- Email: [email protected]
Bladder Avulsion as a Complication of Extraperitoneal Cesarean Section
BLADDER AVULSION AS A COMPLICATION OF EXTRAPERITONEAL CESAREAN SECTION A Case Report EDUARD EICHNER. M.D., F.A.C.S., ARTHUR RoTH, M.D., F.A.C.S., HYATT REITMAN, M.D., AND KALMAN KUNIN, M.D., CLEVELAND, OHIO
(From the Division of Obstetrics and Gynecology ana the Department of Urology, Mount Sinai Hospital, Cleveland)
primigravida, was admitted to Mount Sinai Hospital (No. AD M RS.2536)R. inA., early34-year-old active labor on March 11, 1950. The last menstrual period had begun 1t
on May 27, 1949. Painful contractions had started six hours preceding her admission at 7 A.M. at which time the bag of waters was intact, the fetus in occiput right anterior presentation with the vertex iloating. Contractions occurred at three-minute intervals and lasted 30 to 45 seconds. Several small subserous fibromyomas ranging up to 3 em. in size were palpated on the anterior uterine wall. The cervix was thick, posterior, and admitted only a fingertip. Blood pressure, pulse, temperature, and fetal heart tones were normal. Analgesia was started at 1 P.M., and during the next twenty-four hours she received a total of Seconal, 600 mg., Demerol, 300 mg., and morphine sulfate, 30 mg. She was given 2,000 mi. 5 per cent glucose in water during the night when acetonuria and a slight temperature elevation were noted. Penicillin was started. Roentgen pelvimetry was done on the morning of the twelfth, and disclosed an adequate pelvis with no apparent abnormaltties. The placenta was high and anterior, the fetus engaged in left occiput posterior. When progress failed, consultation was held at 3:30 P.M. on March 12 and the report was asynclitic posterior vertex, station 0 (presenting part at the spines), cervix 7 em. dilated, membranes probably ruptured. Maternal pulse 120, fetal heart tones 180, satisfactory. The impression was: adequate pelvis with uterine inertia secondary to uterine myomas and fetal malpresentation. Rest, iluids, and morphine were recommended, and a check examination including sterile vaginal was to be done after a period of adequate rest. Extraperitoneal section was to be done if progress were not satisfactory. Mild but irregular contractions recurred at 11 P.M. on March 12. Additional iluids were given during the night. There was no further progress. Through a series of unusual mishaps the section was not started until 3 P.M. on March 13, 1950. A living male infant that weighed 3,830 grams was delivered by Norton extraperitoneal section. Difficulty was encountered with the delivery of the fetal head, impacted in the maternal pelvis. After delivery it was noted that the bladder and part of the urethra had been completely avulsed from the symphysis and the remainder of the urethra, and the vagina had been separated from the cervix. The uterocervical incision was repaired in a routine fashion, and the senior obstetrician (E. E.) notified. Figs. 1 and 2 are self-explanatory, and demonstrate the condition at that time. The location of the left ureter was identified, and verified by temporary ureteral catheterization. The right ureter was never seen. The vagina was replaced, and sutured to the cervix. The urethrourethral anastomosis was done over the catheter originally introduced for bladder identification. The bladder rent was closed with a suprapubic Foley catheter 1191
Am . }, Obst. & Gyn<< .
1192
Octoher. · 1911
in place. A Penro~e nf H. ctziu~ . and shock was t:reat.ed routinely. On the following tlay both ;·atlwters were dru ining- im]Jroperly. Binei.' the right ureter had not been idfmtilied at O}tt~nd.ion, awl sinee irrigating fluid was nut •.o(11u pletely recovered, the iuc,ision wa~ reopened a nd the bladder and e.xtrav.,.sieal >J·""'l , 1vestigated (A. R.) . Again, the right uretet eould not be loeated. Jt was noted that th e urethral catheter had pushed. through the late ral bladder wound all
REFLECTION
L . URETER
BROAD LIGAMENT
URETERAL RIDGE CATHETER OPEN BLADDER
OPEN VAGINA
Fig. 1.-The retropubic space as it appeared after the cesarean section. . The cervical incision has been repaired. The oPen bladder lay free In th e space, pulled -high to the right by the still intact peritoneum. The left ureter and ureteral ridge are seen. Tbe uretbr!l-l catheter tip is free, lying on the open posterior portion of the -torn vagina. The ante:rtor vaginal wall is not apparent, and there i,; only a vo;ry short posterior segment still attached to the cervix.
