is inconsistent and based on limited evidence. The Eastern Association for the Surgery of Trauma recommends against postoperative cystography for simple injuries and routine use for complex injuries at an unspecified interval, citing an estimated postoperative leak prevalence of 0.1% and 9%, respectively.¹ In contrast, the American College of Surgeons Best Practice Guidelines states routine cystography is recommended for most cystorrhaphies, at least 7 days following repair.⁴ These discordant recommendations may contribute to variability in postoperative practice.

Overall, 5.9% of patients had postoperative leaks (7.1% among those undergoing cystography), consistent with published rates (0–13%).^6–13 Despite a higher proportion of high-grade bladder injuries in the early cohort, the leak rates were similar between cystography cohorts (3.5% vs. 8.6%). Most leaks in the late cohort required ≥3 imaging studies to document resolution at ≥5 weeks postoperatively, whereas the single early cohort leak resolved on repeat imaging 1 week later. Although this patient may ultimately have required a single study with delayed imaging, the overall low leak rate in the early cohort suggests minimal downstream imaging burden. No leaks were identified in the no cystography cohort. However, this likely represents selection bias, as imaging decisions were likely influenced by measured and unmeasured clinical factors in this retrospective study without standardized protocols. When postoperative cystography is pursued, early imaging appears to safely identify patients in whom urinary catheters may be removed.

Unlike prior studies, we did not classify injuries as simple or complex, as these definitions are inconsistently applied and not uniformly reflected in current guidelines. Instead, we performed a descriptive analysis of factors associated with postoperative leak. Although several variables were associated with leak on univariate analysis, none were independently predictive, likely reflecting the multifactorial nature of leak and the low event rate. When considering postoperative cystography, factors such as penetrating mechanism, associated bowel injury, multiple bladder injuries, AAST grade 5 injury, and surgical control of pelvic hemorrhage may warrant consideration (Fig. S2, Supplemental Digital Content 3, http://links.lww.com/TA/F402).

Patients in the early imaging cohort had shorter durations of urinary catheterization compared with those in the late and no imaging cohorts (7 d vs. 14 d and 10 d, respectively). This reduction is expected, as catheter removal is often deferred pending confirmatory imaging, and earlier cystography provides reassurance that facilitates timely catheter removal when longer durations might otherwise be pursued in the absence of confirmatory testing. Although no prior studies have stratified patients by cystography timing, one study stratified by catheter duration and indirectly suggested that earlier imaging is associated with shorter catheterization.¹⁰

Early postoperative cystography facilitates earlier catheter removal and improves patient-centered outcomes. In a survey of radical prostatectomy patients, approximately half reported moderate or severe catheter-related bother and limitation in physical activity, exceeding postoperative pain, and 96% were willing to undergo early cystography on postoperative day 7 if it conferred at least a 70% likelihood of catheter removal rather than waiting until day 14 without imaging.¹⁴ Similar catheter-related discomfort and mobility limitations have been reported among hospitalized patients.¹⁵ These findings highlight the substantial morbidity associated with prolonged catheterization and support early cystography as a patient-centered strategy to safely shorten catheter duration following traumatic bladder repair.

Our overall CAUTI incidence was 23.7%, comparable to reported rates in traumatic bladder literature (3–25%).^6,10,16–18 Patients in the early cystography cohort had fewer CAUTIs than those in the late cohort (6.9% vs. 30%). This aligns with a prior study demonstrating reduced CAUTI with earlier catheter removal (3% vs. 12%).⁶ Delayed imaging independently predicted longer catheter duration, which in turn was independently associated with CAUTI, supporting a duration-dependent relationship between catheterization and infection. These findings are consistent with prior literature demonstrating a strong duration-dependent relationship between catheterization and urinary tract infection.^19–22 CAUTI is a major source of morbidity and cost in hospitalized patients, contributing to bacteremia, prolonged hospitalization, antimicrobial use, and financial penalties, with attributable costs exceeding $13,000 per episode.^19,21–23 Accordingly, earlier cystography may reduce CAUTI by facilitating earlier catheter removal while offering a value-based opportunity to decrease avoidable morbidity and cost.

The median length of hospitalization in our cohort was 11 days, consistent with previously reported lengths of stay for traumatic bladder injuries (11–14 d).^16,18 Although patients in the early cystography cohort had shorter stays than those in the late cohort, this association was driven by overall injury severity rather than bladder-specific factors on multivariate analysis.

The majority of cystorrhaphies in our cohort were performed by trauma surgeons (90.7%), a higher proportion than previously reported (24–58%).^6,11,18 Notably, 6.8% were performed by orthopedic surgeons, likely reflecting repair at the time of anterior pelvic fixation.

Intraoperative leak testing was not statistically associated with lower postoperative leak rates. However, this finding should be interpreted with caution. Although the observed difference in postoperative leak rates between patients with and without a positive initial intraoperative leak test (15.4% vs. 1.8%) did not achieve statistical significance, the magnitude of this difference is clinically substantial and may reflect limited power due to small sample size and the rarity of postoperative leaks. As such, the absence of statistical significance does not exclude a potentially meaningful association. Notably, among patients without an intraoperative leak following initial repair, 1.8% were found to have a postoperative leak, indicating that a negative initial intraoperative assessment alone should not preclude cystography. These findings mirror urologic data in vesicourethral anastomosis, where 4-17% of patients have postoperative leaks despite negative intraoperative testing.^24,25 Collectively, this supports cautious interpretation of intraoperative leak testing and reinforces the role of postoperative cystography in confirming repair integrity after traumatic bladder injury.

Although pelvic drains were placed in most patients, they did not meaningfully improve urinary leak detection or alter management. Three leaks were identified on postoperative cystography among patients who underwent drain creatinine testing: 1 with an elevated drain-to-serum creatinine ratio and 2 without elevation, underscoring the limited sensitivity of this measure. These findings are consistent with prior trauma and urologic literature demonstrating no clear benefit of routine pelvic drain placement in detecting or managing postoperative urinary leaks.^6,26

This study is limited by its retrospective design. Postoperative cystography timing was not randomized and was influenced by surgeon judgment, injury severity, associated injuries, and management strategies, introducing potential selection bias. Review of operative and postoperative documentation did not identify rationales linking injury characteristics (size, location, mechanism), intraoperative findings (leak testing), or adjunct management strategies (drain output characteristics or creatinine testing) to the timing or omission of postoperative cystography or catheter duration, limiting our ability to account for provider-level decision-making. The modest sample size, particularly within certain AAST grades and outcome subgroups, limits precision and may obscure smaller differences. Imaging practices were not standardized, and variation in timing or modality may have affected leak detection. As a single-system study, generalizability may be limited, and complications managed outside our institution may be underreported.

CONCLUSION

In this study, early cystography after bladder repair was associated with shorter catheter duration and lower CAUTI rates without increasing postoperative leak detection. Intraoperative leak testing and pelvic drains did not meaningfully alter postoperative management or leak detection. Factors such as penetrating mechanisms, associated bowel injury, multiple bladder injuries, AAST grade 5 injuries, and surgical control of pelvic hemorrhage may inform selective use of postoperative cystography. Collectively, these findings suggest that early postoperative cystography may reduce catheter-related morbidity and improve patient-centered outcomes without increasing downstream imaging. Prospective studies are needed to define optimal timing and modality of postoperative cystography to identify clinically significant urinary leaks and to better define patients in whom postoperative imaging may be safely omitted.

Supplementary Material

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ta-101-810-s003.pdf ^{(1.3MB, pdf)}