Journal of Pediatric Surgery (2012) 47, 1677–1681

www.elsevier.com/locate/jpedsurg

Repair of pediatric bladder rupture improves survival:

results from the National Trauma Data Bank
Christopher M. Deibert a,b,⁎, Kenneth I. Glassberg b , Benjamin A. Spencer a,c
a
Department of Urology, Columbia University College of Physicians and Surgeons, New York, NY
b
Morgan Stanley Children's Hospital of New York, New York, NY
c
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY

Received 7 November 2011; revised 9 January 2012; accepted 14 February 2012

Key words:
Abstract
Bladder injury;
Background/purpose: The urinary bladder is the second most commonly injured genitourinary organ.
Trauma;
The objective of this study was to describe the management of pediatric traumatic bladder ruptures in
National Trauma Data
the United States and their association with surgical repair and mortality.
Bank
Methods: We searched the 2002-2008 National Trauma Data Bank for all pediatric (b18 years old)
subjects with bladder rupture. Demographics, mechanism of injury, coexisting injury severity, and
operative interventions for bladder and other abdominal trauma are described. Multivariate logistic
regression analysis was used to examine the relationship between bladder rupture and both bladder
surgery and in-hospital mortality.
Results: We identified 816 children who sustained bladder trauma. Forty-four percent underwent
bladder surgery, including 17% with an intraperitoneal injury. Eighteen percent had 2 intra-abdominal
injuries, and 40% underwent surgery to other abdominal organs. In multivariate analysis, operative
bladder repair reduced the likelihood of in-hospital mortality by 82%. A greater likelihood of dying was
seen among the uninsured and those with more severe injuries and multiple abdominal injuries.
Conclusions: After bladder trauma, pediatric patients demonstrate significantly improved survival when
the bladder is surgically repaired. With only 67% of intraperitoneal bladder injuries being repaired, there
appears to be underuse of a life-saving procedure.
© 2012 Elsevier Inc. All rights reserved.

In pediatric trauma, the urinary bladder is the second most
commonly injured genitourinary organ [1]. The American
Association for the Surgery of Trauma grades bladder injury
from a grade 1 contusion to a grade 5 extraperitoneal or
intraperitoneal rupture involving the bladder neck or ureteral
orifices [2]. Incomplete drainage of intra-abdominal urine
⁎ Corresponding author. Department of Urology, College of Physicians
and Surgeons of Columbia University, New York, NY 10032. Tel.: +1 212
305 1371; fax: +1 212 305 0113.
E-mail address: cmd2176@columbia.edu (C.M. Deibert).
may lead to infection, peritonitis, and death [3,4]. Hence,
intraperitoneal ruptures are generally treated with surgical
repair, whereas urethral catheter drainage is considered
sufficient for uncomplicated extraperitoneal ruptures [5,6].
Our prior examination of the National Trauma Data Bank
(NTDB), which excluded children, demonstrated that surgical
repair of bladder injury can contribute to improved survival in
the multiorgan injured adult trauma patient [7]. To our
knowledge, that publication is the only multicenter review to
examine bladder injury outcomes. The American College of
Surgeons NTDB was designed as a clinical research tool to

