Urinary Tract Injury During Cesarean Section SCOTT M. EISENKOP, MD, ROBIN RICHMAN, MD, LAWRENCE D. PLATT, MD, AND RICHARD H. PAUL, MD Lower urinary tract injury at the time of cesarean section is an uncommon complication. During a 5-year period, the incidence of bladder and ureter injuries at the Los Angeles County/University of Southern California Medical Center was .31 and .09%, respectively. When bladder injury occurs, it usually is due to surgical difficulty encountered while developing the bladder flap over the lower uterine segment. ‘The difficulty is caused usually by scar tissue from previous surgery. Ureteral injury is a rare complication of cesarean section. Itis attributable most often to ureteral transection or ligation associated with uterine incision extensions in the lower uterine segment or the vagina, and to attempts to achieve hemostasis. The data presented in this report indi- cate that cystotomy, when adequately repaired, is not associ- ated with any complications. Furthermore, diagnostic cystot- omy with intravenous injection of indigo carmine isa rapid, safe method of evaluating ureteral patency. (Obstet Gynecol 60:591, 1982) Reports of bladder and ureter injuries sustained durin gynecologic surgery are widespread in the literature.'* Urinary tract injury during cesarean section is poten- tially a serious complication, but rarely reported.”* Authorities agree that the most important prognostic indicator of ultimate patient morbidity is the time of recognition of the injury.** Bladder and ureteral inju- ries discovered intraoperatively can be repaired, and return of normal function may be anticipated. If, however, the injury becomes apparent upon recogni- tion of a vessicovaginal, vessicouterine, or ureterovag- inal fistula, the patient usually will require a second operation and may experience considerable inconve- rience in the interim. In this report, the Los Angeles County/University of Southern California (LAC/USC) Medical Center exper ence with accidental cystotomy, ureteral injury, and diagnostic cystotomy at the time of cesarean section is, ram the Department of Obstetrics and Gynecology, University of Southern California School of Medicine: and Women’ Hospital, Los ‘Angeles CountylSC Medical Center, Los Angeles, California. ‘Submitted for publication October 6, 1981 ‘VOL. 60, NO. 5, NOVEMBER 1982 reviewed. The literature pertaining to this topic is surveyed, and suggestions on the intraoperative diag- nosis and management of ureteral injuries are offered. Materials and Methods From July 1976 to October 1980, the surgical logs and hospital statistics compiled weekly at LAC/USC Medi- cal Center were used to identify patients who had bladder and ureteral injuries at the time of cesarean section, as well as those who underwent cystotomy to evaluate ureteral patency. Data was obtained by chart review and, when necessary, interview of the physi- cians involved. When ureteral injury was suspected, physicians chose to assess ureteral patency by one of 3 methods: 1) Diagnostic cystotomy with intravenous injection of 5 to 10 ml of indigo carmine dye and direct observation of the ureteral orifices for efflux of blue urine; 2) diagnostic cystotomy with atraumatic passage of ure- teral catheters through the ureteral orifices; or 3) a postoperative intravenous pyelogram. When diagnos- tic cystotomy was performed, approximately 200 ml of 5% methylene blue solution was usually instilled into the bladder through a Foley catheter, which was then clamped. Bladder distention elevates the area to be incised and thus avoids injury to the trigone. A 3- to 5- ‘cm vertical incision was then made through the retro- pubic area or dome of the bladder. In a similar ap- proach, one may digitally elevate the Foley balloon against the bladder to stabilize the tissue, and then incise the bladder wall with a scalpel down to the balloon. Defects in the bladder were repaired with 2-0 or 3.0 chromic suture in 2 layers. Multiple combinations of interrupted, running locked, and unlocked sutures were used. Often the bladder closure was tested by instilling the bladder with methylene blue, and addi- tional sutures were placed as needed. Commonly, the bladder was drained by both suprapubic and transure- thral catheters until significant hematuria resolved, at (0029-7844/62/110595-06802.50 591Table 1. Clincial Data of Cystotomy Patients ‘Accidental Diagnostic cystotomy gstotomy. No, of patients 2 8 ‘Average parity 152 278 “Average weight (kg) 2 % ‘Average gestational age (wk) 7 32 ‘Average fetal weight (g) 3073 3536 ‘Average hospitalization (ays) 2. 