Routine Cystogram Prior to Catheter Removal for Non‐Iatrogenic Bladder Injury May Not Be Necessary—The Auckland City Hospital Experience

Abstract

BACKGROUND: The optimal duration of urinary catheterisation and the necessity of routine follow-up cystogram prior to catheter removal in non-iatrogenic bladder injury remain controversial. International guidelines vary, and no local protocol exists. This study reviewed our institutional experience to evaluate the yield of routine cystogram prior to catheter removal. METHODS: A retrospective audit was conducted of patients with non-iatrogenic bladder injuries managed at a Level 1 trauma centre between 2005 and 2024. Patients with partial thickness or complex injuries and those who died within 7 days were excluded. Demographics, injury characteristics, management strategy, catheter duration, use of follow-up cystogram and complications were analysed. Urinary tract infection was defined as a clinically diagnosed or microbiologically confirmed urinary infection documented during admission requiring antibiotic treatment. Intraperitoneal (IP) and extraperitoneal (EP) injuries were compared using non-parametric and categorical statistical tests. Follow-up cystography at our institution was performed using conventional fluoroscopic cystography. Contrast was instilled retrograde through an indwelling urethral catheter using diluted Omnipaque 350 in saline. The bladder was passively filled to approximately 300-350 mL, or until the patient reported fullness or resistance to filling was encountered. Standard anteroposterior and oblique radiographs were obtained. A positive cystogram was defined as any radiologically reported contrast extravasation consistent with a persistent urinary leak. RESULTS: Thirty-two patients were included (53% male; median age 35 years [IQR 26-53]). All included cases were attributable to blunt trauma. Eighteen (56%) injuries were IP and 14 (44%) EP. Twenty-two (69%) injuries underwent operative repair. Thirty patients (94%) underwent routine follow-up cystogram prior to catheter removal; all studies were normal. The median duration of catheterisation was 17 days (IQR 11-25). Urinary tract infection occurred in 38% of patients. Patients who developed urinary tract infection had a longer median duration of catheterisation compared with those who did not develop urinary tract infection (27 days [IQR 12-34] vs. 15 days [IQR 10-22]). There were no urinary leaks identified following catheter removal and no mortality within the available follow-up documentation. CONCLUSION: Routine follow-up cystogram prior to catheter removal demonstrated a very low diagnostic yield in uncomplicated non-iatrogenic bladder injuries within our cohort. Prolonged catheterisation was common and associated with high rates of urinary tract infection. A selective approach to cystography and earlier catheter removal in uncomplicated injuries, particularly following IP repair, may be appropriate.