0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpedsurg.2012.02.012
1678
examine trauma management and outcomes, and it has become
the largest trauma repository in the United States. It includes a
large and diverse sample from all regions of the country. The
purpose of this study is to use the NTDB to assess national
practice patterns after bladder injury in the pediatric age group
and to examine associations between bladder injury and
mortality. We hypothesized that pediatric patients with
intraperitoneal bladder rupture patients will demonstrate
improved survival if the bladder is repaired surgically.
1. Materials and methods
1.1. Data resource
The NTDB of the Committee on Trauma of the American
College of Surgeons houses more than 3 million patient
entries from more than 900 US trauma centers. Using 2002-
2008 NTDB data, we identified children (b18 years old) with
bladder injury using the International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-
CM) codes 867.0 and 867.1. Bladder injury was described as
injury to the bladder and urethra without mention of open
wound (extraperitoneal, ICD-9-CM code 867.0) and injury
to bladder and urethra with open wound into cavity
(intraperitoneal, ICD-9-CM 867.1). Demographics, includ-
ing age, race, sex, and insurance status; clinical information;
and details of the trauma were available.
Race was categorized as white, African American,
Hispanic, Native American, or Asian. We collapsed
insurance status into 3 groups: uninsured (including self-
pay), Medicaid, and privately insured (including managed
care organizations, Medicare, commercial indemnity, work-
er's compensation, BlueCross, no-fault, and government and
military programs). Mechanism of injury was either blunt or
penetrating. Injury severity is described by 3 unique
variables: total number of nonbladder abdominal organs
injured, including solid (spleen, liver, kidney, pancreas) and
hollow (stomach and small and large intestine); initial patient
triage to an inpatient floor, an intensive care unit, or the
operating room; and the categorical Injury Severity Scale
(ISS), a marker of overall injury severity to the entire body,
with higher scores indicating more severe injuries [8,9].
Surgical interventions are described as including only the
bladder or involving other abdominal organs. The trauma
center level of the treating hospital is designated as pediatric
level I, II, or unknown. Cause of death for inpatient mortality
in the NTDB is attributed directly to trauma in all subjects.
1.2. Statistical analysis
Initially, univariate analyses using χ2 tests for all categorical
variables and Kaplan-Meier survival curves for all variables
were developed to assess differences in receipt of bladder
repair surgery and in-hospital mortality. The final multivariate
C.M. Deibert et al.
regression analyses included variables that were clinically or
statistically significant in univariate analysis. These multivar-
iate logistic regression models examined factors associated
with operative bladder repair and in-hospital mortality. Cox
proportional hazards modeling was not used because no
common baseline hazard function was shared between the
survival groups, a violation of a key assumption of the
statistical method. A sensitivity analysis was completed for age
categorization because prepubertal (age, b11 years), pubertal
(age, 11-13 years), and postpubertal (age, 14-17 years) children
may have different evaluation and management after trauma.
STATA software (version 11; StataCorp, LP, College Station,
TX) was used for all statistical analyses [10].
Because the NTDB provides deidentified data, this study
received exempt status from the Human Subjects Institutional
Review Board of Columbia University Medical Center.
2. Results
We identified 816 pediatric subjects who sustained a
bladder injury in the NTDB (Table 1, column 1). Sixty-four
percent were male, 7.8% were uninsured, 19.1% were
African American, and 14.8% were Hispanic. Blunt trauma
was the mechanism of injury in 81% of the subjects, 37% of
the injuries were of a severity score of 25 or greater, 55% had
a concomitant pelvic fracture, 45% had at least 1 other intra-
abdominal injury, and 40% underwent surgery on other
abdominal organs. Subjects were triaged to the operating
room in 36% of cases and to the intensive care unit in 40%.
The pediatric trauma center was level I in 22% and level II in
5% of cases. Seventeen percent of the bladder injuries were
intraperitoneal, and 83% were extraperitoneal. Mortality
with and without surgical repair was 2.4% and 7.7%,
respectively (Table 2). Compared with no repair, surgical
repair was associated with improved survival in both closed
and open injuries (from 4.3% to 2.1%, and 8.0 to 2.5%).
Overall, 5.5% of the sample died during hospitalization.
Bladder repair was performed in 40.9% of subjects,
including 34% and 66% of closed and open bladder injuries,
respectively. Multivariate logistic regression identified
several factors related to undergoing bladder repair surgery
(Table 1, column 4): male children (odds ratio [OR], 0.63;
95% confidence interval [CI], 0.41-0.95 vs females) were
less likely to undergo bladder repair; other abdominal
surgery (OR, 8.8; 95% CI, 5.6-13 vs none) and triage
directly to the operating room from the emergency
department (OR, 3.9; 95% CI, 2.1-6.9 vs inpatient floor)
were predictive of bladder repair; and subjects having an
intraperitoneal injury were more likely to undergo surgical
repair (OR, 3.3; 95% CI, 1.5-7.3 vs extraperitoneal).
Multivariable logistic regression analysis of in-hospital
mortality (Table 1, column 5) showed that ISS greater than
47 (OR, 68.3; 95% CI, 12-372 vs ISS b25) and 3 (OR, 8.7;
95% CI, 1.3-56 vs none) other abdominal injuries had greater
Repair of pediatric bladder rupture improves survival 1679

Table 1 Pediatric bladder injury in the NTDB (n = 816)

