Bladder Injury During Cesarean Section 2329 9126.1000125
Bladder Injury During Cesarean Section 2329 9126.1000125
Bladder Injury During Cesarean Section 2329 9126.1000125
http://dx.doi.org/10.4172/2329-9126.1000125
General Practice
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Review
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Associate Professor, OBGYN, College of Medicine & JNM Hospital, WBUHS, Kalyani, Nadia, West Bengal, India
Associate Professor, OBGYN, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur, India
Abstract
Bladder injury during cesarean section is associated with significant morbidity. It can lead to prolonged operative
time, urinary tract infection and formation of vesico-uterine or vesico-vaginal fistula. Post cesarean pregnancy,
presence of abdominal and or bladder adhesions, emergency cesarean section, placenta previa and/or accrete/
increta/percreta, all are significant risk factors for bladder injury during cesarean section. Immediate repair of the
bladder injury always yield better result. But the availability of an urologist is not always certain. The obstetrician
should better be well conversant with the bladder repair, which is relatively simple technique and can manage the
situation effectively.
Incidence
1. For post cesarean pregnancy chance of injuries increases
3-fold. (0.6% vs 0.19%; repeat cesarean vs primary cesarean)
[7]. In another study repeat cesarean associated with bladder
injury in 0.81% cases in compare to primary cesarean 0.27% [2].
2. Risk increases to 1.5% after 4 or more previous uterine incision [8].
3. For patient in labor 24% vs 16% in elective cesarean (RCOG) [1].
4. Dilatation of cervix 9-10 cm dilatation 33% vs 0-1 cm
dilatation 17% (RCOG) [1].
5. During cesarean hysterectomy - (1-4) % [6].
*Corresponding author: Manidip Pal, Associate Professor, OBGYN, College of
Medicine & JNM Hospital, WBUHS, Kalyani, Nadia, West Bengal, India, E-mail:
[email protected]
Received Jun 03, 2013; Accepted September 19, 2013; Published September
24, 2013
Citation: Pal M, Bandyopadhyay S (2013) Bladder Injury during Cesarean Section.
J Gen Pract 1: 125. doi: 10.4172/2329-9126.1000125
Copyright: 2013 Pal M, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Citation: Pal M, Bandyopadhyay S (2013) Bladder Injury during Cesarean Section. J Gen Pract 1: 125. doi: 10.4172/2329-9126.1000125
Page 2 of 4
Diagnosis
1. Urine dribbles out in the operative field.
2. Hematuria; 95% of bladder injury have gross hematuria [9].
Thats why; it is always advisable to ask the ancillary staff in
the OT to check the urine color whenever there is doubt about
bladder injury, even if there is no spill of urine in the operative
field.
3. If anytime there is any doubt about the bladder injury it can be
confirmed by instillation of methylene blue, indigo carmine or
sterile milk, 300-400 ml into the bladder.
7. F
or rupture uterus with bladder injury, the rent margins are
trimmed and repaired [12].
8. Th
e first bite can incorporate all layers including bladder
mucosa, although many surgeons attempt to omit the bladder
mucosa and include only the submucosa and muscularis layers
[8].
9. Th
e second imbricating layer may be either a parallel Lembert
or a perpendicular Connell stitch [8].
10. Authors had applied both the technique either inclusion of
whole layer in first layer of stitch or include whole layer only in
both angles and omit the mucosa in rest of the first layer. Both
the repairs healed well, without any subsequent complication.
First layer was continuous simple stitch and second layer was
continuous interlocking stitch.
11. Injuries involving ureteric orifices and trigonal area may
require ureteric stenting, ureteroneocystostomy etc.
J Gen Pract
ISSN: 2329-9126 JGPR, an open access journal
Lembert suture All bite partial thickness bite First bite is taken
a little away from the margin and needle is directed towards the margin
needle came out nearer to the margin but through the intact superior
surface, not through the cut area now suture crossed to other side
Citation: Pal M, Bandyopadhyay S (2013) Bladder Injury during Cesarean Section. J Gen Pract 1: 125. doi: 10.4172/2329-9126.1000125
Page 3 of 4
bite is taken nearer to the margin through the intact superior surface,
not through the cut area and came out little away from the margin
return to the opposite site same procedure repeated (Figure 2).
Connell stitch All full thickness bite first one simple knot one
side now take bite from outside to inside next bite on the same
side 3 mm from previous bite, inside to outside cross to the other
side now take bite outside to inside again pierce same side 3 mm
from the just previous bite, inside to outside continue like this. Start
suturing from each angle separately and then unite the two ends at the
middle, outside (Figure 3).
Before starting repair it is advisable to become ensured that ureteric
orifices and other parts of trigone are not involved. This we may come
across in tear of posterior wall adherent to post cesarean scar.
If there is any doubt about the integrity of the ureters, cystoscopy
should be performed postoperatively, preferably having given
intravenous indigo carmine 10-15 minutes before to highlight the efflux
of dye-stained urine from the ureters. If no cystoscope is available, a
diagnostic hysteroscope can be used [6].
In placenta previa percreta with invasion of bladder wall
depending on the area of bladder involvement it can be opened and
an ellipse of the posterior bladder wall containing the percreta can
be excised and bladder sutured. Other alternative is to retain that
portion of the uterine wall that is adherent to the bladder and perform
hysterectomy, leaving that area with over-sewing on the uterine side
to achieve hemostasis of the remnant of uterine wall. Cases of percreta
with bladder involvement are among the most suitable one in which to
consider conservative management [13].
Medico-legal aspect
From a medico-legal point of view, it is wise to include a description
of the identification of the bladder and ureters in the operation record [6].
1. I f the bladder injury sustained during dissection of adhesion it
may be defensible.
2. I f the bladder is in an abnormal position for example, high
up over the uterus then injury is much more likely to occur.
In such cases, the damage caused to the bladder would not be
negligent [1].
3. I f there is no abnormal anatomy but the bladder is still injured
- it may invite penalty.
4. I f the intra-operative injury is not recognized during operation
it may invite penalty.
Hence, to avoid these medico-legal problems it is wise to discuss
about these bladder injury problems during the counseling while
preparing for cesarean section of those predisposing patients and keep
a written evidence of it.
References
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Citation: Pal M, Bandyopadhyay S (2013) Bladder Injury during Cesarean Section. J Gen Pract 1: 125. doi: 10.4172/2329-9126.1000125
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Special features:
J Gen Pract
ISSN: 2329-9126 JGPR, an open access journal