Obstetric-associated lower urinary tract injuries: A case series from a tertiary centre in a low-resource setting Shantel Naicker a, ⁎, Thinagrin D. Naidoo a , Jagidesa Moodley b a Department of Obstetrics and Gynaecology, Greys Hospital, Pietermaritzburg and Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa b Department Obstetrics and Gynaecology and Women's Health and HIV Research Group, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa abstract article info Article history: Received 21 April 2020 Received in revised form 5 May 2020 Keywords: Lower urinary tract injury Caesarean delivery Bladder injury Obstetric-associated lower urinary tract injuries may occur during vaginal and abdominal deliveries. If these in- juries go unrecognised, these patients may suffer both physical and psychosocial complications. We describe the management of 19 patients with such injuries, including their demographic profile, associated factors, and com- plications at a tertiary institution in a retrospective case series over a 5-year period. Bladder injuries were the most common (89.5%), mostly occurring during emergency caesarean delivery, with previous caesarean delivery and adhesions being risk factors. A primary repair was attempted at the referring institution in 35.7% of cases. Re- pair at the tertiary institution was mostly performed by consultants (42.9%). Early recognition and primary repair are found to reduce further complications. © 2020 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction Anatomically, the female genital tract and the lower urinary tract are in close proximity to one another. Injuries to the lower urinary tract (LUT) are recognized complications of parturition, but are relatively un- common during childbirth. The reported incidence of obstetric associ- ated bladder injuries is between 0.14% and 0.94% [1–5], with majority of bladder injuries occurring at caesarean delivery (CD). The incidence of bladder injuries at CD was shown to be 0.4% by Moodliar et al. in 2004 [6]. The incidence of ureteric injuries at CD have been reported to be between 0.013% to 0.09% [1,2,5,7,8]. The current rise in the CD rate may therefore result in an increase in urological injuries during ob- stetric surgery [1,3,4,7]. The identified risk factors for bladder injuries at emergency delivery include, a previous lower segment CD, adhesions, uterine rupture and caesarean hysterectomy [1,2,5,9,10]. Tarney et al. [2] and Oliphant et al. [5] reported that urological complications occur in 3–6% of caesar- ean hysterectomies. Incorrect application of forceps or ventouse suction and failure to empty the bladder prior to performing assisted deliveries may result in direct trauma to the urogenital structures [11,12]. Ureteric injuries require a high index of suspicion for early detection [8]. A delay in recognizing bladder and/or ureteric injury may lead to fistula forma- tion, incontinence and renal damage [13]. This in turn may result in severe physical and psychosocial suffering [2,7,13]. The time of injury to time of recognition and primary repair are important prognostic fac- tors in their outcome [8]. Often, a primary LUT injury, especially if recognized at the time of CD, is managed at the district hospitals without the supervision of a urologist or obstetrician. The obstetric department in many district hos- pitals in South Africa are managed by medical officers and family physi- cians. Surgical repair of LUT injuries is, however, not a requirement in the training of a South African obstetrician. Little is reported with regards to obstetric associated LUT injuries in South Africa. The aim of our case series was to identify and assess the circumstances in which these injuries occur and recommend measures to reduce their risk and improve the success of repair, where necessary. 2. Methods This was a retrospective case series, carried out at a single centre, Grey's Hospital, a tertiary institution in KwaZulu-Natal Province, South Africa. The population targeted were obstetric cases referred to and deliv- ered over a 5-year period. Those included were: post-delivery cases re- ferred to or delivered at the tertiary hospital with ureteric, bladder or urethral injury sustained during vaginal delivery or CD, where primary repair was performed at the referring institution or at our tertiary facil- ity, or secondary repair carried out at our facility. Case Reports in Women's Health 27 (2020) e00218 ⁎ Corresponding author. E-mail address: shantelnaicker@yahoo.com (S. Naicker). Contents lists available at ScienceDirect Case Reports in Women's Health journal homepage: www.elsevier.com/locate/crwh