Urinary Tract Injury Research Articles

Pediatric blunt renal trauma practice management guidelines: Collaboration between the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society.

Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma. Grading of Recommendations Assessment, Development and Evaluation methodology was used to aid with the development of these evidence-based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was performed. Fifty-one articles were used to inform the statements presented in the guidelines. When possible, a meta-analysis with forest plots was created, and the evidence was graded. When comparing nonoperative management versus operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%. Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus surgical intervention for ongoing or delayed bleeding. (3) In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma. Guidelines study, level III.

Traumatic renal injury in a UK major trauma centre - current management strategies and the role of early re-imaging.

To analyse the contemporary management of renal injuries in a UK major trauma centre and to evaluate the utility and value of re-imaging. The prospectively maintained 'Trauma Audit and Research Network' database was interrogated to identify patients with urinary tract injuries between January 2014 and December 2017. Patients' records and imaging were reviewed to identify injury grades, interventions, outcomes, and follow-up. Renal injury was identified in 90 patients (79 males and 11 females). The mean (sd; range) age was 35.5(17.4; 1.5-94)years. Most of the renal traumas were caused by blunt mechanisms (74%). The overall severity of injuries was: 18 (20%) Grade I, 19 (21%) Grade II, 27 (30%) Grade III, 22 (24%) Grade IV, and four (4%) Grade V. Most patients (84%) were managed conservatively. Early intervention (<24h) was performed in 14 patients (16%) for renal injuries. Most of these patients were managed by interventional radiology techniques (nine of 14). Only two patients required an emergency nephrectomy, both of whom died from extensive polytrauma. In all, 19 patients underwent laparotomy for other injuries and did not require renal exploration. The overall 30-day mortality was 13%. Re-imaging was performed in 66% of patients at an average time of 3.4days from initial scan. The majority of re-imaging was planned (49 patients) and 12% of these scans demonstrated a relevant finding (urinoma, pseudoaneurysm) that altered management in three of the 49 patients (6.1%). Non-operative management is the mainstay for all grades of injury. Haemodynamic instability and persistent urine leak are primary indications for intervention. Open surgical management is uncommon. Repeat imaging after injury is advocated for stable patients with high-grade renal injuries (Grade III-V), although more research is needed to determine the optimal timing.

Delayed recognition of lower urinary tract injuries following hysterectomy for benign indications: A NSQIP-based study

To describe the incidence of and factors associated with lower urinary tract complications recognized in the immediate postoperative period following hysterectomy for benign gynecologic indications using the NSQIP (National Surgical Quality Improvement Program) database. Patients who underwent hysterectomy for benign indications from 2014 through 2016 were identified in the NSQIP database using Current Procedural Terminology codes and International Classification of Diseases codes. Patient demographics, preoperative comorbidities, ASA classification system scores, and total operating time were collected. Data on 30-day postoperative complication rates, including rates of reoperation and readmission, were also captured. Genitourinary complications were defined as ureteral obstruction, ureteral fistula, and bladder fistula. A total of 45,139 patients met inclusion criteria during the study period. Mean age and body mass index were 31 ± 11years and 32 ± 8 kg/m2. The majority of patients were white (66%), had an ASA class of 2 (67%), and had no major medical comorbidities (68%). The most commonly performed primary surgery was laparoscopic hysterectomy (43%), followed by abdominal hysterectomy (27%). The incidence of anylower urinary tract complication was 0.2% (95% confidence interval, 0.19-0.28): 55 ureteral obstructions (0.1%, 95% confidence interval, 0.09-0.16), 33 ureteral fistulae (0.07%, 95% confidence interval,0.05-0.1), and 28 bladder fistulae (0.06%, 95% confidence interval, 0.04-0.09). In a multivariable logistic regression model, black race (adjusted odds ratio, 1.90; 95% confidence interval, 1.20-2.96), endometriosis (adjusted odds ratio, 2.29; 95% confidence interval, 1.44-3.52), and prior abdominal surgery (adjusted odds ratio, 1.53; 95% confidence interval, 1.01-2.28) remained significantly associated with the occurrence of any lower urinary tract complication recognized in the immediate 30-day postoperative window. Lower urinary tract complications recognized in the immediate postoperative period following hysterectomy for benign gynecologic disease are rare, with ureteral obstruction being the most commonly reported complication. The risk of these complications may be higher in patients who identify as black, had prior abdominal surgery, and/or have a diagnosis of endometriosis.

