Bladder injury

  • Most commonly occurs at the time of abdominal entry or with dissection of the bladder flap away from the lower uterine segment
  • Majority are bladder dome lacerations (95%)
  • Previous cesarean contributes by:
    • Creating adhesions between bladder and lower uterine segment
    • Tethering the dome of the bladder higher than expected on the anterior uterus
  • Suspect injury to the trigone if the bladder laceration is very low and posterior
[Ref: Williams Obstetrics. Labels added. Note proximity of the bladder dome to the peritoneal entry point and to the site of bladder flap dissection.]

Prevention of bladder injuries

  • Anticipate difficult dissection if risk factors are present
  • Arrange good assistance, excellent visualization
  • Consider elective referral to a high risk center if abnormal placentation is suspected or if multiple risk factors are present
  • Enter the peritoneum higher (more cephalad) than usual
  • Transilluminate the bladder at the time of lower peritoneal dissection
  • Use sharp dissection with direct visualization to separate the bladder from the lower uterine segment
  • In obstructed labour with a fully dilated cervix: avoid making the uterine incision too low (vaginal); this risks injuring the bladder trigone as it abuts the upper vagina.

Intraoperative repair of bladder laceration

  • Straightforward if recognized at the time of surgery
  • Check for bladder integrity after uterine closure
  • Instill methylene blue via the Foley if required to identify the defect
  • Grasp edges of cystotomy with Halsted clamps
  • Close first layer with 2.0 or 3.0 Chromic or Polysorb, running suture.
  • Second layer with umbricating interrupted or running suture to close the mucosa and reinforce the repair
    • Do not use non-absorbable suture as this promotes stone formation
  • Leave Foley in place (to keep bladder collapsed).
    • The bladder wall heals quickly as long as there is no tension on the suture line

Demonstration of bladder repair

Note: double layer closure recommended; video only shows single.
Updated on November 3, 2021

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