BLADDER INJURY DURING HYSTERECTOMY OR CAESAREAN SECTION

bladderOne of the most distress injuries that can occur during surgery to an individual is a bladder injury which can have serious implications going forward if not identified in a timely fashion.   It is important to understand that most bladder injuries are preventable, identifiable and treatable.   Such an injury is a recognisable complication of hysterectomy or a C-section procedures, however, if an immediate repair is carried out the potential fistula issue can be avoided.   A fistula is a medical condition which leaves leaking from the bladder.

Generally, a bladder injury in either of the foregoing procedures is inconsequential provided it is recognised and repaired and continues to be drained during the recovery period.

Both of the procedures mentioned involve incisions of the uterus which is to the rere of the bladder.   One of the first steps in performing either of these procedures is to push the bladder downwards to expose the uterus.   It is possible during the mobilisation of the bladder that it will be perforated or injured.   The risk is increased, where there have been previous caesareans or where adhesions are otherwise present that impact on the separation of the uterus from the bladder.   An injury to the bladder during this mobilisation process is not considered negligent.  It is a recognised risk of both procedures, however, there can be negligence if it is not diagnosed and repaired before the operation is completed.

The surgeon needs to be particularly careful to identify the anatomy correctly particularly where the patient is fully dilated in the case of an emergency caesarean or the anatomy is otherwise distorted.   If, in the case of a caesarean, the obstetrician does not make the incision high enough the cut will go through the bladder and into the uterus.    This can result in a delivery through the bladder itself.  This can be grounds for a medical negligence claim.   Failure to differentiate between the bladder and the uterus is below the standard expected of a reasonably competent obstetrician.

Generally bladder injuries are uncommon with C-sections unless they are repeat C-sections.

A failure to recognise an injury to the bladder or urinary tract generally can have important later consequences including loss of renal function or the development of fistula.

An unfortunate case in point was the one of Ms. K (52) from Dublin who underwent a hysterectomy procedure at the Mount Carmel Hospital.   She developed a condition known as Hemorrhagia resulting in heavy menstrual bleeding.   She also started to leak from the bladder some weeks after the operation and this led to significant distress and loss of amenity for her.   Ultimately it was concluded, on an exploratory operation, that the position was attributable to a misplaced suture in her bladder.   The Court recognised that due to the combination of the fistula condition and the severe anxiety disorder which she developed as a result of her experiences, Ms. K was entitled to be compensated as it had completely destroyed her work prospects.   She was awarded €438,000 by way of compensation.

Thankfully these complications are generally avoided where a bladder injury occurs in such circumstances.   Once identified during the operation itself the injury can be closed with an absorbable suture and the site drained for 4 to 10 days which allows for full healing.   It seems to be fundamentally important that a hospital confirms that a patient can completely empty her bladder after the removal of the catheter and before discharged.

Recognisable conditions which are more likely to expose a patient to a bladder injury during an operation include prolonged labour with distended bladder, obstructed labour, second or subsequent Caesarean, cases of altered anatomy, fibrosis, and endometriosis.   All of these conditions result in dense adhesions.

Bladder injuries can occur either in the dome of the bladder where it usually will occur, if at all, or in the trigonal region.   This area is proximate to the three openings of the ureteric orifices and internal urethral.

Where the injury is in the trigonal area it is often thought to be better to have an Urologist or Urogynecologist carry out the repair.   Generally speaking if a bladder injury is sustained during the dissection of an adhesion it is not actionable (compensatable) nor is an injury that results from the bladder being in an abnormal position.    However, if there is no abnormal anatomy and the bladder is still injured it is possible that this may well lead to a claim for compensation as will happen if the injury is not actually recognised during the operation itself.

It is the view generally that the potential for such injury should be discussed with the patient before the procedure, noted on the records and included in the Consent to Surgery form.

In summary, when a mistake is made and not noticed promptly and dealt with thereby leading to health problems later in life requiring further surgical procedures or corrective actions claim for compensation may arise.

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