Is the Formation of a Bladder Flap at Cesarean

Necessary? A Randomized Trial

M. Hohlagschwandtner, MD, E. Ruecklinger, PhD, P. Husslein, MD, and E. A. Joura, MD
OBJECTIVE: To evaluate the effects of not forming a bladder flap at lower-segment cesarean delivery.
METHODS: A total of 102 women who underwent cesarean
delivery were prospectively randomized to one of two
groups. In the study group (n 53), a cesarean was performed without formation of a bladder flap. In the control
group (n 49), cesarean was performed with formation of
a bladder flap before the uterine incision.
RESULTS: There were differences of median skin incisiondelivery interval (5 versus 7 minutes, P < .001), median
total operating time (35 versus 40 minutes, P .004), and
median blood loss ( hemoglobin 0.5 versus 1 g/dL, P
.009) in favor of the study group. Postoperative microhematuria was reduced in the study group (21% versus 47%,
P < .01). The median need for analgesics was reduced in
the study group (75.0 mg diclofenac versus 150.0 mg, P <
.001), and there was a lower percentage of patients receiving analgesics 2 or more days after cesarean in the study
group (26.4% versus 55.1%, P .006). There was no difference in bowel function.
CONCLUSION: Omission of the bladder flap provides shortterm advantages such as reduction of operating time and
incision-delivery interval, reduced blood loss, and need for
analgesics. Long-term effects remain to be evaluated.
(Obstet Gynecol 2001;98:1089 92. 2001 by the American College of Obstetricians and Gynecologists.)

Creation of the bladder flap is a standard part of cesarean

technique.1 It has yet to be established whether there is any
advantage in dissecting the urinary bladder from the lower
segment of the uterus. Many studies2 6 have demonstrated
that simplification of cesarean delivery may lead to a significant decrease in operating time, postoperative febrile morbidity, and hospital costs. Wood et al6 demonstrated no
adverse effect from a simplified method of cesarean (PelosiType), which included the omission of bladder dissection
together with other modifications. To our knowledge, this
is the only report6 on the elimination of the bladder dissection in cesarean delivery, but these authors did not investigate this single modification.
From the Department of Obstetrics and Gynecology, University of Vienna (AKH),
Vienna, Austria.

Based on these observations, we conducted a prospective randomized trial to evaluate short-term effects of the
omission of the bladder flap.
MATERIALS AND METHODS
A total of 102 women, who underwent cesarean delivery
in the Department of Obstetrics at the University Hospital of Vienna between January and May 2000, were
included in the study. There were no significant differences between the groups with respect to maternal and
gestational age. All participating women were white, and
informed consent was obtained in all cases. The study
was performed in accordance with the ethical standards
for human experimentation established by the Declaration of Helsinki of 1975, revised 1983. Exclusion criteria
were fetal malformations and previous surgery on the
uterus. During the observation period, 255 women were
eligible for recruitment, but not all obstetricians on call
participated in the study. Randomization was performed
with a computer-based program (zero/one system). Before entering the operating room, the obstetrician took a
sealed envelope containing the randomization number
and the mode of cesarean delivery. In the study group,
low-segment cesarean delivery was performed in the
following way: the abdomen was opened with a Pfannenstiel incision, and a low-transverse uterine incision
was performed about 1 cm above the vesicouterine
peritoneal fold, without dissection and formation of a
bladder flap (Figure 1). After the delivery of the fetus and
the placenta without cord traction or manual removal,
the uterine incision was closed in one layer (Vicryl 1,
CTX plus, Figure 2). The visceral and parietal peritoneum were not sutured, and the rectus sheath was closed
in a continuous fashion (Vicryl 1, CT-1). The subcutaneous fat was closed if the thickness was more than 2 cm,
followed by skin closure (all suture material by Ethicon,
Norderstedt, Germany).
In the control group, cesarean delivery was performed in
the same way together with formation of a bladder flap
before the uterine incision.4 All surgical procedures were
performed by resident medical staff, who were not aware of

VOL. 98, NO. 6, DECEMBER 2001

2001 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.

0029-7844/01/$20.00
PII S0029-7844(01)01570-8

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Figure 1. Uterine incision without bladder dissection. Incision is made 1 cm above the vesicouterine peritoneal fold
(elective cesarean delivery at term, UB urinary bladder).
Hohlagschwandtner. Bladder Flap and Cesarean Delivery. Obstet Gynecol 2001.

the parameters being measured. All patients were administered 10 IU oxytocin and prophylactic antibiotics
after cord clamping. All women were offered solid food
within 8 hours after cesarean delivery. The standard
postoperative analgesic drug was diclofenac (Novartis
Pharma, Vienna, Austria) administered according to the
womens requirements, either intravenously or as a suppository.
The following parameters were evaluated: total operating time (from skin incision to closure of the skin), skin
incision-delivery time, pre- and postoperative (obtained
on the first day after delivery) hemoglobin levels, preand postoperative (first day after delivery) urine test for
blood (dip stick Combur, Bohringer, Mannheim, Germany), febrile morbidity (defined as two separate episodes of fever greater than or equal to 38C for 2 or more
days postoperatively), postoperative need of analgesics,
and bowel function defined as postoperative day of first

Figure 2. Exteriorized uterus after repair. Note the descended urinary bladder in absence of any bleeding (UB
urinary bladder).
Hohlagschwandtner. Bladder Flap and Cesarean Delivery. Obstet Gynecol 2001.

