What is the management of a bladder injury during a repeat cesarean section?

Management of Bladder Injury During Repeat Cesarean Section

Bladder injuries during cesarean section require immediate surgical repair with a two-layer closure using absorbable suture material, followed by urinary drainage with an indwelling catheter for 7-10 days. 1

Incidence and Risk Factors

• Bladder injury occurs in approximately 0.44-0.47% of cesarean deliveries 2, 3
• Higher risk in repeat cesarean sections (0.81%) compared to primary cesarean deliveries (0.27%) 3
• Major risk factors:
  • Previous cesarean delivery
  • Adhesions (present in 75.3% of cases) 2
  • Emergency cesarean delivery
  • Cesarean during second stage of labor 4

Diagnosis

• Most bladder injuries (>95%) are recognized intraoperatively 2
• Common sites of injury:
  • Peritoneal entry (67.9% of cases)
  • Bladder dome (60.5% of cases) 2
• Delayed presentation may occur with:
  • Abdominal pain and distension
  • Oliguria or hematuria
  • Elevated blood urea and creatinine
  • Urinary ascites 5

Management Algorithm

1. Intraoperative Recognition

• Immediate repair is essential for optimal outcomes 2, 3
• Consult urology if available, but proceed with repair if consultation would delay treatment 6

2. Surgical Repair

• For intraperitoneal bladder rupture:
  • Two or three-layer closure with absorbable suture material 1, 6
  • Standard repair includes closure of the mucosa and muscle layers 1
  • Ensure watertight closure 1

3. Post-Repair Management

• Urinary drainage:
  • Place indwelling urethral catheter for 7-10 days 6, 2
  • Catheter drainage is mandatory in adult patients (GoR 1B) 1
  • No need for additional suprapubic catheter in adults 1

4. Follow-up Imaging

• Consider cystography before catheter removal:
  • CT cystography has 85-100% accuracy for detecting persistent leakage 1
  • Typically performed 7-10 days post-repair 2
  • Requires bladder distention with at least 300 mL of diluted contrast 1

5. Special Considerations

• For complex injuries (bladder neck injuries or combined ureteral/bladder injuries):
  • More extensive urologic intervention may be required 2
  • These cases have higher risk of complications including vesicovaginal fistula 2

Non-Operative Management

Non-operative management may be considered in select cases:

• For isolated intraperitoneal injuries without signs of infection or ileus 1
• Consists of urinary catheter placement for at least 7 days 1, 5
• In rare cases of delayed diagnosis, combined approach with:
  • Indwelling urethral catheter
  • Percutaneous peritoneal drainage 5

Complications and Outcomes

• When properly repaired, bladder injuries rarely lead to long-term complications 3
• Potential complications include:
  • Urinary leakage (seen in 14% of post-repair cystograms) 2
  • Bladder wall irregularity
  • Vesicovaginal fistula (rare, primarily with complex injuries) 2

Prevention

• Consider adhesive barriers during cesarean section 4
• Prefer Pfannenstiel skin incision over vertical midline incision 4
• Use double-layer closure of the hysterotomy 4
• Exercise caution during adhesiolysis and development of the bladder flap in repeat cesarean deliveries 3

Prompt recognition and proper repair of bladder injuries during cesarean section are crucial for preventing long-term urologic complications and ensuring optimal maternal outcomes.