Risk Of Bladder Injury Research Articles

Increased bladder injury rate during emergency and repeat cesarean section

Bladder injury is one of the complications of cesarean section (CS). It is reported that the overall incidence of bladder injury is 0.22-0.44% of CS. It is, however, unclear what factors influence this rate. The aim of this study was to determine if there is a difference in bladder injury rate between scheduled and emergency CS, as well as in primary and repeat CS at a large metropolitan hospital that serves a population at high risk for obstetric complications. In addition, the use of urology consultation following bladder injury and whether demographic factors and labor characteristics affect the rate of bladder injury were investigated. A total of 8,488 records were reviewed (4,292 primary CS and 4,196 repeat CS) from January 1, 2013 to December 31, 2020. The incidence of bladder injury was calculated and the rate of intraoperative urology/urogynecology consultation was recorded. Then the association between bladder injury and intraoperative urology/urogynecology consultation and between bladder injury and maternal age, body mass index (BMI), and gestational age were compared. There was a significant increase in risk of bladder injury in repeat CS versus primary CS (p=0.01). There was also a significant increase in risk of bladder injury in emergency CS versus scheduled CS (p=0.04). Intraoperative urogynecology/urology consultations were significantly higher in the bladder injury versus no bladder injury groups (p<0.0001). Both emergency CS and repeat CS are predictors of bladder injury with odd ratios of 5.7 and 7.4, respectively. These results add to the existing evidence that bladder injury is a rare complication in CS that may occur more often in women undergoing repeat or emergency CS than primary or scheduled CS. Given that the risk increases with repeat or emergency CS, patients should be made aware of such risks and surgeons should make careful intraoperative considerations with close postoperative follow-ups.

Epidemiologic study of bladder and urethral injury in Korea: A nationwide population-based study.

PurposeWe aimed to analyze the characteristics and management of bladder and urethral injuries in Korea by use of the National Health Insurance Service (NHIS) database.Materials and MethodsData from the NHIS database representative of all cases of Korean bladder injury (n=4,631) and urethral injury (n=17,858) reported between 2012 and 2016 were analyzed. We used the International Classification of Diseases, 10th revision, clinical modification codes to identify the diagnoses.ResultsA total of 491 males (1.97/100,000) and 590 females (2.39/100,000) experienced bladder injury in 2012, and 449 males (1.76/100,000) and 624 females (2.47/100,000) in 2016. The risk of bladder injury was higher in female than in male (hazard ratio [HR], 1.267; p<0.001). The annual incidence of bladder injury did not increase (HR, 0.992; p=0.409). A total of 2,886 (62.3%) patients were managed with conservative treatment, and 1,745 (37.7%) patients underwent surgical treatment. A total of 4,114 males (16.5/100,000) and 285 females (1.2/100,000) had urethral injury in 2012, while 4,465 males (17.5/100,000) and 303 females (1.2/100,000) had urethral injury in 2016. The incidence of urethral injury is increasing annually (HR, 1.010; p=0.036).ConclusionsThe incidence of urethral injury increased continuously over the years studied, whereas that of bladder injury remained unchanged in Korea. The incidence of bladder injury was higher in females, and more than 90% of total urethral injuries were reported in males. This is the first study to evaluate the epidemiology of bladder and urethral injury using a nationwide population database.

