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INTRODUCTION

KEY QUESTIONS

  • What are the most common sites of unintentional cystotomy?

  • How is a unintentional cystotomy confirmed?

  • What are the steps in a repair?

  • What postoperative follow-up is required to confirm that a cystotomy has healed?

CASE 61-1

A 30-y.o. G4P2103 at 38 weeks gestation presents to L&D triage with persistent contractions. She is found to be 4 cm dilated, and the infant is in the frank breech position. Her prenatal care during this pregnancy has been limited, but she describes a history of three previous C-sections. The decision is made to proceed with a repeat C-section, which is complicated by marked abdomino-pelvic adhesions covering the anterior uterine wall. In the process of dissecting, a gush of clear yellow fluid leaks into the operative field, and the Foley bulb can be seen.

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.

TABLE 61-1Incidence of Iatrogenic Cystotomy

Box 61-1 Risk Factors for Cystotomy

  • Gravid uterus

  • Fibroid uterus

  • Pelvic organ prolapse

  • Hemorrhage

  • Obesity

  • Malignancy

  • Previous radiation therapy

  • Adhesions

  • Previous pelvic surgery

  • Endometriosis

ANATOMY

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.

FIGURE 61-1.

Anatomy of the bladder. A. Anteroposterior view of bladder anatomy. Inset: The bladder wall contains mucosal, submucosal, muscular, and adventitial layers. B. Photomicrograph of the bladder wall. The ...

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