Open reduction and internal fixation for acetabular fractures complicated with injury to lower urinary tract: short-term outcomes

Objective To investigate the short-term outcomes and surgical timing in patients who were treated by open reduction and internal fixation (ORIF) for acetabular fractures complicated with injury to lower urinary tract. Methods A retrospective analysis was conducted of the 14 patients with acetabular fracture complicated with lower urinary tract injury who had been treated at Department of Orthopaedics, The First Affiliated Hospital to Nanjing Medical University from January 2011 to September 2017. They were 12 males and 2 females, with an average age of 40.3 years (from 30 to 56 years). According to Letournel-Judet classification, there were one anterior column, 2 transverse, 3 anterior column plus posterior hemi-transverse, one T-shaped, 5 associated both-column and 2 transverse plus posterior wall fractures. The time from injury to surgery ranged from 6.0 to 30.5 days, with an average of 13.4 days. Of the 8 patients with bladder injury undergoing internal fixation of the acetabulum, a modified ilioinguinal approach combined with a Kocher-Langenbeck approach was used in 4, a single modified ilioinguinal approach in 3, and a Stoppa approach combined with an iliac fossa approach in one; of the 6 patients with urethral rupture undergoing internal fixation of the acetabulum, a modified ilioinguinal approach combined with a Kocher-Langenbeck approach was used in 3, a single modified ilioinguinal approach in one, a Kocher-Langenbeck approach in one and a Stoppa approach in one. The fracture union time, outcomes and complications were recorded. Results The mean follow-up time for the 14 patients was 27.2 months (from 12 to 60 months). The fracture union time ranged from 3.0 to 4.5 months, averaging 3.5 months. According to the Majeed’s scoring, the pelvic function at the final follow-up was excellent in 7 patients, good in 4, fair in 2 and poor in one; their scores ranged from 30 to 92 points, averging 80 points. No infection or implant failure occurred during follow-ups. Heterotopic ossification at the acetabulum was observed in one patient whose Brooker grading was IV at the final follow-up. Conclusion The patients with acetabular fracture complicated with lower urethral or bladder injury should be treated with ORIF as soon as possible so that fine clinical outcomes can be achieved. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Urethra; Bladder

03: A stepwise approach to the difficult bladder flap to prevent urinary tract injury during laparoscopic hysterectomy

03: A stepwise approach to the difficult bladder flap to prevent urinary tract injury during laparoscopic hysterectomy

84: Needs assessment for lower urinary tract injury curriculum for FPMRS fellowships

84: Needs assessment for lower urinary tract injury curriculum for FPMRS fellowships

Ureterovaginal fistula 35 days after laparoscopic hysterectomy: A case report

Introduction: Total laparoscopic hysterectomy as become an increasingly common practice. However, the laparoscopic hysterectomy is not completely out of risks. Data from multiple studies of laparoscopic hysterectomy report a rate of urinary tract injury of 1.2–3 percent. One of the most important urinary tract injury is related to ureteral lesion. Unfortunately, 70% of these lesions are not recognised during surgery and they are lately discovered through hydronephrosis, anuria (bilateral lesion), urine vaginal leaks, paralytic ileus or even peritonitis.

Our Experience with Iatrogenic Ureteric Injuries among Women Presenting to University College Hospital, Ibadan: A Call to Action on Trigger Factors.

Background Ureteric injuries leading to ureterovaginal fistula (UVF) is less common than vesicovaginal fistula, as a cause of urinary incontinence. Recently, there is a surge in the number of UVF cases presenting to University College Hospital (UCH) following a caesarean delivery. The urogynaecology unit at UCH is at the forefront of providing surgical repair for women with all forms of genitourinary fistulas. We describe our experience with managing UVF arising from ureteric injury. Methods A retrospective data collection of UVF cases managed from January 2012–December 2017 at UCH is presented. Information on sociodemographic and obstetric characteristics, presenting complaints, antecedent surgery, treatment received, findings at surgery, and postoperative complications were obtained with a structured proforma. Results Eighteen cases of UVFs due to iatrogenic ureteric injury were managed. Majority (N=11; 61.1%) of the women suffered the injury following the emergency caesarean section (EMCS). Abdominal hysterectomy operation accounted for four (22.2%) cases, and one case each (5.6%) was due to vaginal hysterectomy and destructive operations. Prolonged obstructed labour (POL) (81.8%) was the most common indication for the EMCS, while 18.2% had surgery on account of lower uterine segment fibroid. Most of the ureteric injuries were on the left side. Postoperative complications documented were haemorrhage, urinary tract infection, wound infection, and injury to the neighbouring structure. Conclusion Caesarean section being one of the most performed surgical operations in Nigeria was surprisingly found to be the most common cause of ureteric injury ahead of hysterectomy. It is a pointer that the surgeons might not have properly learnt the art of the caesarean delivery well. We recommend adequate surgical training of medical officers/surgeons that are involved.