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Bladder Flap and Cesarean Delivery

defecation, wound healing, hospitalization days, and readmissions. The ward staff was unaware of the type of surgical technique. Obstetric (gestational age, indication for cesarean section) and neonatal indicators (birth weight, pH of
the umbilical cord, Apgar score) were recorded.
A review of the first 50 patients revealed the favorable
trends for operating time of a power of 0.8. Further inquiry
confirmed primary trends. The Kolmogorov-Smirnov test
was used to determine variables without normal distribution. For comparison of patients with formation of a bladder flap versus patients without formation of a bladder flap,
the Student t test was applied. The Mann-Whitney U test
was applied for variables, where the normal distribution
was questionable. Spearmans correlation coefficient describes associations between operating time and hemoglobin. Independent dichotomous variables were tested by
the 2 test and Yates continuity correction. Frequencies
were quoted with 95% confidence intervals (CI), which
were calculated by the exact method. All statistical tests
were executed two-tailed. Because we did an interim
analysis, which was the basis for sample size estimates, P
values below .025 were considered significant. Statistical
analyses were performed by the use of SPSS (SPSS Inc.,
Chicago, IL) for Windows 8.0 (1997).
RESULTS
Statistical analyses compared the characteristics and variables of 53 patients in whom the formation of the bladder
flap was omitted with those of 49 patients with a standard bladder flap formation. Table 1 lists patient characteristics and obstetric data. The indications for cesarean
delivery are shown in Table 2. The distribution of
individual surgeons between the two groups was similar.
There were significant differences in skin incisiondelivery interval, total operating time, and hemoglobin
in favor of the study group (Table 3). There was a
significant correlation between the total operating time
and hemoglobin. Spearmans coefficient amounted
rs 0.260 (P .008). No woman had microhematuria
before cesarean. Microhematuria was observed in 46.9%
(exact 95% CI 32.5%, 61.7%) in the control group and in
20.8% (exact 95% CI 10.8%, 34.1%) in the study group
(P .010). The need for analgesics was reduced in the
study group (Table 3). The percentage of patients receiving analgesics 2 or more days after cesarean was 26.4%
(95% CI 15.3%, 40.3%) in the study group and 55.1% in
the control group (95% CI 40.2%, 69.3%, 2, P .006).
There was no difference in bowel function between the
two groups (Table 3). In the study group, 62.3% of
women (95% CI 47.9%, 75.2%) had the first defecation at
the first postoperative day, and 49.0% (95% CI 34.4%,
63.7%, 2, P .250) in the controls.

OBSTETRICS & GYNECOLOGY

Table 1. Patient Characteristics and Obstetric Data

Maternal age (y)

Parity
Primiparous
Multiparous
Gestational age (wk)
Birth weight (g)
Fetal presentation
Vertex
Breech

Study group
(n 53)

Control group
(n 49)

30 (1941)

29 (1946)

30 (57%)
23 (43%)
38 (2742)
2950 (10124240)
43 (81%)
10 (19%)

Significance

27 (55%)
22 (45%)
38 (2742)
3040 (11404370)
38 (78%)
11 (22%)

NS
NS
NS
NS
NS
NS
NS

NS not significant.
Values are given in median and range.

During the postoperative course, one woman in each

group developed fever associated with retained placental
fragments. Those patients underwent dilation and evacuation. No cases of wound infection or wound dehiscence occurred. The median hospitalization time was 6
days in both groups, and no readmissions were observed
in both groups.
There were no significant differences between the groups
with respect to Apgar score and the arterial pH value.
DISCUSSION
This study examines whether there are any short-term
benefits in eliminating the bladder flap at cesarean delivery. The creation of a bladder flap and its repair dates to
the preantibiotic era,6 when it was employed to protect
the peritoneal cavity from intrauterine infection. Closure
of the visceral peritoneum remained a clinical standard
procedure,1 even though there are no advantages.3
Our findings indicate that cesarean delivery without
the formation of a bladder flap provides a number of
significant short-term benefits. Several points need to be
addressed: firstly, the level of the uterine incision (Figure
Table 2. Indications for Cesarean Delivery
Study group Control group
(n 53)
(n 49)
Significance
Breech
presentation
PROM
CPD
PIH, HELLP
SGA
Arrest of labor
Fetal distress
Others

8 (15.0)

9 (18.4)

NS

3 (5.6)
7 (13.1)
3 (5.6)
1 (1.8)
3 (5.6)
14 (26.4)
14 (26.4)

3 (6.1)
2 (4.1)
0 (0)
0 (0)
3 (6.1)
15 (30.6)
17 (34.7)

NS
NS
NS
NS
NS
NS
NS

NS not significant; PROM premature rupture of the membranes;

CPD cranial-pelvic disproportion; PIH pregnancy-induced hypertension; HELLP hemolysis, elevated liver enzymes, low platelets;
SGA small for gestational age.
Values are quoted in %.

