Surgical management of placenta percreta complicated by bladder invasion: a case report

Background: Urologic complications of placenta accreta spectrum (PAS) are relatively rare but can be severe. To our knowledge, this is the first case to result in the simultaneous combination of massive hemorrhage, inadvertent cystotomy, bladder necrosis, vaginal cuff necrosis, and vesicovaginal fistula formation. Case Description: A 30-year-old woman with a past medical history significant for 3 prior cesarean sections, found to have placental invasion of the bladder (detected by ultrasound and confirmed by MRI), presented at 33 weeks with premature labor. After a cesarian section, the subsequent hysterectomy was complicated by severe hemorrhage. During removal of adherent placental tissues, a 10 cm inadvertent cystotomy at the bladder dome was created. After her bladder was repaired, she underwent bilateral internal iliac artery embolization. On post-operative day #41, an exploratory laparotomy revealed complete dehiscence of the cystotomy repair with a walled-off urinoma in communication with a necrotic vaginal cuff, forming a large vesicovaginal fistula. The vaginal cuff was debrided and closed horizontally. The bladder was closed vertically (to avoid overlapping suture lines with the vagina) and leak tested. A flap of omentum was interposed between vagina and bladder. The patient recovered well, was discharged home 2 days after surgery; she reported feeling like herself again, without urinary complaints at 3 months after the surgery. Conclusions: This case report highlights the clinical course of a patient with placental invasion into the urinary bladder and the associated urologic complications. Urologists should be aware of this condition as the urinary bladder is the most commonly invaded extrauterine location.