Bladder Injury Research Articles

Rare Case of Traumatic Bladder Herniation and Incarceration Managed Conservatively

Rare Case of Traumatic Bladder Herniation and Incarceration Managed Conservatively

S. Rao Spiral Suturing (SRSS) of Lower Uterine Segment: An Innovative Hemostatic Technique in the Management of Placenta Previa and Accreta Spectrum.

The study aimed to demonstrate the efficacy and safety of an innovative hemostatic technique in managing Placenta Previa and Accreta Spectrum by S. Rao Spiral Suturing (SRSS) of a lower uterine segment. In this retrospective study conducted at Department of Obstetrics & Gynecology Unit-II of Nishtar Medical University, Multan between December 2018 to January 2021, one hundred and thirty consenting patients' clinical records were reviewed with major degree placenta previa/placenta accrete spectrum, either operated electively or presented in an emergency, with or without a history of previous cesarean section. The enrolled patients underwent SRSS, procedure's efficacy and safety were measured by the number of obstetrical hysterectomies, the time required for the procedure, estimated blood loss, blood transfusion volume, need for any other hemostatic technique, bladder trauma, pelvic infection, scar site hematoma or abscess, sepsis, duration of hospital stay and maternal mortality. Out of 130 patients, 17(12.6%) had Placenta Accreta, 86(66.3%) Increta, and 27(21%) Percreta. The Placenta location was anterior dominant in 102(78.4%) cases and posterior in 17(8.4%). Of the patients who underwent surgery, only two required obstetrical hysterectomy due to uncontrolled bleeding. The procedure took three to five minutes in 127 patients and five to seven minutes in three patients. Regarding intraoperative blood transfusion, 54.6% of patients were transfused 1000-2000 ml blood, and 5.38% required > 3000 ml. No blood transfusion was required postoperatively in any patient. Postpartum hemorrhage, infection, fever, and sepsis were not observed in any patient postoperatively. None of the patients suffered bladder injury. All patients were discharged as per routine. SRSS is an innovative, safe, effective, and simple suturing technique for patients with Placenta Previa and Accreta spectrum.

Predictors of catheter-free voiding after spinal cord injury

Context Despite a high prevalence of neurogenic bladder (NGB) in patients with spinal cord injury (SCI), clinicians are unable to predict long-term bladder outcomes due to variable phenotypes of bladder dysfunction. This study investigates if early bladder events, infections, and spinal cord injury characteristics during rehabilitation admission affect bladder outcomes one year after SCI. Methods This retrospective study included patients with SCI admitted to a tertiary rehabilitation center between 1 January 2016 and 1 January 2020. Data was collected on early bladder management, comorbidities, infections and injury characteristics; level of injury, American Spinal Injury Association Impairment Scale (AIS) classification, and International Standards for Neurological Classification of Spinal Cord Injury lower extremity motor score (LEMS). Results Seventy-two patients met inclusion criteria; 63% (45/72) patients had cervical SCI and 31% (22/72) were complete injuries. Twenty-two percent (16/72) did not use an internal catheter to empty the bladder, improving to 41% (29/72) at one year. On multivariate logistic regression accounting for age, sex, Charlson comorbidity index, LEMS, and infections during admission, higher LEMS (OR 1.104, 95%, CI 1.037–1.176, P = 0.002) associated with catheter-free voiding (CFV) at one year while male sex (OR 0.091, 95% CI 0.012–0.713, P = 0.0225), and non-urologic infections (OR 0.088, 95% CI 0.010–0.768, P = 0.0279) were negatively associated. Conclusions Preserved LEMS early after SCI associates with CFV at one year while male sex and early non-urologic infections such as pneumonia are associated with persistent urinary retention. This can be used to counsel SCI patients on expected bladder recovery and outcomes.

Bladder trauma: a guideline of the guidelines.

