帝王切開中の膀胱損傷：危険因子と逆行性膀胱充填の役割

紹介と仮説：帝王切開中の膀胱損傷は、母親の罹患率がかなりの珍しい合併症です。この研究の目的は、帝王切開中の膀胱損傷の可能な危険因子を特定し、膀胱壁の完全性の評価における逆行性膀胱充填の役割を説明することでした。 方法：大規模な三次紹介センターでのレトロスペクティブコホート研究。2003年から2017年の間に帝王切開を受けた女性が含まれていました。膀胱損傷と診断された女性は、そのような損傷を受けていない女性と比較されました。取得されたデータには、人口統計学的特性、一般的な病歴、産科歴、産生内および術中データが含まれていました。同様に、逆脳膀胱充填の使用に関する情報も回収されました。 結果：研究期間中に、21,177の帝王切開が実施され、そのうち68症例の膀胱損傷が特定されました。負傷の3分の2は膀胱ドームにあり、残りの3分の1は後膀胱壁にありました。ほとんどの損傷は、子宮切開延長（60.0％）に続いて腹膜侵入（22.0％）の間に形成されました。統合および多変量解析に続いて、3つのパラメーターは膀胱損傷の独立した危険因子のままでした：膀胱の癒着、帝王切開の前の真空試行の失敗、子宮切開延長のサイズ。膀胱修復後に逆行性膀胱充填が利用された症例の15.4％で、液体の漏れが明らかでした。 結論：膀胱の癒着、帝王切開の前の真空の試みの失敗、子宮切開延長のサイズは、帝王切開中の膀胱損傷の独立した危険因子です。

INTRODUCTION AND HYPOTHESIS: Urinary bladder injury during cesarean delivery is an uncommon complication with substantial maternal morbidity. The aim of this study was to identify possible risk factors for bladder injury during cesarean delivery and to describe the role of retrograde bladder filling in the assessment of bladder wall integrity. METHODS: A retrospective cohort study at a large tertiary referral center. Women who underwent cesarean delivery between 2003 and 2017 were included. Women diagnosed with urinary bladder injury were compared to women who did not have such injuries. Data retrieved included demographic characteristics, general medical history, obstetric history and intra-partum and intra-operative data. Information regarding use of retrograde bladder filling intra-operatively was retrieved as well. RESULTS: During the study period, 21,177 cesarean deliveries were performed of which 68 (0.3%) cases of urinary bladder injury were identified. Two-thirds of injuries were located at the urinary bladder dome with the remaining third located at the posterior bladder wall. Most injuries were formed during uterine incision extension (60.0%) followed by peritoneal entry (22.0%). Following uni- and multivariate analyses, three parameters remained independent risk factors for bladder injury: urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of the uterine incision extension. In 15.4% of cases in which retrograde bladder filling was utilized following bladder repair, leakage of fluid was evident. CONCLUSION: Urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of uterine incision extension are independent risk factors for urinary bladder injury during cesarean delivery.