Video Clips on DVD
- 17-1
Cadaveric Dissection Demonstrating Anatomy of the Bladder and Lower Ureter
- 17-2
How to Perform an Intentional Cystotomy with Visualization and Inspection of the Inside of the Bladder, Passage of Ureteral Stents, and Two-Layered Closure of Cystotomy
Iatrogenic injury to the urinary tract can occur during any vaginal or abdominal surgery. The reported incidence of bladder injury during cesarean delivery ranges from 0.14% to 0.94%. The largest series of 23 bladder injuries reported by Eisenkop and associates in 1982 demonstrated an overall incidence of 0.31% with 0.19% occurring in primary cesarean deliveries and 0.6% occurring in repeat cesarean deliveries.
Nielsen and Hokegard evaluated overall surgical complications in more than 1300 cesarean deliveries. They found most complications occurred during emergency cesarean delivery and that six factors were associated with increased complications. These included station of the presenting part before surgery, labor before surgery, low gestational age of less than 32 weeks, rupture of chorionic membranes prior to surgery, prior cesarean delivery, and skill of surgeon.
Although urethral and bladder injury during vaginal delivery is exceedingly rare, it may occur secondary to large lacerations or rupture of a urethral diverticulum. Cesarean section, which comprises an estimated 25% of deliveries in the United States, has been associated with bladder injury as well as ureteral compromise. Ureteral injury can be secondary to angulation by improperly placed sutures or direct ureteral damage such as a crush injury or a partial or complete transection. As with any surgical complication early recognition of injury and repair during the primary surgery almost always result in less morbidity for the patient with a more successful outcome secondary to increased ease of repair of the involved tissue. When suspected or apparent injury to the bladder or ureter occurs during cesarean section, the primary surgeon or surgical consultant may face several difficulties unique to the cesarean delivery. These include the fact that obstetric facilities designated for abdominal deliveries are inadequately equipped with the urologic tools such as cystoscopes and C-arm–compatible tables required for endoscopic and radiographic assessment of the urinary tract. Also the large uterus as well as bleeding from engorged pelvic blood vessels may render surgical dissection of the bladder and distal ureter difficult. Finally, a Pfannenstiel incision, which is usually made by the obstetrician, may be inadequate for appropriate dissection and exposure of the ureters. However, it remains imperative that appropriate management is prompt recognition of the injury because if left unrecognized and not repaired, these injuries may give rise to significant late consequences including renal damage and genital urinary fistula. If the obstetrician is not comfortable addressing the lower urinary tract injury appropriate urologic or urogynecologic consultation should be obtained. (See the DVD for video demonstration of anatomy of the lower ureter and bladder. 
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Important steps that should be used in the performance of a cesarean section have been reviewed in Chapter 16 . These include appropriate mobilization of the bladder off the lower uterine segment, especially in patients who have had previous cesarean sections as well as the avoidance of blind clamping of the uterine vasculature when lateral extensions occur ( Fig. 17-1 ).
Bladder injuries that occur during cesarean section are usually easily identified and repaired. If the bladder injury is a high extraperitoneal injury such as an inadvertent cystotomy occurring during entrance into the peritoneum, it should be managed with a layered closure of the cystotomy. As this is a high cystotomy in a non-dependent portion of the bladder, it will require minimal postoperative drainage. In contrast to a cystotomy that occurs in the base of the bladder, for example, during the dissection of the bladder off of the lower uterine segment or during an emergency cesarean section when the entire bladder is inadvertently transected as the baby is being delivered ( Fig. 17-2 ). These are intraperitoneal cystotomies in a dependent portion of the bladder requiring drainage for 10 to 14 days and would probably best be served by obtaining a cystogram prior to the removal of the catheter to ensure there is no extravasation of urine. The general concepts of bladder repair are the same as those for vesicovaginal fistula repair. There should be appropriate mobilization of the bladder off any adherent structure to allow a tension-free closure of the injury. Delayed fine absorbable sutures should be used to close the bladder in two layers ( Fig. 17-2C ). Closure can be in an interrupted or running fashion with the first layer approximating the mucosa and the second layer imbricating the muscularis. (See DVD for video demonstration of two-layered closure of cystotomy. 
) As mentioned, the length of postoperative drainage depends on the site and extent of the injury.