To identify and review the most up-to-date guidelines pertaining to bladder trauma in a unifying document as an updated primer in the management of all aspects relating to bladder injury. In accordance with the PRISMA statement, the most recent guidelines pertaining to bladder injury were identified and subsequently critically appraised. An electronic search of PubMed and Scopus databases was carried out in September 2023. A total of six guidelines were included: European Association of Urology (EAU) guidelines on urological trauma (2023), EAU guidelines on paediatric urology (2022), Urotrauma: American Urological Association (AUA) (2020), Kidney and Uro-trauma: World Society of Emergency Surgery and the American Association for the Surgery of Trauma (WSES-AAST) guidelines (2019), Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST) (2019), and EAU guidelines on iatrogenic trauma (2012). Recommendations were summarised with the associated supporting level of evidence and strength of recommendation where available. Several widely recognised professional organisations have published guidelines relating to the diagnosis, investigation, classification, management, and follow-up related to bladder injury. There is consensus amongst all major guidelines in terms of diagnosis and management but there is some discrepancy and lack of recommendation with regards to the follow-up of bladder injuries, iatrogenic bladder injury, paediatric bladder trauma, and spontaneous bladder rupture. The role of increasing minimally invasive techniques seem to be gaining traction in the select haemodynamically stable patient. Further research is required to better delineate this treatment option.

A comparative study in learning curves of laparoscopic lateral suspension vs. laparoscopic sacrocolpopexy: preliminary results.

Determination of the learning curve of new techniques is essential to improve safety and efficiency. Limited information is available regarding learning curves of different techniques in laparoscopic pelvic floor surgery. The aim of this study was to compare the learning curve of two operative techniques, laparoscopic lateral suspension (LLS) and laparoscopic sacrocolpopexy (LSC). We conducted a prospective study to assess the learning curve of LLS and LSC by implementing a structured urogynecologic surgical training program with the use of pelvic trainers for our urogynecology fellow. The fellow was an experienced urogynecologic surgeon, but was laparoscopic suturing and dissection naive at the beginning of the study. She was required to assist in 20 laparoscopic urogynecologic surgeries and undertake laparoscopic suturing and knot tying training with mesh positioning on a laparoscopic trainer for 4 h/week during the trial period. After the completion of this structured training program, the fellow performed LLS and LSC under the supervision of an experienced subspecialist as the primary surgeon. Linear regression analysis was used to compare the data of LLS and LSC learning curves. Subjective pre- and post-operative evaluation of pelvic organ prolapse (POP) and pelvic floor disorders was undertaken preoperatively and 12 months postoperatively using the PFDI-20-Quality of Life validated questionnaire. Follow-up was scheduled 12 months after the surgery and performed by a skilled urogynecologist. Objective cure was defined as Pelvic Organ Prolapse-Qualification (POP-Q) stage <II in any compartment. The mean operative times of laparoscopic sacrocolpopexy and lateral suspension were 168.26 and 160.33 min, respectively. According to linear regression analysis after 43 procedures, the learning curve for laparoscopic lateral suspension was shorter than for laparoscopic sacrocolpopexy (OPTime 134.69 min). In both groups, there was a significant reduction in bothersome POP symptoms (p ≤ 0.005). Bladder injuries in two cases and lumbar pain in one case were recorded during the study. Overall objective success at 12 months was 90.7% for LSC and 89.1% for LLS. Laparoscopic lateral suspension could be an alternative to laparoscopic sacrocolpopexy in the treatment of POP with its good objective and subjective outcomes. Lateral suspension has a shorter learning curve, and it is technically less demanding than LSC. Procedure-dedicated training can accelerate the move from a novice to a master laparoscopic surgeon.

Successful Nonsurgical Management of Peripartum Pubic Diastasis with Bladder Injury: A Rare Case Report

Successful Nonsurgical Management of Peripartum Pubic Diastasis with Bladder Injury: A Rare Case Report

Fetal and maternal outcomes of segmental uterine resection in emergency and planned placenta percreta deliveries.

This study evaluated maternal and fetal outcomes of emergency uterine resection versus planned segmental uterine resection in patients with placenta percreta (PPC) and placenta previa (PP). Patients with PP and PPC who underwent planned or emergency segmental uterine resection were included in this study. Demographic data, hemorrhagic morbidities, intra- and postoperative complications, length of hospital stay, surgical duration, and peri- and neonatal morbidities were compared. A total of 141 PPC and PP cases were included in this study. Twenty-five patients (17.73%) underwent emergency uterine resection, while 116 (82.27%) underwent planned segmental uterine resections. The postoperative hemoglobin changes, operation times, total blood transfusion, bladder injury, and length of hospital stay did not differ significantly between groups (P=0.7, P=0.6, P=0.9, P=0.9, and P=0.2, respectively). Fetal weights, 5-minute Apgar scores, and neonatal intensive care unit admission rates did not differ significantly between groups. The gestational age at delivery of patients presenting with bleeding was lower than that of patients who were admitted in active labor and underwent elective surgery (32 weeks [95% confidence interval [CI], 26-37] vs. 35 weeks [95% CI, 34-35]; P=0.037). Using a multidisciplinary approach, this study performed at a tertiary center showed that maternal and fetal morbidity and mortality did not differ significantly between emergency versus planned segmental uterine resection.