Mini-invasive transvaginal repair of isthmocele: a video case report

To describe our technique for transvaginal treatment of isthmocele. Surgical video article. Local Institutional Review Board approval for the video reproduction was obtained. A scientific institute. A 26-year-old patient complaining of abnormal uterine bleeding and pelvic pain was referred to our gynecological clinic for secondary infertility. At transvaginal ultrasound examination, a cesarean scar defect of 22 × 11mm was identified, with a residual myometrial thickness over the defect of 2mm. Isthmocele excision and myometrial repair was performed transvaginal, under regional anesthesia. Before surgery, a hysteroscopy was performed to identify the dehiscence of the cesarean scar on the anterior wall of the uterus and to confirm the presence of the isthmocele and its distance from the external os. Then an incision was made at the anterior cervicovaginal junction and the bladder was dissected away until the anterior peritoneal reflection was identified. Hysteroscopic guidance by transillumination was used to identify the exact position and the limits of the isthmocele. The fibrotic tissue was then removed, and the myometrial defect was closed with interrupted sutures by using 2-0 Vicryl, engulfing the myometrial fibers that would tend to slide laterally. The vaginal mucosa was then sutured with interrupted Vicryl 2-0 sutures. At the end of the procedure, a hysteroscopy was performed to visualize the correction of the defect and to prove the continuity of the cervical canal with the uterine cavity. Repair of isthmocele and relief of symptoms. The postoperative course was uneventful, and the patient was discharged the day after surgery. At 1-month follow-up pelvic ultrasound showed complete anatomic repair of the uterine defect. The patient was asymptomatic with no more postmenstrual bleeding. She is satisfied with the treatment and is still trying for pregnancy. Symptomatic isthmocele can be treated surgically via a hysteroscopic, laparoscopic, or vaginal approach, depending on the clinical findings and the skill set and comfort level of the surgeon. Unfortunately, there is no consensus about the ideal surgical approach. The hysteroscopic approach has been demonstrated to be effective for the treatment of abnormal uterine bleeding; however, it does not strengthen the uterine wall and it has a risk of bladder injury. The laparoscopic approach provides good anatomic results, but it requires general anesthesia and may be associated with bladder injury. The transvaginal approach appears to be a feasible, effective, and safe modality to repair the uterine defect and to restore the original thickness of the myometrium. It is a minimally invasive, scarless, and low-cost procedure. It ensures quick recovery and a relatively pain-free postoperative course with early return to normal function.

Unintentional transvesical caesarean section: incidence, risk factors, surgical technique and post-operative management

Objective(s)To assess incidence, risk factors, management, and short and long-term outcomes of unintentional transvesical caesarean section (UTV-CS) defined as any extraction of the fetus through a double full thickness bladder wall cystotomy. Study designData about all UTV-CS between January 2013 and December 2017 were retrieved searching the diagnosis of bladder injury and bladder repair during caesarean section (CS) in our comprehensive computerized labor and delivery database and register. CS with bladder wall injury not classified as UTV-CS were excluded. Data analysis included maternal history, demographics and obstetric parameters, details regarding CSs, bladder injury location and extension, and short- and long-term maternal outcomes. ResultsAmong 28,822 deliveries, 7,616 (26.42%) were CSs. Three cases of UTV-CS were identified with comprehensive incidence of 0.039%. We provided details of the reported cases and described bladder repair procedure. Conclusion(s)This is the first study that assessed the incidence of UTV-CS. UTV-CS risk factors are consistent with factors related to milder bladder injuries. The risk of bladder injury during CS should be always considered, despite the low incidence of this complication. Prompt diagnosis and surgical repair seem to allow avoiding severe complications and recovery of a normal urological function even in UTV-CS.

