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Bladder Injuries Associated with Cesarean Section
0022-534 7/78/1206-0762$02. 00/0
THE
Vol. 120, December
JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1978 by The Williams & Wilkins Co.
BLADDER INJURIES ASSOCIATED WITH CESAREAN SECTION PATRICK 0. FARICY, RICHARD R. AUGSPURGER
AND
JOEL M. KAUFMAN
From the Division of Urology, Department of Surgery, University of Colorado Medical Center, Denver, Colorado
ABSTRACT
Bladder injury during cesarean section is unusual and may occur by failure to empty the bladder preoperatively, inadequate bladder flap reflection or incision into the vagina rather than the lower uterine segment. Three bladder injuries during cesarean section are reported. Although 2 women recovered normally 1 has persistent vesicoureteral reflux. With liberalization of indications for cesarean section bladder injuries may be seen more frequently. Bladder trauma resulting from cesarean section is rare. 1 However, iatrogenic vesical injuries may be seen with increasing frequency as indications for cesarean section are broadened. Herein we report 3 cases of major bladder trauma occurring during cesarean section within the last year at the University of Colorado affiliated hospitals. In 1 case bisection of the bladder resulted in delivery through the bladder, which to our knowledge has not been reported previously. CASE REPORTS
Case 1 . An 18-year-old woman (gravida I, para 0) underwent a cesarean section for cephalopelvic disproportion and acute fetal distress. The bladder was emptied preoperatively with a Foley catheter. A vertical incision was made in the anterior vaginal wall, which was mistaken for the lower uterine segment, and an unintentional vertical cystotomy was made from the dome to 1 cm. above the trigone. The injury was repaired with 2-zero chromic catgut in 2 layers. A small leaf of peritoneum was mobilized and inserted beneath the cystotomy to separate the bladder and vaginal suture lines. The bladder was decompressed with urethral and suprapubic catheters, and no drains were used. The patient was discharged from the hospital 8 days postoperatively and subsequent cystography was normal. Case 2. A 30-year-old woman (gravida III, para 0, therapeutic abortion 2) had a cesarean section for cephalopelvic disproportion. A Foley catheter was inserted preoperatively. After prolonged labor the vagina was pulled upward and was mistaken for the lower uterine segment. The surgeon remarked on the difficulty of separating the bladder from this lower uterine segment. After delivery through a transverse vaginal incision a large transverse cystotomy, extending from orifice to orifice above the trigone, was noted. The injury was repaired with 2 layers of 2-zero chromic catgut and with hemovac drainage. A cystogram before the patient was discharged from the hospital 10 days later revealed bilateral grade 3/4 vesicoureteral reflux (see figure). Antibiotic suppression was started but repeat cystography 3 and 6 months postoperatively showed persistence of left vesicoureteral reflux. Case 3. A 25-year-old woman (gravida I, para 0) required a cesarean section for cephalopelvic disproportion, pre-eclampsia and fetal distress. History included an imperforate anus and a rectovaginal fistula requiring several operations during childhood. Before the cesarean section a Foley catheter was inserted. There was difficulty in developing a bladder flap and the lower segment vertical incision also was made through the anterior and posterior bladder walls from the dome through the trigone. A healthy female newborn was delivered through the bladder. The bladder was repaired with 2 layers of 2-zero chromic catgut and the peritoneum was inserted to separate Accepted for publication March 29, 1978.