Late Diagnosis of Bladder Injury During Cesarean Section

Late Diagnosis of Bladder Injury During Cesarean Section

Catheter-associated bladder mucosal trauma during intermittent voiding: An experimental study in pigs.

The objective of this study is to characterize bladder mucosal trauma associated with intermittent catheterization with conventional eyelet catheters (CECs) and to assess if a microhole zone catheter (MHZC) design concept reduces this adverse effect. A porcine model was developed to reflect human catheterization and bladder drainage. Nine pigs were randomized for catheterization with CEC (n= 6) or MHZC (n= 3). The bladder was drained repeatedly 20 times through the catheter. Cystoscopy was performed before and after the procedure, and bladders were analysed by histopathology. Two additional pigs were used for cystoscopy visualization of suction events in vivo. Cystoscopy, gross pathology, histopathological score, leucocyte infiltration, and intracatheter pressure at flow stops during voiding were compared for each group. A significant higher pressure gradient was measured inside the CECs compared with MHZCs during flow stop. Consequently, CECs resulted in suction events inflicting bladder trauma characterized by loss of epithelium, oedema, haemorrhage, and neutrophil tissue infiltration. No significant trauma was identified when using MHZC. Considerable mucosal bladder trauma is inflicted by CECs which may be an overlooked risk factor for urinary tract infection. Catheters can be designed to minimize mucosal suction and reduce associated trauma. This may be a solution to reduce infection frequency and increase user comfort. Furthermore, the study demonstrates the potential of pigs as an attractive animal model for investigating urinary catheter performances.

Clinical study of modified Shirodkar transvaginal cervical cerclage during pregnancy in the treatment of cervical insufficiency

Objective: To investigate the clinical efficacy of modified Shirodkar transvaginal cervical cerclage (TVCC) in the treatment of cervical insufficiency (CI) and its impact on maternal and fetal outcomes. Methods: The clinical data of 218 pregnant women with CI admitted to Fu Xing Hospital, Capital Medical University from January 1, 2015 to August 31, 2021 was retrospectively analyzed. According to different surgical approaches, they were divided into modified Shirodkar TVCC treatment during pregnancy (TVCC group, 108 cases) and non-pregnant women underwent laparoscopic cervical cerclage (LACC) treatment (LACC group, 110 cases). The clinical data and pregnancy outcomes of the two groups were compared. Furthermore, the two groups of pregnant women were stratified according to cervical length (CL) to explore the effects of the two surgical methods on the pregnancy outcomes of CI women with different CL. Results: (1) Related indicators before and during cerclage: there were no complications such as massive hemorrhage, bladder injury and anesthesia accident in the two groups of pregnant women during cerclage. Compared with the LACC group, TVCC group had longer preoperative CL [(2.3±0.6) vs (2.7±0.6) cm], more intraoperative blood loss [(7.5±0.5) vs (14.4±1.4) ml] and longer hospital stay [(6.0±0.1) vs (7.3±0.4) day]. However, the operation time was shorter [(42.9±1.6) vs (25.9±1.4) minute] and the hospitalization cost was less [(9 912±120) vs (5 598±140) yuan], and the differences were statistically significant (all P<0.05). (2) Pregnancy outcomes: live birth rates were 95.4% (103/108) in the TVCC group and 96.4% (106/110) in the LACC group, showing no significant difference between the two groups (χ2=2.211, P=0.232). The preterm birth rate (12.0%, 13/108) in the TVCC group was higher than that in the LACC group (7.3%, 8/110), the neonatal birth weight was lower than that in the LACC group [(3 006±96) vs (3 225±42) g], and the proportion of low birth weight infants was higher than that in the LACC group [15.5% (16/103) vs 1.9% (2/106)], and the differences were statistically significant (all P<0.05). (3) Stratified analysis of CL: for pregnant women with CL<2.0 cm, the miscarriage rate of the TVCC group was higher than that of the LACC group (2/9 vs 3.0%), and the live birth rate was lower than that of the LACC group (7/9 vs 97.0%), and the differences were statistically significant (all P<0.05). For CL 2.0-<2.5 cm, 2.5-<3.0 cm, CL≥3.0 cm, there were no statistically significant differences in preterm birth rate and live birth rate between the two groups (all P>0.05). Conclusions: Modified Shirodkar TVCC is simple and easy to operate, which significantly reduces the cesarean section rate and medical cost compared with LACC, and there is no significant difference in the live birth rate. When there is inevitable late abortion, laparoscopic cerclage removal does not need to be performed again, which could reduce the second operation and is worthy of clinical application.