68. which time the urethral catheter was discontinued and suprapubic drainage continued from 3 to 15 days. All patients had urine cultures performed during hospital- tion. Postoperative febrile morbidity was defined as 2 temperature elevations above 38C on 2 occasions 6 hours apart, 24 hours after the operation. Prophylactic antibiotics were not given before cesarean section, although many surgeons chose to start antibiotics intraoperatively or after completing the operation. Data were analyzed for statistical significance by the y* method. Patient follow-up usually included a clinic visit with examination 2 weeks post partum and additional eval- uation for complications at 6 weeks post partum, at which time the patients were also counseled for family planning. Additional clinic visits were arranged if indicated. Results: Cystotomy During the review period there were 5376 primary and 2151 repeat cesarean sections performed at LAC/USC Medical Center. Fifty-two cystotomies occurred: 23 patients experienced accidental bladder injury (13 dur- ing repeat cesarean section), and 29 underwent diagos- tic cystotomy. Clinical data describing these patients presented in Table 1. ‘The incidence of bladder injury during primary and repeat cesarean section was therefore 0.19 and 0.6%, respectively, whereas the overall incidence of bladder injury was 0.31%. Indications for cesarean section in all patients who had cystotomies are summarized in Table 2. The factors predisposing to bladder injury are noted in Table 3, In 8 of 13 patients who had bladder injury during repeat cesarean section, difficulty removing adhesions between the bladder and the lower uterine segment were noted to be the cause of injury. The injuries usually were encountered with sharp or blunt dissection to create the “bladder flap.” Intraoperative- ly, most injuries were grossly apparent to the opera~ tors. In some cases, the injury was confirmed by 592 Eisenkop et al LIT! During Cesarean Section Table 2. Indications for Cesarean Section in Cystotomy Patients Patients with Patients with Indication for accidental diagnostic cesarean section cystotomy eystotomy Previous cesarean section 10 6 Dysfunctional labor 6 “ Dysfunctional labor and ‘previous cesarean section 3 ° Fetal distress 1 3 Malpresentation 1 6 Placenta previa, 1 o Ruptured uterus 1 o transurethral instillation of methylene blue. When injuries were near the base of the bladder ureteral patency was evaluated as summarized in Table 4. One patient proved to have a ureteral injury, and is de- scribed later in this report. Fourteen of the 29 patients who underwent diagnos- tic cystotomy had cesarean section performed for dys- functional labor (Table 2). Lower uterine segment extension of the incision into the broad ligament or vagina was the most common indication to evaluate ureteral integrity (Table 5). Frequently, the operator described a bloody field with suboptimal exposure and placed some sutures for hemostasis without fully ap- preciating the location of the ureters. Therefore, 29 elective cystotomies were performed to allow visual ization of the ureteral orifices. As presented in Table 4, indigo carmine was used to evaluate ureteral patency, except in 2 cases in which the physician chose to pass ureteral catheters primarily. Twenty-three patients had symmetric efflux of dye from the ureteral orifices. Four patients did not have efflux through 1 orifice. Patency ‘was established by ureteral catheter passage in 1 case and ureteral occlusion was confirmed by catheter ob- struction in 3 cases. After repairing the accidental and diagnostic cystoto- Table 3. Factors Associated with Bladder Injury No. of patients Displacement of bladder base during repeat cesarean section 8 Displacement of bladder bate during primary cesarean section 2 Injury during uterine incision 3 ‘Adherence of bladder to abdominal wall from previous cesarean section 2 Extrperitoneal cesarean section 2 Extensions through bladder andior ureter 2 Distended bladder 1 Ruptured uterus 2 Unspecitied 1 Obstetrics & GynecologyTable 4. Evaluation of Ureteral Integrity Table 6, Febrile Morbidity in Cystotomy Patients ‘Accidenal— Diagrostc Tabor and rupare of Cabor and rupture of gyiotomy _gstotomy membranes > 8 ir _membranes = 8 he Travenoss indigo ermine with Patients Fever Novever_ Fever No fever bilateral ureteral efflux after Cystotomy with cysotomy 7 3 sttsiny wth ae antibiots! 