Intravenous pyelograms on March :JJ demonstrated a mild bilateral hydronephrosis with narrowing of the right ureter ancl tpH,~tionahle stt,nosis. 'l'he report eoncluded: "It cannot be stated with certainty that the ureters t~nte1· the bladder bilaterally." Oonvalescence continued slowly, and evt>ntuated in :~. small vesicocervi.covaginal fistula. Attempt at transvesical closure was unsuccessfu l, hut th" urPt<'r was idHntified at that time as entering the bladder in a slightly abnonnal location. The pat:ient. was discharged on the seventy-eighth hospital day. A ~mall fistula was sti ll pre~eut seven months later; but could not be seen on cyHtoseopie !'Xam imlt ion . Intravenous indigo carmine and dye in· jected directly into the bladder appea re,] iu the vagina at the identical spot. 'l'he con· suiting urologists believed this was a ve~icovagi nal J'ather than ureterovesie.ovaginal 1istula. Shortly thereafter all leakage stopptlll . and tJu.• patil'nt had adequate though not complete vesicle control. Contrary to at1vice, she became prHgnaut. After intradepartmental consultation, a therapeutic abortion and sterilization were done (No. 1129 J by fundal hysterectomy on May 16, 1951. At this time incontinence had redeveloped, and there was a moderately !e· vere Proteus cystitis. The patient was discharged on the eighth postoperative day, again fully continent. There has been no radica.l change in her condition during the intervening years. She still has incomplete control, but this is ample for all times except when Bt~l"ere cystitis is present. She does not dribble during the day, but occasionally is dAmp during the night.
BLADDER AVULSION COMPLICATING CESAREAN SECTION
Volume 68 Number 4
Fl!~·
2.-Schematlc sagittal view of relationships demonstrated In Fig. 1.
Fig. 3.-Schernatlc sagittal view of completed repair.
1193
] 1!14
\tn
J.
~)b~t. &
Octnlv::J,
Summary
A patient with the unusual com plieatiun of complete avulsion of the b1ad der after a Norton extraperitoneal <~esarean section is reported. Immediat~ repair did not hold, and was repeated on the day after ddiverr. 'l'ransv«·sieal repair of the resultant fistula failed, awl the fistula eventually dosed spuntaneously. Fundal hysterectomy for 1het·apeutic abortion and sterilization was done one year later, early in tlH· liext pregnanr·y. The pati«'llt tJOW has adequate but not complete control of the hladtler.
(From the Division of Obstetrics and Gynecology ana the Department of Urology, Mount Sinai Hospital, Cleveland)
primigravida, was admitted to Mount Sinai Hospital (No. AD M RS.2536)R. inA., early34-year-old active labor on March 11, 1950. The last menstrual period had begun 1t
on May 27, 1949. Painful contractions had started six hours preceding her admission at 7 A.M. at which time the bag of waters was intact, the fetus in occiput right anterior presentation with the vertex iloating. Contractions occurred at three-minute intervals and lasted 30 to 45 seconds. Several small subserous fibromyomas ranging up to 3 em. in size were palpated on the anterior uterine wall. The cervix was thick, posterior, and admitted only a fingertip. Blood pressure, pulse, temperature, and fetal heart tones were normal. Analgesia was started at 1 P.M., and during the next twenty-four hours she received a total of Seconal, 600 mg., Demerol, 300 mg., and morphine sulfate, 30 mg. She was given 2,000 mi. 5 per cent glucose in water during the night when acetonuria and a slight temperature elevation were noted. Penicillin was started. Roentgen pelvimetry was done on the morning of the twelfth, and disclosed an adequate pelvis with no apparent abnormaltties. The placenta was high and anterior, the fetus engaged in left occiput posterior. When progress failed, consultation was held at 3:30 P.M. on March 12 and the report was asynclitic posterior vertex, station 0 (presenting part at the spines), cervix 7 em. dilated, membranes probably ruptured. Maternal pulse 120, fetal heart tones 180, satisfactory. The impression was: adequate pelvis with uterine inertia secondary to uterine myomas and fetal malpresentation. Rest, iluids, and morphine were recommended, and a check examination including sterile vaginal was to be done after a period of adequate rest. Extraperitoneal section was to be done if progress were not satisfactory. Mild but irregular contractions recurred at 11 P.M. on March 12. Additional iluids were given during the night. There was no further progress. Through a series of unusual mishaps the section was not started until 3 P.M. on March 13, 1950. A living male infant that weighed 3,830 grams was delivered by Norton extraperitoneal section. Difficulty was encountered with the delivery of the fetal head, impacted in the maternal pelvis. After delivery it was noted that the bladder and part of the urethra had been completely avulsed from the symphysis and the remainder of the urethra, and the vagina had been separated from the cervix. The uterocervical incision was repaired in a routine fashion, and the senior obstetrician (E. E.) notified. Figs. 1 and 2 are self-explanatory, and demonstrate the condition at that time. The location of the left ureter was identified, and verified by temporary ureteral catheterization. The right ureter was never seen. The vagina was replaced, and sutured to the cervix. The urethrourethral anastomosis was done over the catheter originally introduced for bladder identification. The bladder rent was closed with a suprapubic Foley catheter 1191
Am . }, Obst. & Gyn<< .