A novel extraperitoneal cesarean section of supravesical approach: Operative techniques.

We have established a novel extraperitoneal cesarean section technique by supravesical approach. An advantage of this technique over the conventional paravesical approach is that the lower uterine segment is broadly exposed and that all operative procedures can be performed under direct vision. We present the details of this novel technique. The bladder and the peritoneum are exposed by removing the transversalis and extraperitoneal fasciae. Subsequently, a triangular area between the median umbilical ligament, the peritoneum, and the bladder is exposed. The median umbilical ligament is dissected at this site. Bladder dissection from the peritoneum is also initiated from this area and proceeds toward the lower uterine segment. Operative times for pelvic fascia dissection and bladder removal from the peritoneal surface are currently around 15-25 min. During the process of development of this technique, there have been no bladder injuries in 501 patients that caused urine leakage. The supravesical approach has been considered difficult due to the strong adhesion between the perivesical fascia and the peritoneum at the bladder fundus. In this paper, we show how to safely remove the bladder fundus from the peritoneum. The bladder can then be easily lowered down toward the lower uterine segment. Although this technique allows the lower uterine segment to be broadly exposed and all operative procedures can be performed under direct vision, a disadvantage is the comparatively long time currently required to perform it. This technique could be a valuable option for extraperitoneal cesarean section, but disadvantages must also be considered.

Anti-infective therapy durations predict psychological stress and laparoscopic surgery quality in pelvic abscess patients

BACKGROUND The degree of psychological stress and the difficulty and efficacy of laparoscopic surgery differ in patients with pelvic abscesses after different durations of anti-infection treatment. AIM To compare and analyse the effects of different durations of anti-infective therapy on patients’ preoperative psychological stress level and the clinical efficacy of laparoscopic surgery in patients with pelvic abscesses to offer a reference for the selection of therapy plans. METHODS A total of 100 patients with pelvic abscesses who were admitted to the Department of Gynecology of Suzhou Ninth Hospital affiliated to Soochow University (Suzhou Ninth People's Hospital) from January 2018 to December 2022 were retrospectively enrolled. According to the different durations of anti-infective therapy, they were divided into Group S (50 patients, received anti-infective therapy for 24-48 h) and Group L (50 patients, received anti-infective therapy for 48-96 h). Baseline data, state-trait anxiety score at admission and before surgery, self-rating anxiety scale (SAS) + self-rating depression scale (SDS) score, surgery time, adhesion grading score, intraoperative blood loss, presence or absence of intraoperative intestinal injury, ureteral injury or bladder injury, postoperative body temperature, length of hospital stay, and presence or absence of recurrence within 3 mo after surgery, chronic pelvic pain, incision infection, dysmenorrhea, menstrual disorder or intestinal obstruction were compared between the S group and the L group. RESULTS There was no significant difference in the background data between the S group and the L group (P &lt; 0.05). There was no significant difference in the state-trait anxiety score or SAS + SDS score between the S group and the L group on admission (P &lt; 0.05). The state-trait anxiety score and SAS + SDS score of the S group were lower than those of Group L after receiving different durations of anti-infective therapy (P &lt; 0.05). There was no significant difference in the incidence of intestinal, ureteral or bladder injury between the S group and the L group (P &lt; 0.05). The surgery time of Group S was shorter than that of Group L, and the adhesion score and intraoperative blood loss volume were lower than those of Group L (P &lt; 0.05). There was no significant difference in the incidence of incision infection, dysmenorrhea, menstrual disorder or intestinal obstruction between the S group and the L group (P &lt; 0.05). The postoperative body temperature of Group S was lower than that of Group L (P &lt; 0.05), and the hospital stay was shorter than that of Group L (P &lt; 0.05). The incidences of recurrence and chronic pelvic pain within 3 mo after surgery were lower than that of Group L (P &lt; 0.05). CONCLUSION Twenty-four to forty-eight hours of anti-infective therapy is better than 48-96 h of anti-infective therapy for patients with pelvic abscesses because the degree of psychological stress is lower, which is more conducive to achieving better outcomes after laparoscopic surgery.