8 ont 2 9 ‘ster 2 2 Cysotamy without Intravenous indigo carmine with oeasetes : B 2 a undaterl ef ena agenesis Tota ns 4 2 unilaterally 1 ° Intravenous indigo carmine with ‘unilateral efflux: ureter patency established with catheter 0 1 Intravenous indigo carmine with unilateral efflux: ureteral ligation 1 3 mies, the bladder was instilled transurethrally with methylene blue to evaluate the adequateness of closure in 28 patients. Slight leakage was discovered from the suture line in 4 instances and was controlled by the placetientt of additional reinforcement sutures. Transient hematuria commionly was present in the immediate postoperative period and usually resolved within 48 hours. In one patient, hematuria necessitat- ed bladder drainage with a large urethral catheter for 8 days. In this case, clots of blood passed per urethra ‘were too large to pass through a small-bore suprapubic catheter. Nevertheless, the patient's hematocrit re- mained stable throughout the drainage and the post- ‘operative hematuria resolved. Postoperative bladder decompression was used for an average of 8.8 days, with a range of 4 to 15 days. The residual urinary volumes of most patierits were measured after drain- age was discoritinued, and none showed evidence of urinary retention. The febrile morbidity due to endomyometritis in patients who had cystotomies is summarized in Table 6. Twenty-eight of 52 patients were given broad- spectrum antibiotics inttaoperatively or immediately after operation. Of those with diagnostic or accidental cystotomies who had documented labor with rupture of membranes in excess of 8 hours, 12 of 25 (48%) experienced febrile morbidity. Of the patients who underwent cystotomy and did not have prolonged labor with ruptured membranes, 4 of 29 (15%) experi- ‘Table 5. Indications for Diagnostic Cystotomy No. of patients Urerine incision extensions 2% Placenta acereta with hematuria 1 Stent placement 1 Unepecitied 1 ~ Statistical significance for ROM and labor > @ hr 98 ROM and labor = 8 hr: P= .05; x2 = 49. All others NS. Two patents received antibiotics during labor for thorloamnloni- fs enced postpartum febrile motbidity. The incidence of infection in this latter group of patients was not affected by administration of antibiotics. Of the 52 patients in this report, only one had a documented urinary tract infection postoperatively. It was possible to follow 44 of the 52 patients for at least one month after cystotomy. There was no evi- dence of bladder dysfunction or fistula in any of these patients. Furthermore, of 13 patients from the period of review with a vesicovaginal or ureterovaginal fistula whose charts were reviewed, all injuries were related to radiation therapy or hysterectomy. Results: Ureteral Injuries Seven patients sustained ureteral injury among the 7527 who underwent cesatean section, for an ineidence of .09%. Two of the injuries were diagnosed postoper- atively with intravenous pyelograms, whereas the oth- ers were recognized intraoperatively. The circum: stances surrounding the injuries are summarized in ‘Table 7. Both injuries diagnosed postoperatively were tunilateral ureteral ligations, apparently sustained as a result of attempts to achieve hemostasis. In both cases the patients experienced flank pain and ileus. Because of the difficulties experienced during surgery, intrave- nous pyelograms were performed 24 to 48 hours Table 7. Types of Ureteral Injuries No. of No. of| patients with patients with intraoperative postoperative sliagnosis ‘Uterine indsion extension into trigone with ureteral ligation 1 ° Ureteral transection during reeo- peritoneal exploration 1 ° Ureteral ligation while controling bleeding in uterine incision extension 3 2 VOL. 60, NO. 5, NOVEMBER 1982 Bisenkop et al UTI During Cesarean Section $93postoperatively, revealing unilateral ureteral stricture with proximal dilation. The diagnosis was confirmed by retrograde studies in both patients, who underwent immediate reoperation with successful ureteroneocyst- ostomy. Of the 5 patients with ureteral injuries recognized at the time of surgery, 3 had a ligature placed around the ureter while attaining hemostasis of uterine incision extensions into the broad ligament. They were diag- nosed by cystotomy and intravenous injection of indi- go carmine, and were confirmed by feilure to pass a catheter through the occluded ureter. The injuries were managed by isolating the ureter and removing the ligature. A catheter was then placed through the ureteral orifice, exteriorized transurethrally, and re- moved after 2 weeks. All3 patients did well postopera- tively. One patient had a ligation of the distal ureter as a result of attempts to repair a uterine incision extension into the base of the bladder. The injury was confirmed by diagnostic cystotomy and managed with a uretero- neocystostomy. The final injury