the suture lines. Cystography 14 days postoperatively revealed no extravasation or reflux. However, pelvic thrombophlebitis developed as well as a recurrence of the rectovaginal fistula and the patient was not discharged from the hospital until 23 days postoperatively. DISCUSSION
The frequency of cesarean section has increased tremendously during the last several decades and it is no longer considered a procedure of last resort. 1 Currently, at the University of Colorado Medical Center Hospital and the Denver General Hospital 10 to 12 per cent of all births are via cesarean section. Urologic injuries secondary to cesarean section are uncommon. Ureteral obstruction, 1• 2 ureterovaginal fistula, 1 ureterouterine fistula 3 and bladder injury secondary to uterine scar rupture4 • 5 have been reported. Effects of vesical trauma secondary to injuries not recognized at the time of cesarean section include vesicovaginal fistula, 1• 5 vesical calculi owing to penetrating non-absorbable suture material6 and menouria without urinary incontinence secondary to a vesicouterine fistula. 7 However, bladder injury during cesarean section rarely h~s been reported. Jones reported 4 bladder perforations in a series of 2,563 patients. 1 Kaskarelis and associates mentioned 3 injuries in 318 patients. 8 Everett and Mattingly reported a single case of injury to the bladder occurring at the time of the abdominal skin incision. 9 Some consideration of uterine incisions is necessary in discussing bladder injury. The classical vertical incision through the body of the uterus has been replaced by an incision (transverse or vertical) in the lower uterine segment. There are several advantages to this approach: this portion of the uterus is thinner, there is less bleeding, the incision is easier to close, the scar is less likely to rupture and the incision can be covered after delivery with the peritoneum and bladder flap. However, inherent in the lower segment approach is the need to separate the bladder from the anterior uterine wall. Bladder injury may occur in several ways. 1) Failure to empty the bladder preoperatively. Owing to uterine growth the bladder extends well out of the pelvis and into the abdominal cavity. A full bladder can be injured easily during entry into the abdomen. The cystotomy will be in the dome, can be repaired easily and should present no long-term problems. 2) Inadequate reflection of the bladder flap. Inadequate reflection of the bladder from the uterus may result in significant bladder injury. A previous operation may make the dissection more difficult (case 3), although the most recent report concerning repeat cesarean section does not mention bladder injury. 10 3) Incision into the vagina rather than the lower uterine segment. With an effaced, dilated cervix it is possible to mistake the vagina for the lower uterine segment. Although the bladder may be dissected readily from the lower
762
BLADDER INJURIES ASSOCIATED WITH CESAREAN SECTION
uterine segment it is not separated so easily from the vagina. Should the incision be made inadvertently in the vagina the closely adherent bladder also may be entered (cases 1 and 2). Successful management of such injuries depends on recognition, regardless of cause. Unnoticed injuries may result in fistula formation between the. bladder and lower uterine segment or vagina. Good surgical principles dictate a layered closure with adequate bladder drainage for at least 7 days. Peritoneum interposed between the suture lines of the bladder and uterus or vagina aids normal healing. Postoperative cystograms to evaluate bladder healing and potential reflux are important. There is little mention of urologic injury secondary to an obstetrical operation in the urologic literature. Since cesarean section is being used more commonly urologists should be aware of the potential for bladder injury. REFERENCES
1. Jones, 0. H.: Cesarean section in present-day obstetrics. Presi-
dential address. Amer. J. Obst. Gynec., 126: 521, 1976. 2. Crichton, D.: Ureteric injuries in gynaecological surgery. South African Med. J., 39: 686, 1965. 3. Mahgoub, S. and El Zeniny, A.: Ureterouterine fistula after cesarean section. Amer. J. Obst. Gynec., 110: 881, 1971. 4. Hassim, A. M.: Uterine rupture with extrusion of the fetus into the bladder. Int. Surg., 49: 130, 1968. 5. Lawson, J.: Vesical fistulae into the vaginal vault. Brit. J. Urol., 44: 623, 1972. 6. Klugman, S. N. P.: Vesical castanets (a complication of caesarean section). Central African J. Med., 17: 122, 1971.
763
7. Youssef, A. F.: "Menouria" following lower segment cesarean section. A syndrome. Amer. J. Obst. Gynec., 73: 759, 1957. 8. Kaskarelis, D., Sakkas, J., Aravantinos, D., Michalas, S. and Zolotas, J.: Urinary tract injuries in gynecological and obstetrical procedures. Int. Surg., 60: 40, 1975. 9. Everett, H. S. and Mattingly, R.: Urinary tract injuries resulting from pelvic surgery. Amer. J. Obst. Gynec., 71: 502, 1956. 10. Piver, M. and Johnston, R. A., Sr.: The safety of multiple cesarean sections. Obst. Gynec., 34: 690, 1969. EDITORIAL COMMENT This is a timely article because the incidence of cesarean section is definitely increasing. Furthermore, those types of cesarean sections that pose more urological risks are being used with greater frequency. For example, the extraperitoneal cesarean section has had a recent surge in popularity because of the reported improved maternal outcome observed in those patients with intrauterine infections. In addition, the improved pediatric outcome in terms of small premature infants has enabled obstetricians to use cesarean section at much earlier stages of pregnancy. Operative difficulties are encountered occasionally in these early pregnancies because the lower uterine segment often is not well developed. Consequently, a delivery through a transverse incision is more difficult than in the case of term pregnancy. A low vertical incision or a vertical extension of a transverse incision may be required to deliver these small newborns. Either approach poses an increased risk of surgical injury to the bladder. John W. C. Johnson, Jr. Department of Gynecology and Obstetrics The Johns Hopkins University Baltimore, Maryland
THE
Vol. 120, December
JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1978 by The Williams & Wilkins Co.