Prevalence, causes, and clinical course of patients with surgical reintervention due to complications during cesarean section.

The objective of the study is to identify the prevalence, causes, and clinical evolution of patients with surgical reintervention due to complications during cesarean section. The file of the Toco-Surgical Unit of the Gynecological Obstetrics Hospital No. 3 of the National Medical Center "La Raza" Mexican Institute of Social Security was reviewed to know the total number of patients undergoing cesarean section from January to December 2019 and cases with reintervention due to complications during cesarean section were selected. Their general data, the cause of reintervention, stay in the intensive care unit (ICU), hospital stay, and mortality were studied. The data were analyzed with descriptive statistics using the statistical program SPSS version 20. It was found that 3371 patients underwent cesarean section, of which 1.60% (54 cases) underwent reoperation for the following reasons: Unpacking 27.79%, obstetric hemorrhage 20.37%, bleeding due to uterine atony 20.37%, hysterotomy commissure hematoma 18.52%, uterine infiltration 3.70%, vascular injury 3.70%, bladder injury 3.70%, and colonic injury 1.85%. The ICU stay was 3.79 ± 2.03 days, hospital stay was 13.67 ± 11.16 days, and mortality was 1.85%. The prevalence of reintervention was reduced, bleeding was the main cause, and the clinical evolution was satisfactory with low mortality.

The incidence, indications, risk factors and pregnancy outcomes of peripartum hysterectomy at a tertiary hospital between 2013 and 2022.

To analyze the incidence, indications, risk factors and pregnancy outcomes of postpartum hemorrhage resulting in peripartum hysterectomy (PH). We retrospectively reviewed patients with postpartum hemorrhage requiring surgical procedures at ≥ 28weeks of gestation from January 1, 2013 to December 31, 2022 at a tertiary hospital in Shanghai, China. The patients were divided into a PH group and a non-PH group. Maternal clinical characteristics, the management of postpartum hemorrhage, pregnancy outcomes were compared between groups. Logistic regression was used to analyze the correlations between risk factors and PH. The incidence of hysterectomy was 0.2/1000 deliveries (31/150194). The variables significantly associated with PH were placenta previa with placenta increta/percreta (OR36.26), uterine rupture (OR266.16) and an estimated blood loss ≥ 3513mL (OR431.11). The proportion of cases involving hemorrhagic shock, disseminated intravascular coagulation, bladder injury, neonatal severe asphyxia, neonatal death and hypoxic-ischemic encephalopathy were significantly higher in the PH group (P < 0.05). The most common indications of PH were placental pathology. Efforts should be made to reduce the rate of cesarean deliveries and uterine curettage to lower the probability of abnormal placental invasion and appropriate medical indications for trial of labor after cesarean should be strictly followed to avoid the risk of uterine rupture.

Emergency Peripartum Hysterectomy and its Outcome in a Tertiary Care Hospital in Dhaka City, Bangladesh