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.

Could Bladder Inflation Prior to Cesarean Section Prevent Urinary Tract Injury in High Risk Group? A Randomized Controlled Trial

Background: Accidental urinary tract particularly bladder injury during cesarean delivery has a significant maternal morbidity, as it may lead to extended operative time, infection of urinary tract and sometimes development of urinary tract fistulae. Objective: To find out the efficacy of urinary bladder inflation immediately prior to cesarean section (CS) procedure in minimizing incidence of accidently urinary tract injury in high risk patients. Setting: Obstetrics and Gynecology Department, Faculty of Medicine, South Valley University, Qena, Egypt. Duration: From August 2017 to November 2018. Study Design: A prospective randomized controlled trial. Methods: Seventy six pregnant women recruited from attendants of outpatient antenatal care unit of obstetrics and gynecology department who planned for cesarean delivery and carried one or more risk factors for urinary tract injury. Patients randomly were classified into 2 groups (group I included 38 cases, underwent bladder inflation using triple way Foley’s catheter immediately before CS and group II included 38 cases, and underwent bladder deflation with 2 ways Foley’s catheter immediately before CS. Results: The overall incidence of urinary tract injury was significantly higher in group II (7 cases = 18.4%) than in group I (2 cases = 5.2%) with p value < 0.001. The incidence of urinary bladder injury was moderately significantly higher in group II (5 cases = 13.1%) than group I (2 cases = 5.2%) with p value < 0.01; ureteric or combined vesico-ureteric injuries had been reported only in group II (1 case = 2.6% and 1 case = 2.6%) respectively with no case reported in group I (p < 0.001). There was a highly statistically significant difference between group I and group II as regard to hospital stay (p < 0.001) but mildly significant differences in operative time and remote urinary tract fistulae (p < 0.05). Conclusions: There was significant reduction in urinary bladder injury, ureteric injury, operative time and hospital stay. Urinary bladder inflation immediately before cesarean section should be applied in patients who have any risk factor of dense bladder adhesion as a protective procedure against urinary tract injuries.

Maternal and neonatal outcomes of placenta accreta: a descriptive case series study

Objective The objective of this study was to evaluate maternal and neonatal outcomes of placenta accreta. Background Placenta accreta is the leading cause of maternal and neonatal morbidity and mortality. Patients and methods This descriptive case series study included 40 pregnant women with placenta accreta and was carried out at Department of Obstetrics and Gynecology of Menoufia University Hospitals for 10 months. The study cohort included all admitted pregnant women with the diagnosis of placenta previa accreta whether presenting with or without vaginal bleeding after 28 weeks of gestation confirmed by ultrasound scan. Data were collected and confirmed by positive ultrasonographic criteria of placenta accreta. The study outcomes included maternal mortality, urinary tract injuries, cesarean hysterectomy admission to ICU, preoperative and postoperative hospital stay, perinatal mortality, neonatal birth weight, Apgar score at 1 and 5 min, admission to neonatal ICU, or any other complications. Results Our study included 40 patients, and there was a highly significant statistical difference between patients who underwent hysterectomy (n = 21) and who did not (n = 19) regarding type of cesarean delivery (elective or emergency) (P = 0.005). There was a significant statistical difference in neonatal mortality in cases that were admitted to ICU (P = 0.040). Conclusion Morbidly adherent placenta is becoming an increasingly common complication of pregnancy with increasing rates of cesarean births. Prenatal diagnosis and management is the most important factor in optimizing the treatment and outcome of women with adherent placenta.

Clinical Practice Guidelines for Child Sexual Abuse.

