Traumatic extraperitoneal bladder repair is associated with fewer leaks and shorter catheter duration

BACKGROUND: Societal guidelines for the management of extraperitoneal bladder injuries (EBIs) are based on limited evidence. Current recommendations support nonoperative management of simple EBIs despite a high persistent urinary leak rate. Conversely, operative management is often associated with a lower leak rate. This study evaluated clinical outcomes associated with operative versus nonoperative management of EBIs. We hypothesized that cystorrhaphy would be associated with fewer persistent urinary leaks, reduced catheter duration, fewer infectious complications, and decreased interval imaging use and timing. METHODS: An 8-year retrospective review (2017–2024) of EBIs was conducted within a university-based Level I/II trauma system. Those who died during hospitalization, underwent suprapubic catheterization, or sustained ureteral, urethral, or intraperitoneal bladder injuries were excluded. Demographic, injury, and management variables were abstracted. Patients were stratified by initial management strategy (operative vs. nonoperative). Outcomes included persistent urinary leak, catheter duration, infectious complications, and interval imaging use and timing. RESULTS: Seventy patients met the inclusion criteria, of whom 39 (55.7%) underwent operative repair. Demographics and injury characteristics were similar across cohorts, although operative patients had larger (2.3 vs. 1.3 cm, p <0.01) and higher-grade injuries (American Association for the Surgery of Trauma grade ≥3: 71.8% vs. 25.8%, p <0.01). Operative repair was associated with fewer urinary leaks on interval imaging (2.6% vs. 25.8%, p =0.01) and shorter urinary catheter duration (17.6 ± 13.2 vs. 31.1 ± 24.9 d, p =0.01). No significant differences were observed between cohorts with respect to catheter-associated urinary tract infections (38.5% vs. 45.2%, p =0.57), pelvic hardware infections (15.4% vs. 12.9%, p =0.73), frequency (84.6% vs. 96.8%, p =0.12) or timing (15.9 vs. 19.7 d, p =0.39) of interval imaging. CONCLUSIONS: Operative repair of EBIs is associated with reduced urinary leak rates and catheter duration despite greater bladder injury severity. Other outcomes were similar between strategies. Concomitant cystorrhaphy during non-urologic abdominal or pelvic operations may expedite recovery in selected patients. ( J Trauma Acute Care Surg . 2026;00:000–000. Copyright © 2026 The Author(s). Published byWolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.) LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.