Introduction: Emergency peripartum hysterectomy (EPH) is a life-saving surgical procedure performed when medical and surgical conservative measures fail to control postpartum hemorrhage. EPH is a challanging but life saving obstetric procedure performed when medical and surgical conservative measures fail to control postpartum haemorrhage .The present study aimed to review the peripartum hysterectomies and to compare the incidence, indications and outcome of EPH. Materials and Methods: This retrospective study was conducted at a tertiary care hospital in Dhaka, Bangladesh. Total 62 cases have taken, who had hysterectomy that was performed in Obstetric and gynaecology department of Addin Womens Medical College Hospital during the period between January 2020 and December 2022. Result: There were total of 36371 deliveries over the study period and EPH was performed in 62 cases making an incidence of 0.408. In this study 33.8% patients were between 35 to 39 years. Here 45.16% had their parity between 2nd and 3rd child. Here 61.2% had previous history of caesarean section, 24.19% had previous history of antepartum haemorrhage, 74.19% cases intrapartum operation had done. Among 62 cases of EPH 77.4% cases subtotal hysterectomy had done. Here, among 62 cases of caesarean section 35.48% had placenta accrete and 20.96% had history of placenta previa with haemorrhage and 12.9% had severe PPH due to atony of uterus. 22.5% cases had fetal outcome of still born but 32.25% baby born alive. In this study 51.6% cases patients develop haemorrhage as perioperative complication, 19.5% develop shock but 100% required blood transfusion among which 50% were in post operative period. Here 6 out of 62 cases had bladder injury, 5 patients needed relaparotomy due to haemoperitoneum caused by vaginal cuff bleeding. Mortality rate was 4.83%. Conclusion: Now a days the indication of EPH has changed from uterine atony to abnormal placentation. It is a most important obstetric surgery performed in life threatening haemorrhage. Involvement of an experienced obstetrician at an early stage of management and efforts should be taken to reduce morbidity and mortality. Sir Salimullah Med Coll J 2023; 31: 107-111

Primary Reconstruction of Bladder Neck Transection and Vaginal Laceration Post Blunt Abdominal Injury a Case Report

Blunt abdominal injury is not uncommon in the paediatric population. The presentation can be immediate or delayed, and if not promptly recognized may be attended with complications such as septicaemia, shock or death. Simple, readily available and cheap imaging techniques such as abdominal radiograph and ultrasound scan still remain relevant in the diagnosis of blunt abdominal injuries where abdominal computerized tomography is unavailable or unaffordable. This can expedite the decision for an early surgical exploration. In girls, complete bladder neck transection with vaginal wall injury is a rarely reported and unusual association of blunt abdominal injury more so with delayed presentation in the absence of an associated pelvic fracture. This rare trauma entity in a child can pose a diagnostic difficulty leading to delayed presentation. This is a case of 3 year old girl with 3 weeks history of trauma to the abdomen from collapsed building fence during a heavy downpour. She later developed progressive abdominal distension with pain, constipation, vomiting, fever and drainage of clear fluid per vaginam. She had visited several hospitals but was managed non-operatively. Over the period the patient had some relief of symptoms until she presented to our facility with poorly defined features of peritonitis following a referral from a peripheral hospital. Abdominal ultrasound scan revealed intraperitoneal fluid collection. She was resuscitated and had exploratory laparotomy with primary reconstruction of the bladder neck transection and vaginal wall laceration. She did well immediate postoperative except for the superficial surgical site infection and during follow-up visits. Primary repair of traumatic bladder neck transection and vaginal wall laceration in paediatric patients with delayed presentation of blunt abdominal injury is a feasible option of management. However, long term follow up is recommended as secondary procedures may become necessary.

Department of Surgery, Pak Emirates Military Hospital/National University of Medical Sciences (NUMS) Rawalpindi Pakistan

Objective: To find the frequency and management outcome of bladder injuries in cesarean section operations. Study Design: Cross-sectional study. Place and Duration of Study: Combined Military Hospital, Okara Pakistan, from Nov 2019 to Nov 2020. Methodology: After Ethical Review Committee, approval 1040 patients who underwent cesarean sections were included.Bladder injuries occurring during cesarean sections and their management outcomes were noticed. Results: The frequency of bladder injury was 214(20.6%), with the number of injuries as 482(48.3%) for primary cesareans and 345(33.2%) for repeat cesareans. The surgeon was called for help in 195(18.8%) cases, and 27(2.6%) cases were transferred to the tertiary care centre. No mortality was noticed during the study. Conclusion: The chances of bladder injuries can be minimized but will never be zero because of the anatomical development similarities of both tracts. It is pertinent to note that bladder injuries are the most common in obstetrics and gynecology surgeries.