Cystoscopy at the time of benign hysterectomy: a decision analysis

Gynecologists debate the optimal use for intraoperative cystoscopy at the time of benign hysterectomy. Although adding cystoscopy leads to additional up-front cost, it may also enable intraoperative detection of a urinary tract injury that may otherwise go unnoticed. Prompt injury detection and intraoperative repair decreases morbidity and is less costly than postoperative diagnosis and treatment. Because urinary tract injury is rare and not easily studied in a prospective fashion, decision analysis provides a method for evaluating the cost associated with varying strategies for use of cystoscopy. The objective of the study was to quantify costs of routine cystoscopy, selective cystoscopy, or no cystoscopy with benign hysterectomy. We created a decision analysis model using TreeAge Pro. Separate models evaluated cystoscopy following abdominal, laparoscopic/robotic, and vaginal hysterectomy from the perspective of a third-party payer. We modeled bladder and ureteral injuries detected intraoperatively and postoperatively. Ureteral injury detection included false-positive and false-negative results. Potential costs included diagnostics (imaging, repeat cystoscopy) and treatment (office/emergency room visits, readmission, ureteral stenting, cystotomy closure, ureteral reimplantation). Our model included costs of peritonitis, urinoma, and vesicovaginal/ureterovaginal fistula. Complication rates were determined from published literature. Costs were gathered from Medicare reimbursement as well as published literature when procedure codes could not accurately capture additional length of stay or work-up related to complications. From prior studies, bladder injury incidence was 1.75%, 0.93%, and 2.91% for abdominal, laparoscopic/robotic, and vaginal hysterectomy, respectively. Ureteral injury incidence was 1.61%, 0.46%, and 0.46%, respectively. Hysterectomy costs without cystoscopy varied from $884.89 to $1121.91. Selective cystoscopy added $13.20-26.13 compared with no cystoscopy. Routine cystoscopy added $51.39-57.86 compared with selective cystoscopy. With the increasing risk of injury, selective cystoscopy becomes cost saving. When bladder injury exceeds 4.48-11.44% (based on surgical route) or ureteral injury exceeds 3.96-8.95%, selective cystoscopy costs less than no cystoscopy. Therefore, if surgeons estimate the risk of injury has exceeded these thresholds, cystoscopy may be cost saving. However, for routine cystoscopy to be cost saving, the risk of bladder injury would need to exceed 20.59-47.24% and ureteral injury 27.22-37.72%. Model robustness was checked with multiple 1-way sensitivity analyses, and no relevant thresholds for model variables other than injury rates were identified. While routine cystoscopy increased the cost $64.59-83.99, selective cystoscopy had lower increases ($13.20-26.13). These costs are reduced/eliminated with increasing risk of injury. Even a modest increase in suspicion for injury should prompt selective cystoscopy with benign hysterectomy.

Rate of Urologic Injury with Robotic Hysterectomy

Study ObjectiveTo evaluate rates of urologic injury in patients who underwent robotic hysterectomy compared with laparoscopic, vaginal, and open hysterectomy. DesignA retrospective analysis (Canadian Task Force classification II-2). SettingHenry Ford Health System, 2013 to 2016. PatientsWomen who underwent robotic, vaginal, laparoscopic, and open abdominal hysterectomy. InterventionsRobotic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, vaginal hysterectomy, and abdominal hysterectomy. Measurements and Main ResultsTo identify patients with urologic injury, a departmental database for quality improvement was searched for reported urologic injuries. In addition, patients who had urology consultation within 90 days of hysterectomy were screened for injury. A total of 3114 hysterectomies were identified by retrospective chart review. One thousand eighty-eight robotic, 782 laparoscopic, 304 vaginal, and 940 abdominal hysterectomies were analyzed for urologic complications. A total of 27 injuries were confirmed (7 during laparoscopic hysterectomy, 10 during robotic hysterectomy, 1 during vaginal hysterectomy, and 9 during abdominal hysterectomy). The overall rate of urologic injury was 0.87% with a 0.55% risk of bladder injury and a 0.32% risk of injury to the ureter. When the route of hysterectomy was taken into account, the risk of urologic injury was 0.92% for robotic hysterectomy, 0.90% for laparoscopic hysterectomy, 0.33% for vaginal hysterectomy, and 0.96% for open hysterectomy. The mean body mass index (BMI) for all patients was 32.7 kg/m2; injured patients had a mean BMI of 34.6 kg/m2, and noninjured patients had a mean BMI of 32.0 kg/m2 (p = .10). ConclusionRates of urologic injury with robotic hysterectomy are similar to those of laparoscopic hysterectomy in our population. BMI was not significantly different in patients who had urologic injuries. Surgeon volume was not associated with risk for urologic injury.

Incidence of Bladder Injury During Retropubic Midurethral Sling Placement After Prior Burch Colpopexy.