Variable Total (%) No bladder Bladder P Multivariate predictors Multivariate predictors
repair (%) repaired (%) of bladder repair of overall mortality
OR CI 95% P OR CI 95% P
Sex
Female 35.5 36.8 33.7 .37 Referent Referent
Male 64.5 63.2 66.3 0.63 0.41-0.95 .03 1.04 0.36-3.01 .93
Race
White 55.7 58.8 51.3 .17 Referent Referent
African American 19.1 17.5 21.4 0.65 0.35-1.1 .15 0.56 0.09-3.3 .53
Hispanic 14.8 12.7 17.9 0.89 0.51-1.5 .71 0.71 0.18-2.6 .61
Native American 1.4 1.3 1.6 2.5 0.60-10 .2 – – –
Other 7.5 8.1 6.6 0.7 0.33-1.7 .55 2.39 0.37-15 .36
Asian 1.4 1.5 1.2 0.37 0.07-1.8 .22 – – –
Insurance status
Insured 69.9 74.1 63.7 b.01 Referent Referent
Medicaid 22.3 19.7 26.2 1.01 0.63-1.62 .95 0.44 0.11-1.8 .26
Uninsured 7.8 6.2 10.9 0.7 0.33-1.48 .35 20.7 4.5-94 b.01
Injury mechanism
Penetrating 18.3 11.2 28.2 b.01 Referent Referent
Blunt 81.7 88.7 71.7 0.72 0.47-1.10 .13 0.31 0.07-1.3 .1
Pelvic fracture
No 44.9 40.9 50.9 b.01 Referent Referent
Yes 55.1 59.1 49.1 0.76 0.49-1.18 .23 0.74 0.22-2.4 .62
ISS
ISS b25 62.7 63.1 62.2 .2 Referent Referent
ISS 25-47 29.7 28.2 32 0.86 0.53-1.4 .56 5.2 1.2-22 .03
ISS N47 7.4 8.6 5.8 0.42 0.17-1.02 .06 68.3 12-372 b.01
Head AIS ≥3 .47
No 91.1 90.5 91.9 Referent Referent
Yes 8.9 9.5 8.1 0.81 0.41-1.6 .54 1.71 0.57-5.1 .33
Bladder injury type
Extraperitoneal 82.8 90.5 71.8 b.01 Referent Referent
Intraperitoneal 17.2 9.5 28.1 3.3 1.5-7.3 b.01 2.23 0.36-13 .39
Bladder surgery
No 59.1 100 0 b.01 Referent Referent
Yes 40.9 0 100 NA NA NA 0.18 0.05-0.59 b.01
No. of abdominal injuries
None 54.7 58.9 48.8 .03 Referent Referent
1 organ 26.5 24.4 29.3 0.82 0.51-1.32 .41 1.9 0.56-7.1 .28
2 organs 13.1 11.2 15.8 0.51 0.27-0.95 .04 1.9 0.50-7.6 .33
3 organs 4.1 4.4 3.9 0.61 0.22-1.7 .35 8.7 1.3-56 .02
≥4 organs 1.5 1.1 2.1 2.2 0.46-10.8 .31 8.4 0.93-76 .06
Other abdominal surgery
No 59.4 78.4 32 b.01 Referent Referent
Yes 40.6 21.6 68 8.8 5.6-13 b.01 2.7 0.94-7.72 .06
Triage
Floor/stable 22.3 30.6 10.5 b.01 Referent Referent
ICU 39.8 40.3 39.2 2.1 1.2-3.7 b.01 5.7 0.87-36 .07
OR 36.5 26.9 50.3 3.9 2.1-6.9 b.01 1.8 0.25-13 .55
Pediatric trauma level
I 22.1 24.9 18 .01 Referent Referent
II 4.9 3.5 6.9 2.4 0.99-5.9 .05 1.56 0.14-17 .71
Unknown 73 71.6 75.1 1.2 0.73-1.9 .47 0.37 0.11-1.1 .09
Died in first 48 h
No 96.2 94.2 99.1 b.01 Referent Referent
Yes 3.8 5.8 0.9 0.05 0.01-0.28 b.01 NA NA NA
Abbreviations: ICU, intensive care unit; OR, operating room; NA, not applicable.
1680
Table 2 In-hospital mortality
Bladder injury type Overall % dying (n/total) % dying with bladder repair (n/total)
Extraperitoneal 6.1% (41/676) 2.5% (6/240)
Intraperitoneal 2.9% (4/140) 2.1% (2/94)
Total 5.5% (45/816) 2.4% (8/334)
likelihood of in-hospital mortality. Uninsured children also
were more likely to die of their injuries (OR, 20.7; 95% CI,
4.5-94 vs insured). Operative repair of the bladder was
associated with improved survival (OR, 0.18; 95% CI, 0.05-
0.59 vs none). In sensitivity analysis, stratification of
children by age group did not alter the analysis for bladder
repair or death.
3. Discussion
In this first national evaluation of pediatric traumatic
bladder injury, we demonstrate that in-hospital mortality is
associated with a decrease of 82% after operative bladder
repair, after controlling for overall bodily injury score. This
novel finding suggests that pediatric bladder injuries,
particularly those without surgical intervention, can be
lethal. Surprisingly, we found that bladder repair improved
mortality regardless of type of bladder injury. We previously
demonstrated this relationship exclusively in adults [7].
However, prior institutional series found no relationship
between bladder injury and in-patient mortality [5,7,11-14].
These results highlight the critical importance of involving
surgeons experienced in the management of bladder trauma
as a member of the multidisciplinary team that manages
multiorgan trauma with concomitant bladder rupture [11,13].
3.1. Operative repair of bladder injury in children
As expected, we found that children with intraperitoneal
bladder rupture were more likely to undergo operative repair
compared with those with an extraperitoneal injury. Overall,
40.9% of the bladder injuries in our cohort were repaired,
including 66% of intraperitoneal injuries. Repair of an
intraperitoneal rupture is considered the standard of care;
hence, a repair rate that does not approach 100% represents
an important deviation from high-quality, guideline-recom-
mended care in the management of pediatric bladder trauma
[3]. An international panel reviewed the literature for both
adults and children and recommended the immediate repair
of intraperitoneal ruptures and any extraperitoneal ruptures
in which the patient is undergoing an exploratory laparotomy
for other injuries or internal fixation of a pelvic fracture [3].