recognized intraopera- tively, a ureteral transection 8 cm from the bladder trigone, occurred as a result of sharp dissection while entering the retroperitoneal space to evacuate a broad ligament hematoma. A uretero-ureteral anastomosis over an indwelling stent was performed. The patient did well postoperatively, Discussion From the data presented in this report and others, it appears that previous cesarean section with dense bladder adhesions to the lower uterine segment repre- sents the most common predisposing factor to intraop- erative bladder injury." It is therefore important to ‘use meticulous sharp dissection to mobilize the blad- der during repeat cesarean section. If the bladder dissection is difficult, evaluation of the integrity of the lower urinary tract is always advisable. At the very least, the bladder should be distended with a dilute solution of methylene blue dye. Ureteral injuries rarely are reported to occur at the time of cesarean section, The largest series (7 ureteral injuries), reported by Feeney in 1959,” included the combined experience of 70 British obstetricians. Only one of these injuries was recognized intraoperatively, and the incidence of ureteral injury relative to the total number of cesarean sections performed was not re- ported. In the present authors’ experience, the inci- dence of ureteral injury was 0.09%. To their know!- edge this is the first reported incidence of ureteral injury during cesarean section. Of the 7 ureteral injuries presented in this report, 6 594 Eisenkop et al UTT During Cesarean Section were associated with extension of the uterine incision into the broad ligament or the vagina. This complica- tion typically occurred in patients with large infants who had prolonged labor, or in cases of breech or transverse lie where low transverse incisions were used instead of low vertical incisions, and difficulty occurred during the delivery. Exposure was often suboptimal, and when hemostasis was obtained ure- teral injury occurred. In only 2 of the 6 patients was there failure to recognize the ureteral injury at the time of surgery. ‘Thus, when obtaining hemostasis in a patient with extension of the uterine incision near the base of the bladder or into the broad ligament, one must always suspect the possibility of ureteral injury and undertake proper steps to document patency. Several methods are available to evaluate the integri- ty of the bladder and ureters. The bladder may be instilled with methylene blue, sterile milk, or indigo carmine through a urethral catheter to detect a bladder defect not grossly apparent. Ureteral injuries may be diagnosed by 1) intraoperative or postoperative py- elography, 2) transperitoneal ureterostomy and ureter- al intubation with catheters, 3) cystotomy with ureteral intubation through the ureteral orifices, or 4) cystot- omy with intravenous injection of indigo carmine and observation of symmetrical efflux at the ureteral ori- fices. An intraoperative intravenous pyelogram is in- formative if ureteral dilation proximal to a site of stricture, or extravasation of contrast material, is not- ed. In some hospitals, however, this may prolong anesthesia time significantly, and hydroureter of preg- nancy may confound interpretation." Mattingly” documents ureteral patency by transperi- toneal intubation of the ureters with ureteral catheters. He suggests entering the retroperitoneal space and placing a small incision in the ureter. A catheter is then inserted and advanced toward the bladder to detect obstruction. The ureteral incision is closed with inter- rupted 4-0 chromic suture and the catheter is allowed to remain in place as a stent if ureteral injury is detected. A retroperitoneal drain should always be placed at the ureterotomy site. Alternatively, one may perform a cystotomy and pass ureteral catheters through the ureteral orifices to demonstrate patency. Reports of ureteral perforation from attempted trans- vesicle passage of ureteral catheters and ureteral spasm with transient anuria after catheter removal are infrequent but potentially significant disadvantages of this technique.'