The bladder is the most commonly injured organ during gynecologic surgery, with a variable incidence that depends on the type of surgery being performed (Table 61-1).¹ Risk factors include pathology that distorts normal anatomy, conditions that impair visualization, and prior surgical or radiation therapy (Box 61-1). Identification of lower urinary tract injuries intraoperatively is crucial, as immediate repair can prevent delayed postoperative complications such as urinomas, sepsis, and fistula formation.² Much of the management of cystotomy repair and subsequent bladder drainage is based on expert opinions and consensus guidelines; as such, there is marked variation in repair techniques and postoperative management. The aim of this chapter is to provide an overview of the most frequently encountered bladder injuries, along with traditional repair options.

The bladder is a hollow, distensible organ that functions to store urine (Fig. 61-1). It lies within the female pelvis posterior to the pubic symphysis, anterior to the uterus and vagina, and between the obturator internus muscles. When empty, the bladder remains in the true pelvis; however, as it fills, it extends upward and assumes a globular shape. While entirely extraperitoneal, only the superior aspect is covered by peritoneum.

Functionally, it can be divided into two segments, the dome and base, located at the level of the ureters. The dome, which originates from the urogenital sinus, is far more distensible, facilitating the storage of urine. The base, on the other hand, is much thicker and composed of the urinary trigone; it is bordered by the ureters, which enter inferiolaterally and the internal urethral orifice medially. In contrast to the dome, the trigone is mesonephric in origin. The obliterated urachus, now the median umbilical ligament, extends as a fibrous band from the dome of the bladder to the umbilicus.

Histologically, the bladder is composed of four layers. Mucosa consisting of a transitional urothelium and lamina propria line the innermost aspect of the organ. A submucosal layer that contains connective tissue lies superior and provides the transition to the detrusor, a smooth muscle layer that functions to contract and empty the bladder during voiding. Finally, an adventitial or serosal layer forms the outermost aspect. The major blood supply to the bladder comes from the superior vesical artery, with contributing branches from the uterine and vaginal arteries (all branches of the anterior division of the internal iliac arteries). The inferior vesical artery does not exist in females.

The bladder has both sympathetic and parasympathetic innervation. Sympathetic innervation involves preganglionic nerves in the spinal cord between T10 and L2, which terminate in ganglia, where they interact with postganglionic neurons that travel as the hypogastric nerve to the adrenergic ganglia of the pelvic plexus. This system essentially functions to store urine, as it inhibits detrusor contraction via norepinephrine release on beta adrenergic receptors and stimulates urethral smooth muscle via alpha adrenergic receptors. The parasympathetic nervous system, on the other hand, facilitates micturition. This system originates in sacral nerve roots S2–S4 and travels via the pelvic splanchnic nerve to synapse with postganglionic neurons near the bladder wall, where acetylcholine stimulates cholinergic receptors to contract the detrusor and relax the urethra.

All iatrogenic cystotomies should be repaired unless the patient becomes hemodynamically unstable. However, it is advisable to wait until after the procedure, as reinjury can occur during completion of index procedure.

IDENTIFICATION OF CYSTOTOMY

Intraoperative

While a large laceration will be immediately apparent by a clear gush of fluid in the operative field, smaller injuries may be more difficult to detect. Hematuria is suggestive but not indicative of a possible cystotomy, as this can commonly occur transiently during cesarean section (C-section) after dissection of the vesicouterine peritoneum. If hematuria persists throughout the procedure, or if there are gross blood clots in the Foley catheter, further evaluation is warranted. Cystourethroscopy can help to visualize any potential injury.