Child sexual abuse (CSA) is the involvement of children and adolescents in sexual activities (usually for adult sexual stimulation or gratification) that they cannot fully comprehend and to which they cannot consent as a fully equal, self-determining participant, because of their early stage of development [Box 1]. Open in a separate window Box 1 Defining child sexual abuse

A case of total laparoscopic hysterectomy for uterine cervical cystic adenomyosis. -Two techniques to avoid urinary tract injury-

A case of total laparoscopic hysterectomy for uterine cervical cystic adenomyosis. -Two techniques to avoid urinary tract injury-

Intraoperative Evaluation of Urinary Tract Injuries at the Time of Pelvic Surgery: A Systematic Review.

The aim of this study was to determine the safety and efficacy of methods for intraoperative evaluation of urinary tract injury during pelvic surgery. PubMed, EMBASE, CINAHL, Web of Science, Scopus, ProQuest, the Cochrane Library, and Clinicaltrials.gov were searched from 1947 to February 2018. Articles or abstracts describing the routine evaluation of urinary tract injuries during pelvic surgery in adults were included, surgical indications of urinary tract anomaly, stones, or malignancy were excluded. There were no restrictions on study design or language. Outcomes included injuries diagnosed intraoperatively, delayed diagnoses, adverse effects, subjective assessments, time to use, and cost. Data were extracted in duplicate at an individual-participant level. Prevalence of injuries, sensitivity, specificity, and predictive values of each diagnostic method were calculated. A combination of generalized linear models and a Bayesian approach were used to separately pool diagnostic accuracy measures. There were 5303 titles, 527 abstracts, and 164 full-text articles assessed for eligibility; 69 articles were analyzed. Diagnostic methods retrieved were cystoscopy using saline, dextrose or unspecified distention media, oral phenazopyridine and vitamin B, intravenous (IV) methylene blue, IV sodium fluorescein, IV indigo carmine, prophylactic retrograde ureteral stents, and transabdominal Doppler ultrasound. Prevalence of urinary tract injury ranged from 0.3% to 2.8%. Sensitivity ranged 63% to 91%, and specificity, 99.7% to 100%, with no significant differences suggested between methods. All evaluable methods of intraoperative urinary tract assessment during pelvic surgery are safe and effective with specificity of greater than 99% and low rates of complications. Larger, more rigorous studies are required to evaluate the diagnostic accuracy of some newer methods.

Cystoscopy at the time of incontinence and prolapse surgery.

This article provides an update on the use of cystoscopy at the time of prolapse and incontinence surgery. Iatrogenic lower urinary tract injury is a known complication of antiincontinence procedures and surgical repair of pelvic organ prolapse. Intraoperative cystoscopy improves detection of lower urinary tract injuries in women undergoing pelvic floor surgery. The pelvic surgeon has a number of agents available to aid in the cystoscopic visualization of ureteral efflux. When injuries of the urinary tract are identified and treated intraoperatively, there is decreased morbidity, lower healthcare costs, and a lower risk of litigation than when detection is delayed. Therefore, many organizations, including the American College of Obstetricians and Gynecologists (ACOG), the American Urogynecologic Society (AUGS), and the American Urological Association (AUA) recommend cystoscopy at the time of pelvic floor surgery. Cystoscopy should be universally employed at the time of prolapse and incontinence surgery, except in instances of isolated repair of the posterior compartment.

Vesico-vaginal fistula post Right radical nephroureterectomy with bladder cuff excision

Case: 61 years, female presented at KMH OPD with involuntary urinary leakage per vaginum for seven months following Right radical nephreureterectomy with bladder cuff excision for urinary bladder carcinoma at other centre. Dye test was positive. Cystoscopy revealed VVF defect around 2 cm (Goh’s stage 3biii) at right posterior wall of urinary bladder. Ureteric catheter was placed in left ureter and VVF repair was done. Dye test following 14 days of Foley’s catheterization was negative and patient went home dry. We present here a case of successful repair of VVF following Right radical nephreureterectomy with bladder cuff excision. &#x0D; Key words: dye test, Goh’s stage, pelvic surgeries, urinary tract injuries, vesico-vaginal fistula

Emergency peripartum hysterectomy in a Western Australian population: Ten-year retrospective case-note analysis.

