General indications and surgical approach
Surgical interventions on the urinary bladder are performed for various pathological conditions, including hernias, diverticula, calculi, foreign bodies, tumors, and traumatic injuries.
Traditionally, the lower midline extraperitoneal approach is used to perform these operations. It provides reliable visual and technical control over the organ while minimizing the risk of peritoneal injury.
Cystotomy and completion of cystostomy
The creation of an artificial fistula or opening of the organ cavity requires adherence to specific sequential steps:
- An incision is made in the center of the muscular wall of the organ, through which a drainage tube is inserted.
- A purse-string suture is placed around the drain and tied.
- The anterior abdominal wall is closed layer-by-layer either tightly or up to the level of the placed drain.
- After tube removal, the opening in the wall closes spontaneously due to the natural contraction of muscle fibers.
Bladder resection
The operation is indicated for malignant neoplasms and large papillomas.
Technical features:
- The dome of the bladder is separated from the peritoneum with mandatory division of the median umbilical fold (obliterated urachus).
- If separating the peritoneum is technically impossible, extraperitonealization is performed: dissection of the peritoneum followed by closure of the defect.
- After vessel ligation, excision of the affected segment is performed with a margin of at least 2.5 cm from the boundaries of the neoplasm.
- The resulting wall defect is closed with two-row interrupted sutures.
If the tumor involves the ureteral orifice, ureterocystoneostomy is performed: the ureter is transected 3 cm from its entrance and reimplanted into the preserved part of the bladder.
Cystectomy and bowel substitution techniques
Complete removal of the organ requires restoration of urinary diversion function using bowel plastic procedures:
- Ileal conduit (Option A): an isolated 15–20 cm loop of the ileum on its mesentery is used. The proximal end is closed and the ureters are implanted into it, while the distal end is brought out to the anterior abdominal wall as a stoma. Bowel continuity is restored with an end-to-end anastomosis.
- Orthotopic neobladder (Option B): the reservoir is formed from the small intestine or sigmoid colon, the ureters are implanted into it, and an anastomosis with the urethra is created.
Briefly: answers to topical questions
What type of suture is used to close a urinary bladder wall defect during resection or injury?
A urinary bladder wall defect during resection or injury is closed with a two-row suture. For resection, two-row interrupted sutures are used. For peritoneal injuries, sutures are applied layer-by-layer:
- First row — catgut without involving the mucosa.
- Second row — seromuscular suture with fine silk.
Depending on how the operation is completed, the following are used:
- Cystotomy (Cystotomia) — the wall is closed tightly with a two-row suture.
- Cystostomy (Cystostomia) — the wound is closed with a two-row suture down to a rubber drain.
What is the surgical strategy for an intraperitoneal rupture of the urinary bladder?
The surgical strategy for an intraperitoneal rupture of the urinary bladder involves surgical intervention to prevent peritonitis. The set of measures includes:
- Surgical approach — laparotomy or laparoscopy is performed.
- Defect closure — placement of a two-row suture: the first row with catgut without involving the mucosa, the second is a seromuscular suture with fine silk.
- Abdominal cavity drainage.
- Bladder drainage — insertion of an indwelling catheter for several days.
How is drainage of the perivesical space performed in extraperitoneal urinary bladder injuries?
Drainage of the prevesical cellular space in the development of urinary extravasation or phlegmon is performed via MacWhorter–Buyalsky and Kupriyanov approaches. Drainage is difficult due to the deep location of the adipose tissue.
In most cases, the extraperitoneal bladder rupture itself is managed with transurethral or suprapubic drainage.
For tumor resection, remember the "Two and a half" rule: stay at least 2.5 cm away from the tumor margin.
Class and exam questions
What surgical approach is used for operations on the urinary bladder?
The primary and safest approach is the lower midline extraperitoneal approach.
What is the minimum distance required when resecting the organ for a tumor?
Excision of the segment with the neoplasm is performed with a margin of at least 2.5 cm from its edge.
How does the wall opening close after cystostomy?
The opening closes spontaneously due to the natural contraction of the muscular layer after removal of the drainage tube.
What else to study on this topic
- Anatomical structure of the bladder wall and its topography
- Technique of placing purse-string and two-row interrupted sutures
- Anatomical variants of the organ's blood supply
- Complications in forming an ileal conduit and orthotopic reservoir
- Features of defect closure in combined pelvic trauma
Master the complete topic in the "Topographic Anatomy" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Operations for urinary bladder injuries" and 2,777 more subject pages
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 91 video lessons on the subject
Other topics in the section «Pelvic and Perineal Surgery»
Free video lessons: topographic anatomyShort lessons with study notes — no registration required.
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.