DOI:10.2214/AJR.05.0971
AJR 2006; 187:1296-1302
© American Roentgen Ray Society
CT Cystography with Multiplanar Reformation for Suspected Bladder Rupture: Experience in 234 Cases
David P. N. Chan1,
Hani H. Abujudeh2,
George L. Cushing, Jr.2 and
Robert A. Novelline2
1 Department of Diagnostic Radiology and Organ Imaging, Prince of Wales
Hospital, Shatin, Hong Kong.
2 Department of Radiology, Massachusetts General Hospital, Boston, MA
02114.
Received June 7, 2005;
accepted after revision September 18, 2005.
Presented at the 2005 annual meeting of the Radiological Society of North
America, Chicago, IL.
Address correspondence to D. P. N. Chan
(chanponin{at}gmail.com).
Abstract
OBJECTIVE. CT cystography has replaced conventional cystography in
the evaluation of patients with suspected bladder rupture in most trauma
centers. We performed this retrospective review to determine the accuracy of
CT cystography and the role of multiplanar reformation in the diagnosis of
bladder injury.
MATERIALS AND METHODS. The patient cohort was composed of trauma
patients with clinically or CT-suspected bladder ruptures who were evaluated
with CT cystography using two different MDCT scanners at our level 1 trauma
center. The patients were identified through Folio, a radiology research tool
software system. The CT cystography results were compared with the findings at
surgery, clinical follow-up, or both.
RESULTS. Between January 1, 2000, and December 31, 2004, 234
patients were examined in our level 1 trauma center with CT cystography. From
the total of 234 examinations, 216 (92.3%) 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 nine of the 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.
CONCLUSION. CT cystography is accurate for diagnosing bladder
rupture. Sagittal and coronal multiplanar reformations may be helpful in
identifying most sites of bladder rupture.
Keywords: bladder trauma • CT cystography • multiplanar reformation
Introduction
Bladder rupture is an uncommon injury, occurring in 10% of patients with
pelvic fractures. However, 83% of patients with bladder rupture have a pelvic
fracture [1]. Bladder injuries
can be categorized into several types: contusions, intraperitoneal rupture,
extraperitoneal rupture, and combined intraperitoneal and extraperitoneal
rupture. Contusion represents an intramural injury, with hematoma within the
bladder wall. Extraperitoneal bladder rupture is more common, with an 80-90%
frequency rate, whereas intraperitoneal bladder rupture occurs in 15-20% of
patients. Combined rupture occurs in as many as 12%
[2].
Accurate identification of bladder injury is of paramount importance for
proper management. Surgical repair is required for intraperitoneal rupture and
combined intraperitoneal and extraperitoneal rupture. Catheter drainage is
required for extraperitoneal rupture, whereas contusion can be managed
conservatively. Delay in the diagnosis and treatment of bladder trauma may
increase patient morbidity and mortality. Therefore, rapid diagnosis is
essential for optimal patient management
[3].
In the past, conventional cystography was considered the standard procedure
for evaluating patients with suspected bladder injury
[4-6].
However, it is time-consuming, cannot provide information regarding other
pelvic structures, and is sometimes limited by the presence of overlying
fracture fragments or fixation devices.
CT is now considered to be a diagnostic procedure of choice in the
evaluation of abdominal and pelvic injury after blunt trauma. The conventional
CT protocol for abdominal trauma may or may not show the presence of bladder
trauma because visualization of bladder rupture on CT requires the bladder to
be filled with fluid and under pressure. Therefore, if a conventional
abdominal trauma CT examination fails to show bladder rupture and bladder
rupture is suspected, especially when water-dense fluid is seen in the
peritoneal cavity, CT cystography is indicated. The value of CT cystography
has been evaluated by other investigators
[4,
5] who concluded that it was as
accurate as conventional cystography in diagnosing bladder trauma.
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Fig. 1A —19-year-old man with extraperitoneal bladder rupture after
motor vehicle collision. CT cystography images (A, axial; B,
coronal; C, sagittal) show site of bladder rupture at right lateral
wall (arrows) with contrast extravasation into extraperitoneal space
(arrowheads).
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Fig. 1B —19-year-old man with extraperitoneal bladder rupture after
motor vehicle collision. CT cystography images (A, axial; B,
coronal; C, sagittal) show site of bladder rupture at right lateral
wall (arrows) with contrast extravasation into extraperitoneal space
(arrowheads).
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Fig. 1C —19-year-old man with extraperitoneal bladder rupture after
motor vehicle collision. CT cystography images (A, axial; B,
coronal; C, sagittal) show site of bladder rupture at right lateral
wall (arrows) with contrast extravasation into extraperitoneal space
(arrowheads).
