Bladder Flap Unnecessary in Cesarean Deliveries

Omission of the bladder flap in cesarean deliveries does not increase intraoperative or
postoperative complications, according to results of a new randomized controlled trial.¹
Eliminating the bladder flap also shortens the incision-to-delivery interval but has no effect on
total operating time.

Worldwide, cesarean sections are the most common surgical procedure performed on
women. Creation of the bladder flap-superficially incising and dissecting the peritoneal lining
to separate the urinary bladder from the lower uterine segment-is common practice during
cesarean sections, but there is no evidence that doing so provides any benefit.¹ Before the advent
of antibiotics, the creation of and subsequent closure of the bladder flap was a way for surgeons
to protect a woman’s peritoneal cavity from intrauterine infection. Closure of the bladder flap is
no longer performed because it has since been deemed unnecessary. However, surgeons continue
to create the bladder flap during cesarean deliveries.

Involved in this new study were 258 women who underwent primary or repeat cesarean deliveries at 32 weeks of gestation or later.¹ During surgery, the bladder flap was created in 131 women, and the bladder flap was omitted in 127 women. Exclusion criteria were emergency cesarean deliveries, planned vertical uterine incisions, and previous abdominal surgeries besides cesarean sections. The study authors found that median skin-to-delivery time was shorter for the group in which the bladder flap was omitted (9 minutes vs 10 minutes). However, the median total operating time was the same for both groups (51 minutes). There were no occurrences of bladder injury in either group and no significant differences in estimated blood loss, postoperative microhemia, changes in hemoglobin level, postoperative pain, number of hospital days, and occurrences of endometritis or urinary tract infections.

According to the study authors, there is just one other randomized controlled trial assessing only the utility of the bladder flap; the findings of this other study showed that omission of the bladder flap provided short-term advantages-reduction in operating time, a shorter incision-to-delivery interval, reduced blood loss, and less need for analgesics.² However, the study was criticized for evaluating only short-term outcomes and excluding repeat cesarean deliveries.

Other studies have compared the outcomes for traditional cesarean sections with a simplified method of the surgery (often called the Pelosi method³) that also omits the bladder flap and have found the Pelosi method to be not only safe but also less costly.^4,5

Pertinent Points:
- Creating a bladder flap is an unnecessary step when performing cesarean sections.
- Omitting the bladder flap does not increase intraoperative or postoperative complications.

References:

References1. Tuuli MG, Odibo AO, Fogertey P, et al. Utility of the bladder flap at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2012;119:815-821.2. Hohlagschwandtner M, Ruecklinger E, Husslein P, Joura EA. Is the formation of a bladder flap at cesarean necessary? A randomized trial. Obstet Gynecol. 2001;98:1089-1092.3. Pelosi MA 3rd, Pelos MA. A simplified method of cesarean delivery. N J Med. 1998;95:37-45.4. Yale study reference: Wood RM, Simon H, Oz AU. Pelosi-type vs. traditional cesarean delivery. A prospective comparison. J Reprod Med. 1999;44:788-795.5. Malvasi A, Tinelli A, Guido M, et al. Effect of avoiding bladder flap formation in caesarean section on repeat caesarean delivery. Eur J Obstet Gynecol Reprod Biol. 2011;159:300-304.