To elucidate if prior Burch changes the risk of bladder injury or rates of voiding dysfunction and continence in the immediate postoperative period when undergoing retropubic midurethral sling (MUS) placement. In this retrospective case control, charts were selected by Current Procedural Terminology codes for MUS placement. Women undergoing retropubic MUS placement with history of Burch urethropexy were considered. For every case, 2 age-matched and parity-matched controls without prior Burch were selected. In total, 538 charts were reviewed from 2010 to 2014. Twenty cases were found. There was a difference (P = 0.023) in trocar penetration of the bladder. Twenty-five percent (5/20) of women with prior Burch had a 9-fold (odds ratio [OR], 9.0; 95% confidence interval [CI], 1.0-82) higher chance of bladder penetration compared with women without prior retropubic surgery as calculated with Mantel-Haenszel paired test. Women with prior Burch had more success passing their voiding trials (OR, 7.5; 95% CI, 1.1-49.2). At 6 weeks, there was no difference in voiding dysfunction. Cure of stress incontinence at 6 weeks occurred more in controls than cases (P = 0.044) with match pairs manifesting an OR of 0.20 and 95% CI of 0.04-1.1. This study shows a significant increase risk of trocar penetration of the bladder during retropubic MUS placement in women with a history of Burch urethropexy. Despite this, MUS placement was successful in all women. Women with prior surgery were much more likely to pass their voiding trials. There was no difference in voiding dysfunction at 6 weeks between the 2 groups. This indicates that though bladder penetration with a trocar is more common in the setting of previous retropubic surgery, it does not impact a woman's short-term intraoperative or postoperative course.

Trans-obturator tape technique and bladder injury. Cysto-urethroscopic management of intravesically-exposed sling

An intravesical exposed mesh may result from an unrecognized bladder perforation or from bladder erosion after a mid-urethral sling procedure performed to treat a stress urinary incontinence. Introduction of trans-obturator tape and tension-free vaginal tape-obturator techniques have minimized, but not eliminated, the risk of bladder injury. The suggested management of the above complication is removal of the polypropylene mesh from the bladder. Herein, we describe a case of partial intravesically-exposed sling, first diagnosed by trans-labial ultrasound, confirmed by cystourethroscopy and successful treated with endoscopic transurethral resection.

Adhesions Following Cesarean Delivery: A Review of Their Occurrence, Consequences and Preventative Management Using Adhesion Barriers

The objective of this article is to provide a comprehensive review of the occurrence and consequences of postoperative adhesions following cesarean delivery (CD), and an overview of the published clinical data on prevention in this setting using adhesion barriers. Adhesions occur frequently after CD and the incidence increases with each subsequent CD. Repeat CDs are complicated by adhesions, which increase operating time, time to delivery and risk of bladder injury. Clinical data on the efficacy of adhesion prevention strategies specific to the setting of CD are limited. Two small, nonrandomized studies found that the use of absorbable anti-adhesion barriers was associated with a significant reduction in adhesion formation and a shorter time to delivery at repeat CD, compared with no barrier use. Implications for practice and research are discussed. There is a significant need for well-controlled, randomized clinical studies investigating adhesion prevention in the labor and delivery setting.

Intraoperative Fluoroscopic Monitoring during TVM Surgery: Safer Procedure Even for Beginners

Tension-free vaginal mesh (TVM) surgery is a common and minimally invasive procedure for female pelvic organ prolapse. In 2004, this procedure was developed by a French group, and standardized surgical kits are now commercially available in many countries. Although it is less invasive, one of the shortcomings of this procedure is that it involves a single surgeon groping around with their fingers without any intraoperative monitoring. Therefore, using Intraoperative fluoroscopic monitoring during TVM surgery makes it safer, even for beginners. In this case, we performed TVM for the anterior vaginal wall. First, we used the c-arm of a fluoroscope to insert bilateral ureteral stents. A urethral catheter was then used for both urine drainage and contrast medium injection. In all procedures, we were able use fluoroscopic imaging whenever necessary. We were able to easily confirm the positions of the prolapsed bladder and the bilateral ureteral stents with fluoroscopic imaging, and the ischial spine was easy to locate before the procedure. We were also able to confirm the position of the top of the needle with fluoroscopic imaging whenever necessary. If a surgeon is worried about the risk of bladder injury during TVM surgery, they should inject contrast medium into the bladder at the start of the procedure. Intraoperative fluoroscopic monitoring during TVM surgery is easy and makes the procedure safer, even for beginners. Moreover, fluoroscopic imaging also allows intraoperative training. To avoid exposing the body to excess radiation, we must minimize the total length of the fluoroscopic examination.