VOL. 98, NO. 6, DECEMBER 2001

1). In this setting, some obstetricians consider the uterine

incision may be too high in a thicker portion of the
uterus. In all cases in both groups, the incision was made
essentially at the same level in the lower segment below
the uterine physiologic retraction ring. In addition, the
omission of the bladder flap prevents the incision from
being made too low. Low uterine incision should be
avoided when the cervix is fully effaced and dilated to
prevent rupture of the cervix. Because the omission of
the bladder flap is a new modification, there are no
long-term data relating to future pregnancies. Further
studies are required to investigate the safety of this
technique with respect to subsequent pregnancies and
trial of labor. A further point of discussion is the delivery
of the infant. Throughout the study period, no problems
were encountered in either group.
It is important to consider that the anatomic situation
is the same whether the bladder flap is created actively or
not. If the uterine incision is made slightly above the
vesicouterine peritoneal fold, the loose connective tissue
between the uterus and the urinary bladder allows the
spontaneous descent of the bladder (Figure 2). During
this process, no vascular injury occurs. This may have
contributed to the decreased blood loss in the study
group. Blood loss increases the risk of postoperative
complications, including infection.7 Because the omission of the bladder flap causes less trauma and vascular
injury, subsequently fewer additional hemostatic sutures
are required. This is associated with a decreased operating time in the study group. Recently, a short operating
time was shown to reduce the risk of developing mild
ileus symptoms in early-fed women after cesarean.8 The
reduced need for analgesic drugs probably also reflects
the reduced trauma. The median hospital stay of more
than 6 days results from the European reimbursement
system and should be considered by American readers.
The rate of retained placental fragments (one in each
group), higher than in other series,3,4 is unexplained.
Bladder injuries are rare complications of cesarean

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Bladder Flap and Cesarean Delivery

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Table 3. Incision-Delivery Interval, Total Operating Time, Change in Hemoglobin, Postoperative Need of Diclofenac, and
Bowel Function in the Two Study Groups
Study group
(n 53)
Incision-delivery interval (min)
Total operating time (min)
Hemoglobin (g/dL)
Need of diclofenac (mg)
Postoperative day of first defecation

Control group
(n 49)

5 (110)
35 (1250)
0.5 (0.02.6)
75 (0300)
1 (13)

7 (214)
40 (2058)
1.0 (0.02.7)
150 (0375)
2 (15)

Significance
(P value)
.001*
.004*
.009
.001
.188

Values are given as median and range.

* P values are results of the Student t test.

P values are results of the Mann-Whitney U test.

and were not observed in the study group. These findings are in accordance with the results of Wood et al.6
When bladder injury occurs, it is usually caused by
surgical difficulty encountered while developing the
bladder flap.9 The low incidence of 0.14 0.31%9,10 requires a large number (n 40,000) of investigated
cesareans to draw valid conclusions with respect to major bladder injuries. The lower rate of postoperative
microhematuria also reflects a reduced manipulation and
trauma of the urinary bladder.
Long-term effects, such as adhesions and fertility,
remain to be evaluated. Bowel obstruction and pain
caused by adhesions are rare after cesarean delivery. In a
study by Al-Took et al,11 the incidence of small bowel
obstruction after cesarean delivery (five of 100,000 cesarean deliveries) was significantly less than after other
abdominal operations. We observed no postoperative
ileus among the study population. The practice of nonclosure of the peritoneum does not appear to promote
adhesions.12 We are carefully following up all women of
the study population. One year after completing the
study, six women (three of each group) have presented
pregnant at our department. One woman had a repeat
cesarean for breech presentation, and another woman a
spontaneous vaginal delivery. One fetus with an omphalocele suffered an intrauterine death in the 20th week of
pregnancy. After the favorable results from the study,
routine creation of a bladder flap is now omitted in our
institution. Long-term results on a larger scale are under
evaluation and will be reported.
In conclusion, the results of the present study demonstrate that the omission of the bladder flap provides shortterm benefits such as reduction of operating time and
incision-delivery interval, reduced blood loss, and reduced
need for analgesics. Long-term effects remain to be evaluated.
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Address reprint requests to: M. Hohlagschwandtner, MD,

Department of Obstetrics and Gynecology, University Hospital of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; E-mail: maria.hohlagschwandtner@akh-wien.ac.at.
Received February 6, 2001. Received in revised form July 31, 2001.
Accepted August 2, 2001.

OBSTETRICS & GYNECOLOGY