1192
Octoher. · 1911
in place. A Penro~e
REFLECTION
L . URETER
BROAD LIGAMENT
URETERAL RIDGE CATHETER OPEN BLADDER
OPEN VAGINA
Fig. 1.-The retropubic space as it appeared after the cesarean section. . The cervical incision has been repaired. The oPen bladder lay free In th e space, pulled -high to the right by the still intact peritoneum. The left ureter and ureteral ridge are seen. Tbe uretbr!l-l catheter tip is free, lying on the open posterior portion of the -torn vagina. The ante:rtor vaginal wall is not apparent, and there i,; only a vo;ry short posterior segment still attached to the cervix.
Intravenous pyelograms on March :JJ demonstrated a mild bilateral hydronephrosis with narrowing of the right ureter ancl tpH,~tionahle stt,nosis. 'l'he report eoncluded: "It cannot be stated with certainty that the ureters t~nte1· the bladder bilaterally." Oonvalescence continued slowly, and evt>ntuated in :~. small vesicocervi.covaginal fistula. Attempt at transvesical closure was unsuccessfu l, hut th" urPt<'r was idHntified at that time as entering the bladder in a slightly abnonnal location. The pat:ient. was discharged on the seventy-eighth hospital day. A ~mall fistula was sti ll pre~eut seven months later; but could not be seen on cyHtoseopie !'Xam imlt ion . Intravenous indigo carmine and dye in· jected directly into the bladder appea re,] iu the vagina at the identical spot. 'l'he con· suiting urologists believed this was a ve~icovagi nal J'ather than ureterovesie.ovaginal 1istula. Shortly thereafter all leakage stopptlll . and tJu.• patil'nt had adequate though not complete vesicle control. Contrary to at1vice, she became prHgnaut. After intradepartmental consultation, a therapeutic abortion and sterilization were done (No. 1129 J by fundal hysterectomy on May 16, 1951. At this time incontinence had redeveloped, and there was a moderately !e· vere Proteus cystitis. The patient was discharged on the eighth postoperative day, again fully continent. There has been no radica.l change in her condition during the intervening years. She still has incomplete control, but this is ample for all times except when Bt~l"ere cystitis is present. She does not dribble during the day, but occasionally is dAmp during the night.
BLADDER AVULSION COMPLICATING CESAREAN SECTION
Volume 68 Number 4
Fl!~·
2.-Schematlc sagittal view of relationships demonstrated In Fig. 1.
Fig. 3.-Schernatlc sagittal view of completed repair.
1193
] 1!14
\tn
J.
~)b~t. &
Octnlv::J,
Summary
A patient with the unusual com plieatiun of complete avulsion of the b1ad der after a Norton extraperitoneal <~esarean section is reported. Immediat~ repair did not hold, and was repeated on the day after ddiverr. 'l'ransv«·sieal repair of the resultant fistula failed, awl the fistula eventually dosed spuntaneously. Fundal hysterectomy for 1het·apeutic abortion and sterilization was done one year later, early in tlH· liext pregnanr·y. The pati«'llt tJOW has adequate but not complete control of the hladtler.