™"! Therefore, bilateral ureteral cathe- terization should be performed only in those rare instances of suspected bilateral ureteral injury. An additional disadvantage of this technique is the theo- retic possibility of passing a catheter through a partial- ly transected ureter and thus being falsely assured. Obstetrics & Gynecology‘The approach most commonly used at the LAC/USC Medical Center involves performing a cystotomy and administering an intravenous bolus (5 ml) of indigo carmine, In an adequately hydrated patient, indigo ‘carmine is excreted rapidly in the urine. In addition to allowing the detection of ureteral obstruction, this technique may alert one to a partial ureteral transection if blue liquid is noted to extravisate retroperitoneally In the authors’ experience with this technique, 4 inju- ries have been detected that might have been over- looked at the time of surgery. Caution is advised, as with partial ureteral obstruction one may theoretically see some efflux from the orifice. Thus if efflux is not symmetric, further investigation by retrograde cathe- terization is indicated. Also, some urinary tract anoma- lies with duplication of the collecting systems may not readily lend themselves to evaluation by this tech- nique, It is important to be certain that only a single ureteral orifice is present on each side of the vesical trigone, and one should also palpate the kidneys. Interestingly, one of the ureteral injuries not recog- nized intraoperatively occurred in a patient with bilat- eral duplication of the ureters, renal pelves, and kid- neys. One can only speculate on whether this patient ‘would have benefited from cystotomy and injection of indigo carmine. It is probably advisable to obtain an intraoperative intravenous pyelogram in cases with suspected lower urinary tract injury in which the patient is known to have ureteral anomalies, or when the presence of such anomalies is highly probable, as in patients with uterine anomalies. ‘The data in this report indicate that cystotomy does not increase the morbidity associated with cesarean section. The febrile morbidity in patients who had the bladders entered, either accidentally or intentionally, ‘was not greater than the febrile morbidity associated with other similarly indicated cesarean births in the authors’ institution and in other reports." The most significant causes of febrile morbidity in this study are prolonged labor with ruptured membranes, multiple vaginal examinations, and other well-established risk factors for infection."*-"" Furthermore, the data pre- sented in Table 6 do not justify the use of prophylactic antibiotics merely because a cystotomy was per- formed. A variety of methods of bladder closure have been described.' The authors chose to repair a bladder rent or incision with a wide variety of 2-layer closures using chromic suture. It is advisable to incorporate the blad- der mucosa in the deepest layer as opposed to using a submucosal stitch, to avoid postoperative bleeding from the mucosal edges, and to assure a more anatom- ic closure. Recently, some have advocated the use of synthetic absorbable suture, although no advantages VOL. 60, NO. 5, NOVEMBER 1982 to this material have been established.'* Permanent suture, especially silk, is contraindicated, because it may serve as a nidus for stone formation." The period of postoperative urinary drainage was highly variable in this group of cases. The average time of drainage for bladder and ureter injuries was 9.3 and 14 days, respectively. No complications occurred even, though the time alloted for drainage was as brief as 3 days in a few patients. Maximum bladder scar strength is approached after 14 days, and 50% of the original tensile strength is regained after 10 days."* Therefore, 10 days of postoperative bladder decompression seems reasonable, and this can be achieved with minimal ‘comfort using a suprapubic catheter. Because of the transient nature of the population at the LACIUSC Medical Center, long-term follow-up was often not possible, Nevertheless it has been re- ported that most urinary fistulas resulting from unrec- ‘ognized bladder and ureteral injuries usually manifest themselves within 2 weeks of the operation.” Further- more, all the patients who presented with a urinary fistula during the period of review had their complica- tion related to radiation therapy or hysterectomy. The authors therefore conclude from the study that a defect from bladder entry during cesarean section, whether entry is accidental or intentional, can be repaired without complication if the defect is recognized intra- operatively. Management of ureteral injury at the time of cesare- an section is more complicated and must be individual- ized. Crush injuries and ligations may be managed conservatively if the tissue is not devitalized and ureteral continuity is clearly established.” One may therefore catheterize the ureter through the ureteral orifice, exteriorize the catheter through the urethra or abdominal wall, and remove it 10 or 14 days later. If the ureter is transected or devitalized within 5 cm of the bladder, primary reimplantation is the treatment of choice." Injuries further removed from the bladder may be managed by either reimplantation with a psoas muscle hitch or end-to-end anastomosis.”