Bladder Injury During Vaginal Hysterectomy After Cesarean Delivery
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: Cumulative data from 4 studies published between 1980 and 2003 show that the risk of bladder injury during vaginal hysterectomy does not appear to be increased in women who have undergone cesarean delivery.
Source: Agostini A, et al. Risk of bladder injury during vaginal hysterectomy in women with a previous cesarean section. J Reprod Med. 2005;50:940-942.
A medline search was conducted for comparisons of vaginal hysterectomy in patients with/without previous cesarean delivery. As might be anticipated, the studies were heterogeneous. For example, in one study, some cases had laparoscopic assistance. In some studies, patients with prolapse were included. The studies were typically retrospective, the statistical analysis was multivariate in only 1 study, and the total number of patients relatively small (n = 430 with previous cesarean delivery, 1227 without). Due to the size of the population, the authors were unable to address the effect of the number of cesarean deliveries.
The rates of bladder injury were not statistically different (1.86% vs 0.89%). Unfortunately, several key factors could not be analyzed. The presence/absence of previous vaginal delivery could be important, but was not addressed here. Similarly, the size of the uterus and the presence of fibroids would logically be potential predictors of bladder injury. The authors suggest that the indication for the cesarean delivery would potentially impact on the rate of bladder injury. Particularly in patients who were deemed to have an inadequate pelvis at the time of cesarean delivery, the likelihood of limited visualization at the time of hysterectomy is increased. Also, post-cesarean adhesions may well reduce the uterine mobility.
For the gynecologic surgeon, the choice of approach for hysterectomy is a very personal one. For example, the size of the uterus may well exceed an individual surgeon’s comfort level for a vaginal approach while well within that of another’s. Previous pelvic surgery, and particularly previous delivery, remains a key historical point for many surgeons, and, therefore, their patients. One doesn’t have to work very hard to find a gynecologic surgeon who considers previous cesarean delivery to be a relative contraindication to a vaginal hysterectomy due to the risk of bladder injury. Interestingly, many would argue (myself included), that it is easier to dissect a scarred bladder off the cervix vaginally rather than abdominally, if nothing else, because of the ability to visualize the anatomy more closely.
This is not a "right/wrong" decision, but a "better/best" one. Surgeons should not only rely on their experience and clinical acumen, but also the literature in order to make the best decisions for their patients. A previously scarred bladder flap does not necessarily mandate an abdominal approach, only closer attention to how the bladder is advanced. This is why I am not a proponent of teaching younger surgeons to use a spongestick to develop a bladder flap, even on patients with no previous scarring of the bladder flap. I much prefer to have them learn sharp dissection so that they can be more facile in cases where the bladder is expected to be scarred.
An article such as this doesn’t give us the definitive answer. It should, however, stimulate us to think about how we do certain things, such as decide on a surgical approach for hysterectomy, or incise the vagina in preparation for developing a bladder flap, or advance the bladder as the supportive structures of the vagina are being clamped, cut, and tied. In my own experience:
- previous cesarean delivery does not necessarily rule out a vaginal approach to hysterectomy;
- to attempt a vaginal hysterectomy, there should be a wide pubic arch, reasonable mobility of the uterus, a reasonable sized uterus, and no suspected significant adnexal pathology;
- you don’t have to "get in anteriorly" in order to proceed with the vaginal hysterectomy, but you do need to keep advancing the bladder before the next bite;
- sharp dissection of the bladder flap is a good thing to become comfortable with on uncomplicated cases in anticipation of the scarred bladder flap.
There are certainly other factors which weigh into our decision-making, but I would challenge each of us to keep advancing our surgical expertise and not operate in a certain way just because "that’s the way I was taught."