Gorovitz & Borten, P.C.
Attorneys at Law

400-1 Totten Pond Road
Waltham, Massachusetts 02451
Tel: (781) 890-9095
Bladder Injuries
Injury to the bladder or urethra (Lower urinary tract) complicating a
gynecologic procedure has long been recognized. Accidental injury to the
bladder during a gynecologic surgical procedure is usually inconsequential if
recognized and repaired at the time of the surgical operation. A simple
closure in layers followed by continuous drainage for a period of time has no
long term consequences for the patient. Gynecologists should be skilled in
the prevention and early detection of accidental bladder injuries during
gynecologic surgery. It is essential that injury to the bladder should be
identified before the operation is concluded and immediately repaired. If the
gynecologist does not posses the required training in repairing a bladder
injury, an intraoperative consultation with a urologist to perform the bladder
repair is mandatory.

The close anatomical association between the urinary bladder and the female
reproductive organs is well known to any surgeon operating in the abdomen
and pelvis of a woman. Working knowledge of the proximity of the bladder at
all times during a surgical procedure is essential to prevent its injury. It is a
well know and accepted fact that injury to the bladder at the time of a
gynecologic operation performed through the abdomen can be almost
completely avoided by the simple preliminary measure of routine identification
of the pelvic tissue planes.

The principles that contribute to the safety of the bladder in all pelvic
procedures include: adequate exposure of the surgical field; appropriate
dissection of the retrovesical and paravesical spaces; clamping and suturing
under direct vision. In patients who had undergone prior pelvic surgery
(cesarean section, urinary incontinence repair) anatomical distortion is to be
expected. Failure to properly identify the bladder perimeter and the pelvic
tissue planes increase the risk of bladder injury during a gynecologic
procedure.  

The most common causes of Injuries to the bladder are:

  • Obstetric
         o        Prolonged labor
         o        Midforceps procedures
         o        Cesarean section
         o        Cesarean hysterectomy
  • Gynecologic
         o        Abdominal hysterectomy
         o        Vaginal hysterectomy
         o        Radical oncologic surgery
         o        Anterior colporrhaphy
         o        Urinary incontinence surgical repair
         o        Untrained surgeon
  • Postradiation
  • Cancer (cervix, bladder, urethra)
  • Trauma (blunt)

Quite often, bladder injuries at the time of gynecologic surgery escape the
recognition by the surgeon until postoperative complications present itself.
Unrecognized bladder injury following a cesarean section or a hysterectomy
may result in the formation of a vesicovaginal fistula. Vesicovaginal fistulas
are the most common complication resulting from undiagnosed and
unrepaired injuries to the bladder. They are classified according to the
organs they connect and include:

  • Vesicovaginal fistula (between bladder and vagina)
  • Vesicocervical fistula (between bladder and cervix)
  • Vesicouterine fistula (between bladder and uterus)

The uncontrolled leakage of urine into the vagina is the hallmark sign and
symptom described by a woman suffering from a vesicovaginal fistula
following a gynecologic pelvic surgical procedure. The drainage of urine may
be constant or intermittent if the fistula is very small.  Bladder injuries can
present themselves by extravasation (spillage) of urine intraperitoneally into
the peritoneal cavity, extraperitoneally into a close space (urinoma) or by
spontaneous healing and formation of a fistula. A fistula is defined as the
communication between two organ sites that is lined with epithelium. In the
case of the bladder, they are named in accordance with the adjacent
affected  organ. Although bladder injuries secondary to obstetrical
complications will manifest themselves within the first 24 hours after delivery,
the majority of vesicovaginal fistulas associated with pelvic surgery will
present symptoms between one week and one month following the surgical
operation.

Most bladder injuries are preventable, identifiable and treatable at the time of
the abdominal or pelvic surgical procedure if the surgeon and/or surgical
assistant performs the proper and required dissection and identification of the
bladder before cutting and suturing the tissues. Eventhough an injury to the
bladder at the time of abdominal hysterectomy can occur regardless of the
experience of the surgeon, proper identification of the bladder disruption at
the time of the surgical procedure allows:

  • the prevention of an bladder injury
  • immediate recognition the bladder injury
  • immediate repair to obviate further complications or the need for a
    subsequent operative procedure or in the alternative can lead to the
    formation of a genitourinary fistula.

Some indications for the surgical procedure (large uterine fibroid(s)) as well
as prior surgical history should alert the operating surgeon that an enlarged
uterus is associated with a distortion of the normal pelvic anatomy. As such, it
became mandatory for the operating surgeon and his assistant to identify the
tissue planes surrounding the bladder before any tissues are cut and/or
sutured as part of the abdominal or pelvic surgical procedure. Failure to do
so is a clear deviation of the acceptable standard of care for a gynecologist
performing and/or assisting in the performance of an abdominal and/or pelvic
surgical procedure and increases the chances for injury to the bladder to
occur.

The failure of a surgeon (or assistant) to timely identify that the bladder or
urethra had sustained an injury before completing the abdominal or pelvic
surgical procedure and closure of the abdominal cavity or vaginal surgical
layers is a clear deviation from the acceptable standard of care expected
from an obstetrician- gynecologist performing an abdominal or pelvic surgical
operation. Early detection and repair of intraoperative injuries to the bladder
or urethra usually can restore normal function, prevent postoperative
complications and possibly subsequent surgery..

If you believe that you or your loved one have been injured as a result of an
obstetrical or  gynecologic error that was diagnosable, avoidable and/or
preventable, you may have a valid cause of action. The injury may be the
result of a medical provider's mistake in handling your gynecologic condition
and the result of medical negligence. Dr. Borten has over 35 years of
experience as an obstetrician and gynecologic surgeon to fully evaluate the
merits of your potential case. Allow the Boston area medical malpractice
attorneys at Gorovitz & Borten help you assert your rights and get the
compensation you deserve.
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(when possible), please contact us by phone, fax or e-mail with your question
or concern.

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