Bladder Injuries During Cesarean Section in a University Hospital: A 25-Year Review

In the past 40 to 50 years, a steady increase in the incidence of cesarean section (CS) worldwide has stimulated interest in complications associated with CS. One such complication, bladder injury, occurs infrequently with a reported incidence of less than 1%. This retrospective study investigated the incidence of bladder injury during CS, and identified risk factors associated with injuries, as well as discussing potential means of prevention, suggested management, and ultimate outcome. Review of medical records of 67,618 deliveries between 1983 and 2007 at a hospital in Saudi Arabia identified 7708 patients (11.4%) delivered by CS. Demographic and clinical data assessed included number of prior cesarean deliveries and previous pelvic surgery, elective or emergency procedure, presence of adhesions, location and size of the bladder injury, diagnosis, management, and outcome. Among the 7708 CS deliveries, 34 cases of bladder injury were identified (overall incidence: 0.44%). More bladder injuries were found among women with repeat CS (58.6%) than those with primary CS (41.4%) with an incidence of 0.81% and 0.27%, respectively (P < 0.0014). During surgery, there was a significant association between occurrence of bladder injury and separation of the bladder flap over the lower uterine segment (P < 0.024) and previous CS, other pelvic surgery and presence of adhesions (P < 0.0006). Surgeons recognized all bladder injuries intraoperatively and made immediate repairs resulting in an overall satisfactory outcome. Bladder injury occurred more frequently with emergency CS (64.3%) than elective CS (35.7%) (P < 0.024). These data show that optimal outcomes for bladder injuries occurring during CS are associated with early recognition of the injury and adequate repair. Patients with a history of multiple CS are at significant risk for bladder injury.

Urethral injury associated with minimally invasive mid‐urethral sling procedures for the treatment of stress urinary incontinence: a case series and systematic literature search

The introduction of the TVT has brought about dramatic changes in our practice as regards surgery for stress urinary incontinence, although the risk of bladder injury has caused concern. The subsequent development of tapes introduced through the obturator foramina may limit the rate of bladder injury, and some have suggested that cystoscopy is no longer required during stress incontinence surgery. Several cases of urethral injury referred to our unit have caused us concern about this approach. We present here brief details of these cases along with a systematic search of the literature on urethral injury following mid-urethral tape procedures.

Tension-Free Transvaginal (TVT) and Transobturator (TOT) Tapes in Women with Multiple Failed Incontinence Procedures or Complex Urogynaecological Intervention

Objectives: We report the outcomes of transvaginal (TVT)/transobturator (TOT) tape in women with multiple or complex urogynaecological intervention and persistent stress urinary incontinence (SUI). Patients and methods: Thirty-seven patients with multiple procedures (median 3) or complex urogynaecological intervention for SUI, McGuire classified on videourodynamics, underwent TVT ( n = 26) or TOT ( n = 11) placement. Patients categorised outcome as excellent, good or poor. Excellent was defined as dry, asymptomatic and completely satisfied. Good was defined as no SUI but residual or de novo urgency, or lack of complete satisfaction. Poor was defined as minimal improvement of symptoms. All patients with residual symptoms underwent repeat video-urodynamics. Results: Mean follow-up was 37 months. Thirty-two patients (86%) were cured of SUI. According to the outcome definitions 46% were excellent, 30% good and 24% poor. Of six patients with McGuire type III SUI, five (83.3%) had persistent SUI, accounting for all with persistent SUI. Bladder perforation and de novo urgency occurred in 11.5% and 19.2% of TVT, but none of those with TOT. Temporary voiding difficulty occurred in 11.5% TVT and 9.1% TOT. Protracted retention occurred in two TVT cases, of which one required tape division. Conclusions: TVT/TOT cured SUI in 86% of patients with multiple SUI procedures or complex urogynaecological intervention, with minimal morbidity. Subjective outcomes were less than objective outcomes mainly due to urgency. The TOT route reduced the risk of bladder injury and de novo urgency. Type III SUI on preoperative urodynamics predicted failure.