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MDCT was introduced in 1998. Compared with helical CT, it can improve
temporal and spatial resolution, decrease image noise, and provide longer
anatomic coverage. Multiplanar reformation (MPR) is a planar recording of
voxels used to provide alternate reformations for better anatomic delineation.
The thin-section scanning in MDCT allows the production of higher quality MPR
images [7]. Prior
investigations of CT cystography had not emphasized the role of MPR. We
hypothesize a better anatomic understanding of bladder injury can be achieved
with sagittal and coronal images from MPR. We retrospectively evaluated the
role of MPR in the diagnosis of bladder injury using MDCT. The accuracy of
MDCT cystography was also evaluated.
Materials and Methods
Approval for this investigation was granted by our institutional human
studies review board. Using Folio Views, version 4.2 (Folio Division of Open
Market), a radiology research tool software system, we identified 234 patients
(142 males and 92 females; age range, 3.4-93.7 years; mean age, 42.3 years)
admitted to our level 1 trauma center between January 1, 2000, and December
31, 2004, for whom bladder ruptures were suspected and CT cystography was
performed. The mechanisms of injury included motor vehicle collision,
n = 133; pedestrian stuck by motor vehicle, n = 49; fall,
n = 47; bicycle accident, n = 2; and gunshot injury,
n = 3. The medical records and CT cystography images were reviewed.
Variables recorded from medical records included patient age, sex, mechanism
of injury, hematuria (gross or microscopic) at presentation, associated pelvic
fractures, operative findings, and progress at clinical follow-up.
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Fig. 2A —34-year-old woman with intraperitoneal bladder rupture after
motor vehicle collision. CT cystography images (A, axial; B,
coronal; C, sagittal) show site of bladder rupture at dome
(arrows) with contrast extravasation into peritoneal space
(arrowheads). Note enlarged uterus with fibroids (F).
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Fig. 2B —34-year-old woman with intraperitoneal bladder rupture after
motor vehicle collision. CT cystography images (A, axial; B,
coronal; C, sagittal) show site of bladder rupture at dome
(arrows) with contrast extravasation into peritoneal space
(arrowheads). Note enlarged uterus with fibroids (F).
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Fig. 2C —34-year-old woman with intraperitoneal bladder rupture after
motor vehicle collision. CT cystography images (A, axial; B,
coronal; C, sagittal) show site of bladder rupture at dome
(arrows) with contrast extravasation into peritoneal space
(arrowheads). Note enlarged uterus with fibroids (F).
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Our standard CT protocol for abdominal and pelvic trauma was as follows.
Before the CT examination, 3 cups of 1/4 oz meglumine diatrizoate
(Gastrografin, Bristol-Myers Squibb) in 10 oz of water was given as an oral
contrast agent. The Foley catheter was clamped to assist bladder filling.
Scanning was performed after the power injection of 135 mL of IV contrast
agent at a rate of 3 mL/s at 70 seconds delay from the level of diaphragm to
the iliac crest, then from the iliac crest to the ischial tuberosities at a
120-second delay. Scanning parameters were detector configuration, 4 x
2.5 mm; slice thickness, 5 mm; image spacing, 5 mm; and pitch, 6 for 4-MDCT
(LightSpeed Plus, GE Healthcare); and detector configuration, 16 x 1.25
mm; slice thickness, 5 mm; image spacing, 5 mm; pitch, 0.938; and table speed,
18.75 for 16-MDCT (LightSpeed Pro16, GE Healthcare). CT cystography proceeded
afterward if there was suspicion of bladder trauma, for example, presence of
pelvic fracture, low-density pelvic fluid, and clinically detected blood in
the meatus. CT cystography was performed by using a low-gravity drip infusion
of 300-400 mL of diluted water-soluble contrast agent (sterile injection of 40
mL of 60% water-soluble contrast agent into a 1-L bag of saline; the height of
the reservoir was about 1.5 m) through the Foley catheter to the urinary
bladder. After complete filling of the bladder, scanning was performed from
above the top of the iliac crest through the ischial tuberosities to include
the entire bladder. The axial data were reconstructed with 2.5-mm slices at
2-mm intervals in the standard algorithm for the reformation.
The axial CT images and MPR images, including sagittal and coronal
reformatted images of all cases, were retrospectively analyzed by one of the
authors using a PACS workstation (IMPAX, Agfa). The images were evaluated to
assess the types of bladder injury (extraperitoneal rupture, intraperitoneal
rupture, combined intraperitoneal and extraperitoneal rupture) and also the
sites of bladder injury in different planes. These findings were compared with
the operative findings and the progress of the patient's clinical condition
during the hospital stay—for example, any persistent hematuria,
abdominal pain, and follow-up imaging (CT or conventional cystography).
