Urinary bladder injury during cesarean delivery: Maternal outcome from a contemporary large case series.

BACKGROUND: Urinary bladder injury is a rare complication during cesarean delivery. Little is known on maternal outcome following this injury.
OBJECTIVE: To evaluate short and long-term maternal outcome following bladder injury during cesarean delivery. STUDY
DESIGN: A retrospective case series of all pregnancies complicated by full-thickness bladder injury during cesarean delivery in a single university affiliated tertiary medical center (August 2007-June 2016). Data on demographics, labor and surgery parameters, postpartum sequelae, and cystography were collected and reviewed by study personnel. Short-term maternal outcome included catheterization period, cystography results (if performed), any febrile illness and/or need for second operation prior to maternal discharge. Long term maternal outcome was obtained by searching our urology departmental and ambulatory database for follow up for all women. Univariate analysis was used to compare maternal outcome following first or repeat cesarean delivery.
RESULTS: Of 17,326 cesarean deliveries performed during study period, 81 (0.47%) were complicated by bladder injury. Of them, 8 cases (9.9%) occurred during primary cesarean delivery (overall risk in primary cesarean 0.07%). Of the other 73 cases that followed repeated cesarean, adhesions were documented in 55 (75.3%) of them. Six cases (8.2%) had placenta accreta. Bladder injury occurred at peritoneal entry in 55 (67.9%) cases, and involved the bladder dome in 49 (60.5%) of them. Injury was diagnosed during cesarean delivery in all but 3 women, in whom abdominal pain and bloating prompted evaluation on first to third postoperative day. All 3 underwent re-laparotomy with bladder closure without further adverse sequelae. Cystography was performed in 35 patients on median postoperative day 8 (6-11 days). Eleven patients had abnormal findings as follows: 5 urinary leakage, 4 bladder wall irregularity and two urinary reflux. Two of the 11 patients (18%) required additional interventions: One patient required bilateral nephrostomy and re-laparotomy for bladder closure followed by additional surgery to repair consequent vesico-vaginal fistula. The second patient required left nephrostomy and ureteral re-implantation. Both women had combined ureteral and bladder injury. For the rest of the cohort, no febrile illness or other short- or long-term adverse events were reported. There were no clinically significant differences in adverse maternal outcomes between women with repeat cesarean delivery compared to primary cesarean delivery.
CONCLUSION: Bladder injury is a rare complication of cesarean delivery. In our case series, unless there is combined ureteral and bladder injury, prognosis was favorable without any long-term sequelae.