Risk Factors for Bladder Injury in Patients With a Prior Hysterotomy

To estimate the rate of and risk factors for bladder injury in vaginal birth after cesarean (VBAC) candidates. Between 1995 and 2000, a 17-center, retrospective cohort study was performed, evaluating women with prior cesarean delivery for delivery mode-specific morbidity during subsequent pregnancy. Trained nurses extracted information from medical records on demographics, medical and obstetric history, pregnancy, and delivery. This secondary analysis examines the rate and risk factors for bladder injury, defined as having occurred if identified and recorded by the physician at delivery. Univariable and multivariable analyses were performed. Of 25,005 patients with at least one prior cesarean delivery, 107 (0.43%) sustained a bladder injury, and 91.6% (n=98) of these occurred without concurrent uterine rupture. Bladder injury risk was not affected by delivery mode: VBAC trial compared with elective cesarean delivery (0.44% compared with 0.42%, adjusted odds ratio [OR] 1.36, 95% confidence interval [CI] 0.85-2.19). For the women who undertook a VBAC trial and did not experience a uterine rupture, failure to deliver vaginally was the only predictor of bladder injury (0.86% compared with 0.22%, adjusted OR 4.61, 95% CI 2.70-8.11). In women who elect repeat cesarean delivery, greater than one prior cesarean delivery was significantly associated with bladder injury (0.68% compared with 0.29%, adjusted OR 2.40, 95% CI 1.30-4.43). Risk of bladder injury in women with a prior cesarean delivery is not affected by planned mode of delivery. Although rare, bladder injury in women undergoing VBAC is strongly associated with a failed VBAC trial. A heightened awareness for bladder injury is warranted when performing repeat cesarean deliveries in the setting of failed VBAC attempts. II.

Treatment of Stress Urinary Incontinence—Midurethral Slings: Top-down, Bottom-up, “Outside-in,” or “Inside-out”

Two randomized trials have reported no differences in efficacy between suprapubic arc and tension-free vaginal tape at 2 years. There are no long-term studies comparing the inside-out and outside-in transobturator (TOT) approach, although short-term data show no difference in cure rates or complications. The short-term efficacy of TOT midurethral slings is comparable with the retropubic slings; however, preliminary evidence suggests that TOT slings may have a lower success rate compared with retropubic slings for the treatment of intrinsic sphincter deficiency. The risk of bladder injury may be the least with the "inside-out" approach, whereas retropubic techniques have a higher risk of cystotomy as compared with the TOT approach. Four randomized controlled trials comparing the retropubic and TOT approaches show no differences in rate of de novo urgency, retention, frequency, nocturia, or incomplete voiding.

Fistule vésico-vaginale après bandelette transobturatrice

The transobturator approach is gradually replacing the retropubic approach for the treatment of female stress urinary incontinence and suburethral tape. The major argument in favour of this approach is the decreased risk of bladder injury during insertion of the needles, which nevertheless remains a minor complication. Provided another more median approach is used in closer contact with the bone, followed by prolonged bladder catheterization for 24 to 48 hours, this complication has no consequences. However, the authors report a case of bladder injury during insertion of transobturator tape (TOT) in a patient with no particular history, attributable to the technique itself as it occurred during finger dissection towards the obturator membrane. This complication led to secondary formation of a vesicovaginal fistula after insertion of the tape, despite satisfactory repair of the bladder This case illustrates that TOT is not devoid of risks to the bladder; with sometimes even serious consequences. TOT should not be inserted when bladder suture is required. If a fistula is observed after insertion of TOT the tape should be completely removed as soon as possible, but correction of urinary incontinence may persist.