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Fig. 3A —29-year-old man with intraperitoneal bladder rupture who was
struck by motor vehicle. Axial CT cystography image shows contrast
extravasation into peritoneal space (arrowheads), but exact site of
rupture cannot be determined.
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Fig. 3B —29-year-old man with intraperitoneal bladder rupture who was
struck by motor vehicle. and C, Coronal (B) and sagittal
(C) CT cystography images show site of bladder rupture at dome
(arrows) with contrast extravasation into peritoneal space
(arrowheads).
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Fig. 3C —29-year-old man with intraperitoneal bladder rupture who was
struck by motor vehicle. Coronal (B) and sagittal (C) CT
cystography images show site of bladder rupture at dome (arrows) with
contrast extravasation into peritoneal space (arrowheads).
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Fig. 3D —29-year-old man with intraperitoneal bladder rupture who was
struck by motor vehicle. Retrospective review of axial CT cystography image at
corresponding level shows possible location of rupture at bladder dome
(arrow) with contrast extravasation into peritoneal space
(arrowhead), but rupture is not well seen because scanning plane is
parallel to bladder dome.
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Results
A total of 234 patients with suspected bladder trauma were examined on CT
cystography in this 5-year period. Eighteen (7.7%) of the 234 CT cystograms
were interpreted as positive for bladder rupture; 11 of those 18 were
extraperitoneal ruptures (Figs.
1A,
1B, and
1C), five were intraperitoneal
ruptures (Figs. 2A,
2B,
2C,
3A,
3B,
3C, and
3D), and two were combined
intraperitoneal and extraperitoneal ruptures. There was no bladder contusion
reported in this investigation. The mechanisms of injury were motor vehicle
collision, n = 11; pedestrian stuck by motor vehicle, n = 6;
and fall, n = 1. Two patients (one extraperitoneal rupture and one
intraperitoneal rupture) died shortly after admission because of multiorgan
injury. The remaining 216 patients had negative CT cystography results. Ten
died afterward due to multiorgan injury. The remaining 206 patients had
subsequent clinical follow-up that did not show evidence of bladder
injury.
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Fig. 4A —66-year-old woman who was struck by motor vehicle. Axial CT
cystography image shows site of bladder rupture at anterior wall
(arrow) with contrast extravasation into extraperitoneal space
(black arrowhead). Extravasated contrast agent posterior to bladder
wall (white arrowhead) was thought to be intraperitoneal rupture
component. Initial interpretation was combined intraperitoneal and
extraperitoneal rupture.
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Fig. 4B —66-year-old woman who was struck by motor vehicle. and
C, Coronal (B) and sagittal (C) CT cystography images
show site of intraperitoneal bladder rupture (arrow) and
extraperitoneal rupture (black arrowheads). Note extravasated
contrast agent was underneath peritoneal reflection as shown in C
(white arrowheads), and there was no extravasated urine surrounding
loops of bowel.
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Fig. 4C —66-year-old woman who was struck by motor vehicle. Coronal
(B) and sagittal (C) CT cystography images show site of
intraperitoneal bladder rupture (arrow) and extraperitoneal rupture
(black arrowheads). Note extravasated contrast agent was underneath
peritoneal reflection as shown in C (white arrowheads), and
there was no extravasated urine surrounding loops of bowel.
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Pelvic fractures were noted in 163 (70%) of the 234 cases in our study
series. Among the positive cases on CT, 14 (77.8%) of 18 had pelvic fracture;
11 patients had extraperitoneal bladder rupture, one patient had
intraperitoneal rupture, and two patients had combined intraperitoneal and
extraperitoneal rupture. All of them had more than one fracture site. Twelve
of the 18 cases had pubic rami fractures, 11 had sacral fractures, three had
pubic symphysis diastasis, five had sacroiliac diastasis, two had iliac
fractures, and five had acetabular fractures. No fracture was seen in three
patients with intraperitoneal rupture and one patient with combined
intraperitoneal and extraperitoneal rupture.
Gross hematuria was present in 46 of the 234 patients, including all 18
patients with bladder rupture. Microscopic hematuria was seen in 111 of the
234 patients and no hematuria in 77. No bladder injury was seen in these two
groups of patients.
