Bladder Injury During LSCS (Lower Segment Caesarean Section)

Incidence

• Bladder injury occurs in approximately 0.28-0.3% of all caesarean deliveries
• Risk rises dramatically with repeat LSCS - up to 2-3 times higher than primary CS
• In caesarean hysterectomy, the bladder injury rate rises to ~3% - Campbell-Walsh-Wein Urology
• The incidence of vesicouterine fistula (a late complication) is rising in parallel with the global increase in LSCS rates

Why the Bladder is Vulnerable

1. Vesicouterine peritoneal fold - the bladder is dissected off the lower segment before uterotomy
2. Bladder flap creation - pushing the bladder down inferiorly is a critical step and where most injuries occur
3. Previous caesarean scars create dense adhesions between the bladder and lower uterine segment, obliterating the normal tissue plane
4. Placenta praevia/accreta - the posterior bladder wall is the most common site of placental percreta invasion

Risk Factors

Mechanism / Sites of Injury

1. During bladder flap (most common) - sharp or blunt dissection of adherent bladder off the lower segment in a repeat CS
2. During uterotomy - if the bladder has not been sufficiently mobilised, the scalpel or scissors can inadvertently enter the bladder dome or posterior wall
3. During closure of the uterus - a portion of the bladder wall can be incorporated into uterine sutures (this leads to vesicouterine fistula if unrecognised)
4. During haemostasis - lateral angle sutures placed blindly may catch the bladder trigone or posterior wall

• Dome (most common - easiest to repair)
• Posterior wall / trigone (most serious - risk to ureteric orifices)
• Lateral walls

Intraoperative Recognition

• Visible hole/defect in the bladder wall
• Urine spilling into the operative field
• Foley catheter balloon or tubing visible in the wound
• Haematuria in the catheter bag

• Fill the bladder with 200-300 mL of methylene blue or sterile milk via the catheter - extravasation confirms the injury
• If injury is suspected but not visualised, a formal cystotomy may be made to inspect the interior
• Always check the ureteric orifices - any injury near the trigone requires ureteric assessment (spray of urine from both orifices, or indigo carmine IV)

Intraoperative Repair

1. Define the injury fully - assess proximity to ureteric orifices
2. Debride devitalised edges if needed
3. Close in 2 layers with absorbable suture (e.g., 2-0 or 3-0 Vicryl):
   • Inner layer: mucosa + submucosa (interrupted or running)
   • Outer layer: muscularis/serosa (inverting/Lembert suture)
4. Avoid tension
5. Interpose omentum if available (especially for placenta accreta cases)
6. Fill bladder to test water-tightness after repair
7. Leave Foley catheter for 7-14 days post-repair

• If injury is within 1-2 cm of a ureteric orifice, pass a ureteric stent
• Ureteral injury occurs in up to 7% of placenta accreta spectrum cases

Postoperative Management

• Maintain continuous bladder drainage (catheter) for a minimum of 5-7 days for simple dome injuries; up to 14 days for complex or trigonal repairs
• Monitor urine output, urine colour, and catheter patency
• Cystogram before catheter removal is recommended for complex repairs
• Antibiotics per institutional protocol

If Bladder Injury is MISSED (Late Presentation)

Youssef Syndrome

1. Menouria - cyclic passage of urine per vagina at the time of expected menstruation
2. Cyclic haematuria with apparent amenorrhoea
3. Urinary continence (because the cervix acts as a sphincter)

• Campbell-Walsh-Wein Urology, block 72

Diagnosis of Vesicouterine Fistula

• Cystoscopy - midline posterior bladder wall lesion
• Cystogram - contrast fills the uterine cavity
• Hysterosalpingogram - bladder opacification
• CT/MRI - useful for planning surgical repair
• Urine cytology may show endometrial cells
• IVU or CT urogram to exclude ureteric involvement

Management of Vesicouterine Fistula

• Prolonged Foley catheter drainage
• Fulguration of fistula tract + bladder drainage
• Hormonal induction of amenorrhoea - suppressing menstruation induces uterine involution, which may close the fistula; 8 of 9 patients treated successfully in one series

• Fertility desired: Uterine-sparing repair (similar to O'Conor cystotomy technique - open bladder, excise fistula tract, close bladder in 2 layers, repair uterine defect, interpose omentum)
• Fertility not desired: Hysterectomy + bladder repair
• Vaginal approach feasible in selected patients; most require abdominal approach
• Successful pregnancy is possible after vesicouterine fistula repair

Prevention

1. Drain the bladder fully before incision (Foley catheter)
2. Sharp, careful dissection of the vesicouterine fold - especially in repeat LSCS
3. Adequate mobilisation of the bladder before uterotomy
4. Preoperative planning for placenta accreta spectrum - multidisciplinary team including urology
5. In known accreta: preoperative ureteric stents may reduce ureteric injury risk
6. Avoid blind suturing near bladder base during haemostasis
7. In repeat LSCS with dense adhesions: keep close to the uterine surface and avoid entering the bladder

Recent Evidence

Summary