Idées pour faire progresser le TVT

Because of the bladder injuries risk and subsequent increase of the intervention time due to the bladder integrity checking, many surgeons have abandoned TVT. Based on a demonstrative clinical case, we report a simple, fast and effective method meant to minimize the risk of bladder injuries and to wonder about the mandatory bladder checking by cystoscopy during the TVT sling installation. An infiltration of 1% Xylocaïne half diluted is carried out in the area laterally to the urethra and the bladder, through vaginal and pubic ways. A 360 ml blue of methylene solution bladder filling may show quickly and safely a bladder injuries occurrence, either a true transfixion or an under mucous route. Using this procedure, TVT technique could be no more dangerous or longer than the TOT technique.

Choice of abdominal incision and risk of trauma to the urinary bladder and bowel in multiple cesarean sections

Objective To determine if the midline subumbilical incision reduces the risk of trauma to bladder and bowel in women undergoing multiple cesarean sections. Study design Retrospective analysis of hospital histories of 3164 women who had repeat cesarean sections at a referral maternity hospital. Methods The clinical records of women who had between one and eight cesarean sections over a 4-year period to October 2002 were examined for entries on injury to bladder and bowel. The frequency of these injuries in relation to abdominal incision used was determined. Multiple logistic regression analysis was performed to assess the influence of cesarean number, abdominal incision, intraperitoneal adhesions, operator experience, and anterior placenta previa on risk of bladder injury. Main outcome measure Frequency of trauma to bladder and bowel associated with either Pfannenstiel or midline incision. Results There were 3164 women who met the inclusion criteria to the study. The midline incision was associated with significantly higher risk than Pfannenstiel for injury to the bladder ( P < 0.0001, OR 6.7, 95% CI 2.6–16.5). For both incisions, injury to the bladder increased with rising cesarean number. In addition, for a given cesarean other than primary, bladder trauma was more likely with the midline incision. The risk of injury to bowel was higher with the midline incision (RR 5.5), but there were too few events to permit Chi square analysis. Conclusion In repeat cesarean section, the midline incision is associated with a higher risk of bladder and bowel injury than Pfannenstiel.

VESICAL CALCULUS CAUSED BY VASCULAR PROSTHETIC GRAFT

Foreign bodies in the urinary tract are known to provide a nidus for stone formation. Stones in the bladder have been reported around catheter balloons, nonabsorbable sutures, surgical staples and a whole range of self-inserted foreign bodies.1 Crossover prosthetic vascular grafts used for unilateral iliac artery disease can be passed superficially through a subcutaneous tunnel or retropubically. However, the latter pose a risk of bladder injury.2

Avoiding the space of Retzius during the laparoscopic Burch procedure

Although the structures apposed by a Burch colposuspension, the lateral vaginal fornix and Cooper's ligament, are approached surgically by opening the space of Retzius, neither actually lies in the space of Retzius but in the paravesical-paravaginal space. Cooper's ligament cannot be exposed adequately if the paravesical space is opened laparoscopically. Five primary Burch colposuspensions were performed without opening the space of Retzius, four with the uterus in place and one after a hysterectomy. Approaching the operation through the paravesical space has several advantages. A fixed anatomic landmark for the paravesical space is the umbilical ligament, and it can be easily identified laparoscopically. The paravesical space can be opened without risk of bladder injury. The urachus does not have to be divided. All the advantages of a transperitoneal approach are retained. Suture placement is greatly facilitated. Preliminary experience suggests that a laparoscopic Burch procedure can be carried out easily, quickly, and safely through the paravesical space, but this requires confirmation.