Risk factors for bladder injuries during cesarean sections: insights from a 15 year experience at a tertiary care center and a systematic review with meta-analysis

Purpose: To identify potential risk factors for bladder injury during cesarean section (CS). Methods: We conducted an observational case-control study from 2009 to 2024 at our Tertiary Care Hospital, matching each bladder injury case with four controls. Additionally, a systematic review and meta-analysis of the literature was performed using MEDLINE, CINAHL, and Scopus, from inception to 2024; eligible studies were case-control studies assessing risk factors for bladder injury during CS. Random-effects regression with the restricted maximum likelihood method was employed for the meta-analysis. Results: We identified 23 cases of bladder injury out of 15,260 CSs at our hospital, resulting in a rate of 0.15%. Women with bladder injuries were significantly older (p = 0.022), with 47.8% having a history of previous CS, while no significant differences were observed between groups regarding prior abdominal surgery, endometriosis, or body mass index. The systematic review included four case-control studies, whose data were meta-analyzed with our patients, identifying several significant predictors: adhesions (OR 18.6, 95% CI 8.86-39.0), repeated CS (OR 3.25, 95% CI 2.02-5.23), emergent procedures (OR 3.15, 95% CI 1.71-5.80), failed vaginal birth after cesarean (OR 4.74, 95% CI 2.18-10.3), second stage of labor (OR 2.78, 95% CI 1.80-4.29), and macrosomia (OR 2.64, 95% CI 1.25-5.57). Conclusions: Key risk factors for cesarean bladder injury include prior CSs, adhesions, second stage of labor, macrosomia, failed VBAC, and emergent procedures. Identifying these risk factors is critical for preoperative assessment and counseling, allowing for better surgical planning and improved outcomes.