Bladder exploration and repair were performed in nine patients with
positive CT cystography results (three extraperitoneal rupture, four
intraperitoneal rupture, two combined intraperitoneal and extraperitoneal
rupture). The operative findings were consistent with the CT cystogram
findings in seven of the nine cases. In one of those cases, CT was interpreted
initially as combined intraperitoneal and extraperitoneal rupture but on
surgical exploration was found to be extraperitoneal rupture only. However, on
retrospective review only extraperitoneal rupture was seen on CT (Figs.
4A,
4B, and
4C). In one of the nine cases,
CT was interpreted as intraperitoneal bladder rupture with contrast
extravasation into the peritoneal space. A small amount of fluid was seen in
the extraperitoneal space lateral to the bladder wall but no contrast
extravasation to the extraperitoneal space was seen. Operative exploration
revealed combined intraperitoneal and extraperitoneal rupture (Figs.
5A and
5B). The specific type of
bladder rupture was therefore correctly identified on CT cystography in seven
of nine patients (77.8%). In the seven of 11 patients with extraperitoneal
rupture, the treatment was conservative. Follow-up imaging performed 7-38 days
after initial injury in six of the seven (three CT cystography and three
conventional cystography) did not show further rupture (Fig. 2D).
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Fig. 5A —29-year-old woman after motor vehicle collision. Axial CT
cystography image superior to bladder level shows contrast extravasation into
peritoneal space (arrowheads) outlined by adjacent bowel loops.
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Fig. 5B —29-year-old woman after motor vehicle collision. Axial CT
cystography image at bladder level shows a small amount of fluid lateral to
bladder but no contrast extravasation is seen (arrows). CT cystogram
was interpreted as intraperitoneal rupture with probability of extraperitoneal
rupture. Injury was confirmed to be combined intraperitoneal and
extraperitoneal rupture by surgical bladder exploration.
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The overall sensitivity and specificity of CT cystography in diagnosing
bladder rupture were both 100%. For detection of extraperitoneal bladder
rupture, the sensitivity, specificity, positive predictive value (PPV), and
negative predictive value (NPV) of CT cystography were 92.9%, 100%, 100%, and
99.5%, respectively. For detection of intraperitoneal bladder rupture, the
sensitivity, specificity, PPV, and NPV of CT cystography were 100%, 99.6%,
85.7%, and 100%, respectively.
The axial images were retrospectively compared with coronal and sagittal
images from MPR. One case (Figs.
4A,
4B, and
4C) with an initial diagnosis
of combined intraperitoneal and extraperitoneal rupture was found to have only
extraperitoneal rupture on exploration. The MPR images were retrospectively
reviewed and showed no contrast extravasation in the peritoneal space. For the
case with a CT cystography diagnosis of intraperitoneal rupture but an
operative diagnosis of combined intraperitoneal rupture and extraperitoneal
rupture, the axial and MPR images were retrospectively reviewed (Figs.
5A and
5B), but again no contrast
extravasation was seen in the extraperitoneal space in any of the three
planes.
Through the axial images, we could identify the sites of bladder rupture in
14 of the 18 patients (11, extraperitoneal rupture; 1, intraperitoneal
rupture; and 2, combined intraperitoneal and extraperitoneal rupture). In the
remaining four patients with intraperitoneal rupture, the site of rupture was
at the bladder dome but could not be well shown in axial images (Figs.
3A,
3B,
3C, and
3D). However, through the
coronal and sagittal images from MPR we could identify all the bladder sites,
including the four cases not seen in the axial images.
Discussion
One of the advantages of MDCT is its MPR ability
[8]. The coronal plane images
may serve as a useful adjunct to the axial plane images. Images in the coronal
plane are particularly appealing to surgeons because the orientation of
structures is analogous to that encountered during exploratory laparotomy.
Given such advantages, we think MDCT with MPR may better delineate the bladder
injury.
Conventional cystography has been regarded as the standard for the
evaluation of bladder trauma. However, conventional cystography is sometimes
difficult in a trauma setting, particularly if the patient is on a spinal
board, and turning a patient with pelvic trauma may be not be possible. In
addition, conventional cystography is time-consuming, cannot provide
information on surrounding structures, and is sometimes limited by the
presence of the overlying fracture fragment or fixation devices in pelvic
fracture.
CT is generally accepted as an imaging technique of choice for the
evaluation of patients with multiple injuries, and the concept of integrating
CT scanners into the context of the emergency department has contributed to
increasing the use of CT for evaluation of multitrauma patients
[2,
9]. CT is therefore considered
essential for bladder trauma assessment. In addition to the high level of
diagnostic certainty, there is the further advantage of performing the entire
examination at one location. The patient does not have to be transported from
CT room to fluoroscopy room for conventional cystography.