Uncomplicated extraperitoneal bladder injuries may be
managed with catheter drainage alone. Recent success with
catheter drainage alone after iatrogenic intraperitoneal
rupture has been reported [15]. Prompt repair has been
associated with fewer complications and improved out-
C.M. Deibert et al.
% dying without bladder repair (n/total)
8.0% (35/436)
4.3% (2/46)
7.7% (37/482)
comes, including among children [7,16,17]. In multivariate
analysis, only bladder repair and not type of bladder injury
influenced mortality. This suggests that even extraperitoneal
injuries can be associated with death and can benefit from
repair. These extraperitoneal injuries may be complex or
large to a degree that simple catheter drainage is insufficient
to allow healing, a distinction not made in the NTDB.
Children who died in the first 48 hours after hospitalization
were less likely to have bladder surgery. Based on the ISS,
more severely injured children were both less likely to
undergo bladder surgery and more likely to die: clearly, only
some of the increase in mortality is related to absence of
bladder surgery. In this cohort, 45% of the children had
concomitant abdominal injury, requiring surgery in 40%. It is
possible that bladder surgery was underreported during the
repair of other significant abdominal trauma and that the
actual bladder repair rate is higher. Alternatively, misclassi-
fication bias is possible. The relevant International Classi-
fication of Diseases, Ninth Revision, diagnostic codes are
“injury to bladder or urethra with (867.1) or without (867.0)
mention of open cavity.” Potentially, an intraperitoneal
rupture could be documented as “bladder rupture,” without
specifying it as intraperitoneal or open wound. Such an
injury would be misclassified as a closed extraperitoneal
injury by the chart abstracter. Phillips et al [18] have shown
that some procedural codes are not captured in the NTDB.
3.2. Subject level disparity
We identified a sex disparity in access to urologic bladder
surgery, with male children being significantly less likely to
undergo bladder repair surgery. The lower repair rate did not
affect in-hospital mortality. Although insurance status had no
effect on receipt of bladder surgery, uninsured children were
significantly more likely to die after their injuries. Using the
NTDB, Hakmeh et al [19] demonstrated an increase in
pediatric trauma mortality among African Americans and
uninsured children. This mirrors findings in the adult NTDB
population [20-22]. There was no racial disparity in the
pediatric bladder group. Multiorgan trauma surgery may be
another example of a complex surgical milieu where
minorities and the uninsured tend to obtain care at low-
volume, low-quality hospitals with poorer outcomes [23].
3.3. Limitations
This study has several limitations. Although NTDB is a
national sample of participating trauma centers, it is not
Repair of pediatric bladder rupture improves survival
strictly population based. Therefore, the practice patterns
analyzed may not be generalizable to the entire pediatric
population. In addition, this group of children sustained very
severe injuries including a high percentage of pelvic
fractures, which may further limit the generalizability.
Because of the lack of a control group of subjects without
bladder injury, we could not demonstrate the effect of the
bladder trauma itself on survival. National Trauma Data
Bank uses ICD-9-CM codes and the Abbreviated Injury
Scale (AIS) to report bladder injury severity, rather than the
more commonly used American Association for the Surgery
of Trauma scale. The different scales are not directly
comparable. We used ICD-9-CM codes, which offer more
clarity and less overlap in describing bladder injury than the
AIS codes. Finally, the treating physician and whether he or
she is an urologist is unknown; an urologist's participation in
the care of individual children may influence clinical
management and outcome patterns.
4. Conclusions
In this first examination of pediatric bladder injury in the
NTDB, we found underuse of surgical repair of intraperito-
neal bladder rupture. Furthermore, we found that performing
this surgery is associated with a significantly reduced
likelihood of in-hospital mortality. Studies that better
characterize both the indications for bladder repair and the
role of the urologist in complex, multitrauma pediatric
patients are needed.
Committee on Trauma, American College of Surgeons.
NTDB Version 7.2. Chicago, IL, 2010. The content
reproduced from the NTDB remains the full and exclusive
copyrighted property of the American College of Surgeons.
The American College of Surgeons is not responsible for any
claims arising from works based on the original data, text,
tables, or figures.
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