! Manage- ment of a postoperatively discovered injury is more controversial. The type of operation does not change, although there is controversy on whether to operate immediately, as was done at the LAC/USC Medical Center, or to perform a nephrostomy with a percutane- ous Silasic catheter to allow edema and inflammation to resolve before repair.!7729 References 1. Van NagellJR, Reddick W: Vaginal hysterectomy, the ureter and excretory urography. Obstet Gynecol 35.784, 1972 2. Higgins CH: Uretera injuries during surgery: A review of 87 cases. JAMA 118681, 1967 Eisenkop et al UTI During Cesarean Section 59510. n. 2 13. 4. 1B 16. v, 596 Eisenkop et al Foricy FO, Auspurger RR, Kaufman JM: Bladder injuries associt- fed with cesarean section. Urol 120:762, 1978 EI Makgoub S, El Zeniny A: Ureterouterine fistula after cesarean section Am J Obstet Gynecol 110881, 1971 Everett HS, Mattingly RF: Usinary tact injury resulting from pelvie surgery, Am | Obstet Gynecol 7:502, 1956 Keettl WC: Vessicovaginal and ureterovaginal istulee, Gyneco- logie and Obstetric Urology. Edited by Hj Buchsbaum and JO Schmidt, Philadelphia, Saunders, 1978, pp 267-274 7 Feeney JK: injury to the ureter in gynecologic and obstetcie ‘operations. Ir] Med Sci 398:126, 1959 ‘Schulman A, Herlinger H: Urinary tact dlletation in pregnancy. Be] Radiol 43:63, 1975 Mattingly RE: TeLindes’ Operative Gynecology. Fifth edition. Philadelphia, Lippincott, 1977, pp 291-206 Goldstein AG, Kyril CB: Perforation of the ureter during retro- ‘rade pyelography. J Urol 9658, 1965, Harrow BR, Sloane JA: Anuria and hydronephrosis following tureterl catheterization. JAMA 180:415, 1962 Gassner CB, Ledger W): The relationship of hospital-acquired ‘maternal infection to invasive intrapartum monitoring tech niques, Am J Obstet Gynecol 12633, 1976 [D’Angelo , Sokal Rj Time-related peripartum determinants of postpartum marbdity. Obstet Gynecol 35:31, 1980 Gibbs RS, Lista HIM, Read JA: The effect of internal monitoring ‘6n maternal infection following cesarean section. Obstet Gynecol 485653, 1976 Mattingly RF, Borkow! Hl: Acute operative injury to the lower ‘urinary tract, Cin Obstet Gynecol 5123, 1978 Kronberg 0, Osterguard A, Stoven Kt alt Polygycolic acid versus chromic eatgut in bladder surgery. Br J Urol 50:324, 1978 Morrow FK, Kogan SJ, Freed $2, etal: In vivo comparison of polyglycolic acid, chromic catgut and silk i tissue of the genito lrinary trac, An experimental study of tissue retrieval and caleulogeness. } Urol 12:85, 1974 18, Van Winkle N,Salthouse TN: Biological Response to Sutures and Principles of Suture Selection. Sommerville, New Jersey, Ethicon, 1976 19. Mattingly R, Borkow HI Lower urinary tract injury in pregnan- cy, Surgical Disease in Pregnancy. Edited by Hi Barber and Graber, Philadelphia, Saunders, 1974, pp 440-64 20, Raney AM: Ureterl trauma: Effects of ureteral ligation with and without detigation—Experimental studies and case reports. J Urol 119:526, 1978 21, Harrow BR: A neglected maneuver for wreterovesical implanta- tion folowing injury at gynecologic operations. J Urol 100-280, 1968 22, Beland G: East treatment of ureteral injuries found ater gyneco log surgery. J Urol 11825, 1977 23, Hoch WH, Karsh Ed, Persky L: Early, aggressive management of Intraoperative ureteral injusies. } Urol 143530, 1975 ‘Address reprint requests to: Richard H. Paul, MD Women's Hospital 1240 North Mission Road Los Angeles, CA 90033 Revised April 16, 1982. ‘Accepted for publication May 10, 1982. Copyright © 1982 by The American College of Obstetricians and. Gynecologists. AMBULATORY SURGERY AND HYSTEROSCOPY February 7-9, 1983 ‘A course on hysteroscopy and on the performance of minor gynecologic surgery in an ambulatory setting will be held at Frenchman's Reef, St. Thomas, Virgin Islands, on February 7-9, 1983 in sequence with the course Management of Obstetric Complications on February 10-12. (Participants may register for either or both courses.) The course has been approved for 16 cognates, Formal Learning, by ‘The American College of Obstetricians and Gynecologists and 16 hours Category I credit by the American Medical Association. The fee is $250 for Fellows and Junior Fellows, $125 for Life Fellows and Junior Fellow residents, and $300 for others. For further information contact The American College of: Obstetricians and Gynecologists, Suite 300, 600 Maryland Avenue, S.W., Washington, DC 20024. UTI During Cesarean Section Obstetrics & Gynecology