BLADDER INFLATION PRIOR TO CESAREAN SECTION CAN PREVENT BLADDER INJURY IN HIGH RISK PATIENTS

This study aimed to evaluate the effectiveness of inflating the urinary bladder immediately before cesarean section (CS) in reducing the chances of bladder injury in high-risk patients. This was a prospective randomized controlled trial. The study was conducted in Obstetrics and Gynecology Ward 8, Jinnah Postgraduate Medical Centre (JPMC) Karachi, from April 06, 2021 to September 30, 2021. Three hundred twenty-eight pregnant women who delivered by cesarean section and had one or more risk factors for urinary tract injury were recruited. The women were divided into two groups: Group A underwent bladder inflation using a triple-way Foley catheter before CS, while Group B served as the control group without bladder inflation with a Foley catheter before CS. In this study, urinary bladder injury was found in 5.5% of women in Group A who had bladder inflation, while 12.2% of women in Group B without bladder inflation had bladder injury. The efficacy in Group A and B was 94.5% and 87.8%, respectively. The results showed a significant association between the study group and urinary bladder injury (p=0.032). The study significantly reduced urinary bladder injuries, surgery time, blood transfusion, and hospitalization. Inflating the urinary bladder before cesarean section should be used to prevent bladder injury in women with risk factors for dense bladder adhesion.

Feasibility and safety of vNOTES for gynecological procedures in obese patients

IntroductionThis study aimed to determine the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) to treat benign and malign gynecological conditions in obese patients. Material and methodsWe analyzed data from 79 obese patients with a body mass index (BMI) > 30 Kg/m2 operated by vNOTES for gynecological conditions between May 2020 and April 2023. The primary outcome was the feasibility of performing the surgery as initially planned. Data were presented for subgroups of patients with obesity class I (BMI 30.1 - 34.9 Kg/m2), class II (BMI 35.0 – 39.9 Kg/m2), and class III (BMI ≥ 40.0 Kg/m2). ResultsPatients presented obesity class I in 39 cases (49.4 %), class II in 27 cases (34.2 %), and class III in 13 cases (16.4 %). Fifty-two patients (65.8 %) underwent vNOTES hysterectomy, 26 patients (32.9 %) underwent procedures limited to the adnexa, and 1 patient (1.3 %) underwent myomectomy. The conversion rate was 0 %, 11.1 %, and 7.7 % in obesity class I, II, and III, respectively. Intraoperative bladder injury was observed in 1 case (1.3 %) and rectal serosal tear in 2 cases (2.5 %). Postoperatively, we observed 3 cases (3.8 %) of wound infection, 2 cases (2.5 %) of cystitis, and 1 case (1.3 %) of deep vein thrombosis. DiscussionThis study demonstrated the feasibility and safety of performing gynecological vNOTES procedures in obese patients. However, obesity could be associated with longer and more complex interventions, especially in obesity class II and III patients.

Safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in pioneering hospitals in Japan: A nationwide retrospective cohort study.

We aimed to evaluate the safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in 12 pioneering hospitals in Japan. Clinical data of patients who underwent robotic-assisted transabdominal preperitoneal repair between September 1, 2016, and December 31, 2021 were collected. Primary outcome measures were intra-operative adverse events and post-operative complications, whereas secondary outcomes were surgical outcomes, including chronic pain, recurrence, and learning curve. In total, 307 patients were included. One case of inferior epigastric arterial injury was reported; no cases of bowel or bladder injury were reported. Thirty-five seromas were observed, including four (1.3%) cases that required aspiration. The median operative time of a unilateral case was 108 minutes (interquartile range: 89.8-125.5), and post-operative pain was rated 1 (interquartile range: 0-2) on the numerical rating scale. In complicated cases, such as recurrent inguinal hernias and robotic-assisted radical prostatectomy-associated hernias, dissection and suture were safely achieved, and no complications were observed, except for non-symptomatic seroma. All patients underwent robotic procedures, and there was no chronic post-operative inguinal pain, although one case of hernia recurrence was reported. Regarding the learning curve, plateau performance was achieved after 7-10 cases in terms of operative time (P < .001). Robotic-assisted transabdominal preperitoneal repair can be safely introduced in Japan. Regardless of the involvement of many surgeons, the mastery of robotic techniques was achieved relatively quickly. The advantage of robotic technology such as wristed instruments may expand the application of minimally invasive hernia repair for complicated cases.