BLADDER INJURIES ASSOCIATED WITH CESAREAN SECTION PATRICK 0. FARICY, RICHARD R. AUGSPURGER
AND
JOEL M. KAUFMAN
From the Division of Urology, Department of Surgery, University of Colorado Medical Center, Denver, Colorado
ABSTRACT
Bladder injury during cesarean section is unusual and may occur by failure to empty the bladder preoperatively, inadequate bladder flap reflection or incision into the vagina rather than the lower uterine segment. Three bladder injuries during cesarean section are reported. Although 2 women recovered normally 1 has persistent vesicoureteral reflux. With liberalization of indications for cesarean section bladder injuries may be seen more frequently. Bladder trauma resulting from cesarean section is rare. 1 However, iatrogenic vesical injuries may be seen with increasing frequency as indications for cesarean section are broadened. Herein we report 3 cases of major bladder trauma occurring during cesarean section within the last year at the University of Colorado affiliated hospitals. In 1 case bisection of the bladder resulted in delivery through the bladder, which to our knowledge has not been reported previously. CASE REPORTS
Case 1 . An 18-year-old woman (gravida I, para 0) underwent a cesarean section for cephalopelvic disproportion and acute fetal distress. The bladder was emptied preoperatively with a Foley catheter. A vertical incision was made in the anterior vaginal wall, which was mistaken for the lower uterine segment, and an unintentional vertical cystotomy was made from the dome to 1 cm. above the trigone. The injury was repaired with 2-zero chromic catgut in 2 layers. A small leaf of peritoneum was mobilized and inserted beneath the cystotomy to separate the bladder and vaginal suture lines. The bladder was decompressed with urethral and suprapubic catheters, and no drains were used. The patient was discharged from the hospital 8 days postoperatively and subsequent cystography was normal. Case 2. A 30-year-old woman (gravida III, para 0, therapeutic abortion 2) had a cesarean section for cephalopelvic disproportion. A Foley catheter was inserted preoperatively. After prolonged labor the vagina was pulled upward and was mistaken for the lower uterine segment. The surgeon remarked on the difficulty of separating the bladder from this lower uterine segment. After delivery through a transverse vaginal incision a large transverse cystotomy, extending from orifice to orifice above the trigone, was noted. The injury was repaired with 2 layers of 2-zero chromic catgut and with hemovac drainage. A cystogram before the patient was discharged from the hospital 10 days later revealed bilateral grade 3/4 vesicoureteral reflux (see figure). Antibiotic suppression was started but repeat cystography 3 and 6 months postoperatively showed persistence of left vesicoureteral reflux. Case 3. A 25-year-old woman (gravida I, para 0) required a cesarean section for cephalopelvic disproportion, pre-eclampsia and fetal distress. History included an imperforate anus and a rectovaginal fistula requiring several operations during childhood. Before the cesarean section a Foley catheter was inserted. There was difficulty in developing a bladder flap and the lower segment vertical incision also was made through the anterior and posterior bladder walls from the dome through the trigone. A healthy female newborn was delivered through the bladder. The bladder was repaired with 2 layers of 2-zero chromic catgut and the peritoneum was inserted to separate Accepted for publication March 29, 1978.
