From the Guidelines
Bladder injury during cesarean delivery should be promptly recognized and repaired using a two-layer closure with absorbable sutures, and postoperative management should prioritize minimizing the risk of urinary tract infection and promoting patient recovery. The management of bladder injury during cesarean delivery is crucial to prevent long-term complications and promote patient recovery. According to the most recent guidelines, if a bladder injury is suspected during cesarean section, immediate assessment and repair should be performed 1. The injury should be repaired using a two-layer closure with absorbable sutures such as 3-0 or 4-0 Vicryl in a running or interrupted fashion. After repair, the bladder integrity should be tested by filling it with sterile saline or methylene blue solution to ensure watertight closure.
Some key points to consider in the management of bladder injury during cesarean delivery include:
- The use of urinary catheters is associated with higher rates of urinary tract infections, and their use should be minimized whenever possible 1.
- Postoperative management should prioritize minimizing the risk of urinary tract infection and promoting patient recovery.
- Prophylactic antibiotics should be continued while the catheter remains in place, typically with a cephalosporin like cefazolin 1g IV every 8 hours or oral nitrofurantoin 100mg twice daily.
- Risk factors for bladder injury include previous cesarean deliveries, adhesions, emergency procedures, and abnormal placentation.
- Prevention strategies include careful surgical technique, adequate bladder decompression before surgery, and sharp rather than blunt dissection of the bladder flap in patients with previous cesarean deliveries.
In terms of postoperative care, the ERAS society recommendations suggest that urinary catheter placement during cesarean delivery is not necessary and may actually increase the risk of urinary tract infection 1. Instead, patients should be encouraged to void spontaneously after surgery, and catheterization should only be performed if necessary. The duration of bladder drainage with an indwelling Foley catheter should be minimized, typically 7-14 days depending on the extent and location of the injury, with longer duration for injuries involving the trigone or bladder base. Overall, the management of bladder injury during cesarean delivery requires careful consideration of the risks and benefits of different treatment strategies, and a personalized approach should be taken to promote optimal patient outcomes.
From the Research
Bladder Injury During Cesarean Section
- Bladder injury is a rare but severe complication of cesarean delivery, with an incidence of 0.08% to 0.47% 2, 3, 4, 5.
- Risk factors for bladder injury during cesarean section include previous cesarean delivery, adhesions, emergent cesarean delivery, and cesarean section performed at the time of the second stage of labor 3, 4, 5.
- Most bladder injuries are recognized at the time of surgery, and quick recognition and repair are associated with a significant reduction in patient mortality 3.
- The management of bladder injuries typically involves a two-layer closure of the defect with absorbable suture, and an indwelling catheter is left in place for 7-14 days 2, 6.
Diagnosis and Treatment
- Bladder injuries are usually easy to identify and repair, but a high index of suspicion is recommended to avoid late diagnosis and complications 4.
- Cystography may be performed to evaluate the integrity of the bladder repair, and abnormal findings may require additional interventions 5.
- In some cases, suprapubic cystostomy and transurethral catheter may be kept for 10-14 days to ensure proper healing of the bladder 6.
Long-term Outcomes
- Most women with bladder injuries during cesarean delivery do not suffer from long-term adverse effects, and normal kidney function is typically maintained 4, 5.
- However, combined ureteral and bladder injury may be associated with a higher risk of long-term sequelae, such as vesico-vaginal fistula 5.
- A comprehensive protocol for the management of urinary tract injuries during cesarean delivery is recommended to ensure optimal outcomes for women with this complication 4.