How to repair bladder injury at the time of cesarean delivery

An alternative test. Urologists often place ureteral catheters under direct visualization, using the injury in the dome to obtain access to the ureteral orifices.⁴ If a ureteral catheter cannot be advanced to the renal pelvis, a kink or occlusion of the ureter is a possibility. The ureteral catheters not only aid in diagnosing injury but help maintain ureteral patency and prevent ureteral obstruction caused by postoperative swelling.

Ureteral injuries that occur during cesarean delivery often go undetected intraoperatively⁵; most occur when a transverse uterine incision extends into the broad ligament or vagina. If you suspect ureteral injury and have determined that the bladder is intact, you can take either of two approaches to assessing ureteral patency: 1) perform cystoscopy and insert ureteral catheters in a retrograde manner or 2) incise the dome and insert ureteral catheters under direct visualization.⁶

After a complex bladder injury has been repaired, intraperitoneal drains may be placed to monitor for extravasation of urine into the peritoneal cavity and to actively drain fluid that might accumulate there.

Postop care The bladder should be drained by Foley catheter for approximately 7 days after the repair. Most experts recommend that a voiding cystogram be performed before the Foley catheter is discontinued; some, however, note that complete healing after repair of a bladder injury at cesarean delivery is to be expected, making a cystogram unnecessary.

Late detection. Postoperative events that might alert you to undetected ureteral injury include pain at the costovertebral angle, oliguria, hematuria, watery vaginal discharge, persistent fever, and abdominal distention.

“I need help!” Sorry—it may not be on the way.

According to the American College of Surgeons, the median age of urologists is older than 50 years⁷; in many communities, increasing numbers of senior urologists are reluctant to take night and weekend call for emergencies that occur on their hospital’s OB service. Consequently, you and your colleagues might find yourselves compelled to care for a greater number of the urinary tract injuries that occur during cesarean delivery without the immediately available aid of an urologist. But, as I noted, ObGyns are well-trained to take primary responsibility for the repair of most of these injuries.