The accuracy of CT for evaluation of bladder trauma has been assessed. Mee
et al. [10] reported two cases
of missed bladder rupture by CT in which the bladder was filled by the
contrast agent in an antegrade fashion by clamping the Foley catheter while
the delayed scan was taken. It was concluded that inadequate bladder
distention was a limitation of CT, and retrograde infusion of contrast agent
was advocated. A subsequent study by Lis and Cohen
[5] showed that CT cystography
is at least as accurate as conventional cystography in assessing bladder
injury. In a prospective study by Peng et al.
[4], which used CT cystography
to screen 55 patients with hematuria and blunt abdominal trauma, five patients
were identified as having bladder rupture and the diagnoses were confirmed
intraoperatively. There were no false-positive results. Diagnoses for the
remaining 50 patients with negative CT cystography results were confirmed on
conventional cystography. In a retrospective review by Deck et al.
[6], 44 of 316 patients had
bladder rupture, and CT cystography was used to identify 42 cases. The
sensitivity, specificity, PPV, and NPV for CT cystography in diagnosing
extraperitoneal rupture were 97%, 100%, 100%, and 99%. The sensitivity,
specificity, PPV, and NPV for CT cystography in diagnosing intraperitoneal
rupture were 78%, 99%, 70%, and 99%.
In our study using MDCT, the results were comparable with the study by Deck
et al. [6] using helical CT.
There were no false-negative results in our study. The sensitivity of CT
cystography in diagnosing intraperitoneal rupture in our study was higher than
that found by Deck et al. (100% vs 78%), whereas the specificity remained the
same (both 99%). We postulated the use of MDCT may increase sensitivity with
no change in specificity in diagnosing intraperitoneal bladder rupture. The
diagnosis of intraperitoneal bladder rupture is important because surgical
repair is required, and delay in diagnosis or treatment may increase morbidity
and mortality.
There were two cases with discrepancy in the type of bladder rupture. The
first case was interpreted as combined intraperitoneal and extraperitoneal
rupture but exploration found both to be extraperitoneal rupture. The images
were retrospectively reviewed. They were initially misinterpreted because
there was extravasated contrast agent posterior to the bladder. However, on
sagittal MPR images, the extravasated contrast agent was confined to the
extraperitoneal space because all the contrast agent was underneath the
peritoneal surface (Fig. 4C).
Another difficult case showed extravasated contrast agent in the
intraperitoneal space, and a small amount of fluid lateral to the bladder that
was not opacified on the CT cystogram (Figs.
5A and
5B). The finding was
interpreted as intraperitoneal rupture with a probable extraperitoneal rupture
component. Bladder exploration showed a large defect in the bladder dome
involving the peritoneal reflection and confirmed the combined intraperitoneal
and extraperitoneal rupture.
Our investigation also showed that better delineation of the site of the
bladder rupture can be achieved with the use of MPR. The site of the bladder
rupture was identified in 14 of 18 patients in axial images. In the remaining
four cases of intraperitoneal rupture, the sites of rupture were at the
bladder domes, which were parallel to the scanning plane of the axial scan.
They were only detected by either coronal or sagittal images in MPR. One
intraperitoneal bladder rupture with laceration at the dome could be
identified on the axial image (Figs.
2A,
2B, and
2C). We think this was related
to the large size of the laceration because the intraoperative finding of the
laceration was 5 cm.
Our investigation had several limitations. There was no comparative study
to prove the accuracy of CT cystography. The results were obtained
retrospectively from medical records, and therefore small extraperitoneal
bladder ruptures may be missed on CT cystography and regarded as negative
cases. Similarly, only nine of 18 patients with positive CT cystography
results had surgical proof of bladder rupture. The exact site of injury of the
bladder rupture in the remaining nine patients (two died and the remaining
seven were diagnosed as having extraperitoneal rupture) could not be compared
because bladder exploration was not performed in these patients.
CT cystography, however, has several pitfalls that may lead to
false-negative results. The Foley catheter tip may abut the small tear site,
which may occlude the contrast extravasation. The presence of pelvic hematoma
may result in incomplete bladder distention. In addition, the diagnosis of
combined intraperitoneal and extraperitoneal rupture may be missed if the
rupture site is large because full bladder distention cannot be achieved, and
most of the contrast agent is extravasated into the extraperitoneal component
but not into the intraperitoneal component
[11].
In conclusion, we recommend the use of CT cystography in the evaluation of
patients with suspected bladder rupture. Additional sagittal and coronal
images from MPR may be highly informative for identification of the site of
the bladder rupture, particularly in intraperitoneal rupture when the site of
perforation is at the bladder dome, which may be difficult to detect on axial
images.
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Abstract
Introduction
