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34: The bladder flap at cesarean delivery–to create or not to create: a randomized controlled trial

      Objective

      Creation of the bladder flap has been an integral part of the standard cesarean delivery technique without evidence of benefit. We conducted a randomized controlled trial to test the hypothesis that omission of the bladder flap in both primary and repeat cesarean deliveries shortens operating time without significantly increasing intraoperative and postoperative complications.

      Study Design

      We prospectively randomized 259 women undergoing primary and repeat cesarean deliveries at 32 weeks or greater to creation (n=132) or omission (n=127) of the bladder flap. Emergency cesarean deliveries, planned vertical uterine incisions, and prior abdominal surgeries besides cesareans were excluded. The primary outcome measure was total operating time. Secondary outcomes were bladder injury, incision to delivery time, incision to fascial closure time, estimated blood loss (EBL), postoperative microhematuria, postoperative pain, hospital days, endometritis and urinary tract infection (UTI). Analysis followed the intention-to-treat principle.

      Results

      The median skin incision to delivery interval was shorter with omission of the bladder flap (9 [interquartile range 6 - 13] versus 10 [7 - 15] minutes, p=0.04), but there were no differences in total operating time (51[38-62] minutes versus 51 [range 43-68], p=0.10). No bladder injuries occurred in either group and there were no significant differences in EBL, change in hemoglobin level, postoperative microhematuria, postoperative pain, hospital days, endometritis or UTI (Table). Similar findings were obtained when analysis was stratified by primary or repeat cesarean deliveries.
      Tabled 1
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      Conclusion

      Omission of the bladder flap at primary and repeat cesarean deliveries does not increase intraoperative or postoperative complications. Incision to delivery time is shortened while total operating time appears unchanged.