Emergency peripartum hysterectomy (EPH) is a life-saving obstetric procedure reserved for conditions where medical treatment and conservative surgery have failed. EPH is associated with significant morbidity and mortality. To examine the incidence, indications, risk factors, maternal and neonatal outcomes of EPH in a tertiary hospital in Western Australia (WA). A retrospective case-note analysis of all cases of EPH performed at King Edward Memorial Hospital in WA between the years 2006 and 2016. The incidence, indications, risk factors, maternal and neonatal outcomes were reviewed. All cases were ascertained via our hospital obstetric database. A total of 72 cases of EPH were identified among 64999 births. The incidence of EPH in WA was 1.1 per 1000 deliveries. Abnormal placentation was the main indication for EPH accounting for 66.7% of cases. Among women undergoing an EPH, 22.2% had a history of one previous caesarean section and 33.3% had two or more caesarean sections, respectively. Maternal morbidity was significant. There was one cardiac arrest secondary to hypovolaemia, and 84% of the women received blood transfusions with more than half of these women meeting the criteria for massive transfusion protocol (≥4 units of packed red cells). Urinary tract injury and venous thromboembolism were some of the other complications among our cohort of women. EPH is associated with significant morbidity. Our study identifies abnormal placentation as the leading cause of EPH.

Rate of Urinary Tract Injury by Route of Hysterectomy for Benign Disease

Objective: To evaluate and compare the risk of urinary tract injury by route of hysterectomy using a modern cohort.

The incidence, causes, and management of lower urinary tract injury during total laparoscopic hysterectomy

ObjectivesDetermining the incidence and causes of lower urinary tract injury in patients undergoing total laparoscopic hysterectomy and examining the procedures applied for management. MethodsPatients who underwent total laparoscopic hysterectomy in a large referral center between 1 January 2015 and 31 October 2017 for benign gynecological reasons were included in the study. Patients who underwent laparoscopic supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy and robot-assisted laparoscopic hysterectomy were not included in this study. The hospital records of all patients included in the study were examined and the incidence, causes and management of lower urinary tract injuries were reviewed. ResultsTotal lower urinary tract injury rate was found as 2.01%, and these injuries were evaluated separately as bladder and ureter injuries. All the bladder injuries had occurred on the posterior wall of the bladder during vesicouterine dissection; six cases were intraoperatively detected and one case was detected on the first postoperative day. Most of ureteral injury cases were detected in the early postoperative period (75%). The rates of previous cesarean section and endometriosis were significantly higher in patients with injury to the bladder and ureter than in the control group (p<0,001). There was no significant difference between the patients with lower urinary tract injury and the control group regarding uterine weight, estimated blood loss, bilateral salpingo-oophorectomy, the presence and location of fibroids, and laparoscopic or vaginal closure of the vaginal cuff. ConclusionLaparoscopic hysterectomy may be a good option in appropriate patients, but in case of previous cesarean section and endometriosis cases, patients should be informed about the possible complications in detail before the operation and care should be taken during dissection.

Characteristics of total laparoscopic hysterectomy among women with or without previous cesarean section: retrospective analysis.

The number of hysterectomized patients with previous cesarean sections (CSs) has increased due to increasing CS rates. A previous history of CS has been demonstrated to be an important risk factor for major complications in total laparoscopic hysterectomy. The aim here was to evaluate the major complications and safety of TLH in patients with previous CS. Retrospective analysis in a tertiary-level center. The medical records of 504 total laparoscopic hysterectomy patients operated between May 2013 and May 2017 were reviewed retrospectively. Data on age, parity, surgical indications, duration of operation, length of hospital stay, histopathological diagnosis and major intra and postoperative complications were gathered. The patients were categorized into two groups according to their CS history, namely those with and those without previous CS. Major complications were defined as the presence of lower urinary tract injury (bladder or ureter injury), enterotomy/colostomy, bowel serosal injury or vascular injury. There was no difference between the groups in terms of parity, duration of operation, hospital stay or pre and postoperative hemoglobin levels. The conversion rates to laparotomy in the previous CS and no CS groups were 2% and 1.7%, respectively. The rates of major complications in the previous CS and no CS groups were 5% and 1.3%, respectively, and these results did not differ significantly (P > 0.05). TLH could be performed safely in the previous CS group, since the complication rate was not different from that of the patients without previous CS.