- 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
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