the suture lines. Cystography 14 days postoperatively revealed no extravasation or reflux. However, pelvic thrombophlebitis developed as well as a recurrence of the rectovaginal fistula and the patient was not discharged from the hospital until 23 days postoperatively. DISCUSSION
The frequency of cesarean section has increased tremendously during the last several decades and it is no longer considered a procedure of last resort. 1 Currently, at the University of Colorado Medical Center Hospital and the Denver General Hospital 10 to 12 per cent of all births are via cesarean section. Urologic injuries secondary to cesarean section are uncommon. Ureteral obstruction, 1• 2 ureterovaginal fistula, 1 ureterouterine fistula 3 and bladder injury secondary to uterine scar rupture4 • 5 have been reported. Effects of vesical trauma secondary to injuries not recognized at the time of cesarean section include vesicovaginal fistula, 1• 5 vesical calculi owing to penetrating non-absorbable suture material6 and menouria without urinary incontinence secondary to a vesicouterine fistula. 7 However, bladder injury during cesarean section rarely h~s been reported. Jones reported 4 bladder perforations in a series of 2,563 patients. 1 Kaskarelis and associates mentioned 3 injuries in 318 patients. 8 Everett and Mattingly reported a single case of injury to the bladder occurring at the time of the abdominal skin incision. 9 Some consideration of uterine incisions is necessary in discussing bladder injury. The classical vertical incision through the body of the uterus has been replaced by an incision (transverse or vertical) in the lower uterine segment. There are several advantages to this approach: this portion of the uterus is thinner, there is less bleeding, the incision is easier to close, the scar is less likely to rupture and the incision can be covered after delivery with the peritoneum and bladder flap. However, inherent in the lower segment approach is the need to separate the bladder from the anterior uterine wall. Bladder injury may occur in several ways. 1) Failure to empty the bladder preoperatively. Owing to uterine growth the bladder extends well out of the pelvis and into the abdominal cavity. A full bladder can be injured easily during entry into the abdomen. The cystotomy will be in the dome, can be repaired easily and should present no long-term problems. 2) Inadequate reflection of the bladder flap. Inadequate reflection of the bladder from the uterus may result in significant bladder injury. A previous operation may make the dissection more difficult (case 3), although the most recent report concerning repeat cesarean section does not mention bladder injury. 10 3) Incision into the vagina rather than the lower uterine segment. With an effaced, dilated cervix it is possible to mistake the vagina for the lower uterine segment. Although the bladder may be dissected readily from the lower
762
BLADDER INJURIES ASSOCIATED WITH CESAREAN SECTION
uterine segment it is not separated so easily from the vagina. Should the incision be made inadvertently in the vagina the closely adherent bladder also may be entered (cases 1 and 2). Successful management of such injuries depends on recognition, regardless of cause. Unnoticed injuries may result in fistula formation between the. bladder and lower uterine segment or vagina. Good surgical principles dictate a layered closure with adequate bladder drainage for at least 7 days. Peritoneum interposed between the suture lines of the bladder and uterus or vagina aids normal healing. Postoperative cystograms to evaluate bladder healing and potential reflux are important. There is little mention of urologic injury secondary to an obstetrical operation in the urologic literature. Since cesarean section is being used more commonly urologists should be aware of the potential for bladder injury. REFERENCES
1. Jones, 0. H.: Cesarean section in present-day obstetrics. Presi-
dential address. Amer. J. Obst. Gynec., 126: 521, 1976. 2. Crichton, D.: Ureteric injuries in gynaecological surgery. South African Med. J., 39: 686, 1965. 3. Mahgoub, S. and El Zeniny, A.: Ureterouterine fistula after cesarean section. Amer. J. Obst. Gynec., 110: 881, 1971. 4. Hassim, A. M.: Uterine rupture with extrusion of the fetus into the bladder. Int. Surg., 49: 130, 1968. 5. Lawson, J.: Vesical fistulae into the vaginal vault. Brit. J. Urol., 44: 623, 1972. 6. Klugman, S. N. P.: Vesical castanets (a complication of caesarean section). Central African J. Med., 17: 122, 1971.
763
7. Youssef, A. F.: "Menouria" following lower segment cesarean section. A syndrome. Amer. J. Obst. Gynec., 73: 759, 1957. 8. Kaskarelis, D., Sakkas, J., Aravantinos, D., Michalas, S. and Zolotas, J.: Urinary tract injuries in gynecological and obstetrical procedures. Int. Surg., 60: 40, 1975. 9. Everett, H. S. and Mattingly, R.: Urinary tract injuries resulting from pelvic surgery. Amer. J. Obst. Gynec., 71: 502, 1956. 10. Piver, M. and Johnston, R. A., Sr.: The safety of multiple cesarean sections. Obst. Gynec., 34: 690, 1969. EDITORIAL COMMENT This is a timely article because the incidence of cesarean section is definitely increasing. Furthermore, those types of cesarean sections that pose more urological risks are being used with greater frequency. For example, the extraperitoneal cesarean section has had a recent surge in popularity because of the reported improved maternal outcome observed in those patients with intrauterine infections. In addition, the improved pediatric outcome in terms of small premature infants has enabled obstetricians to use cesarean section at much earlier stages of pregnancy. Operative difficulties are encountered occasionally in these early pregnancies because the lower uterine segment often is not well developed. Consequently, a delivery through a transverse incision is more difficult than in the case of term pregnancy. A low vertical incision or a vertical extension of a transverse incision may be required to deliver these small newborns. Either approach poses an increased risk of surgical injury to the bladder. John W. C. Johnson, Jr. Department of Gynecology and Obstetrics The Johns Hopkins University Baltimore, Maryland