The patient’s postoperative course was complicated by intermittent fevers and multiple blood transfusions. A voiding cystourethrogram (VCUG) was performed on postoperative day (POD) #14, which demonstrated a small leak from the posterior bladder wall. Foley catheter was maintained, and a repeat

VCUG was performed on POD #21 showing this website persistent leak. She was discharged home with a Foley catheter in place. At her follow-up visit on POD #39, a VCUG revealed resolution of the leak, and the Foley catheter was removed. The patient’s ureteral stent was removed 11 weeks postoperatively. The incidence of PP has increased 50-fold in the last half-century to a currently estimated 1 in 1000 pregnancies. This increased prevalence is attributed to the increased frequency of Caesarean deliveries. The incidence of concomitant bladder invasion is much lower, occurring in approximately 1 in 10,000 births.2 The diagnosis of PP might be made during prenatal screening ultrasound; however, bladder involvement is usually not identified until the time of delivery. Symptoms such as gross hematuria, which might be expected, occur in only approximately 25% of cases.3 The gravest complication

of PP is severe hemorrhage. Karayalçin et al4 described in a series of 73 cases that the most common indication (42.4%) for unplanned hysterectomy was placenta previa and/or accreta. Massive resuscitation with numerous blood products is often required to adequately resuscitate the patient after hemorrhage. Our management of the case is presented as previously mentioned; however, the methods of handling bladder invasion by PP vary widely. For example, complete surgical devascularization see more of the uterus before attempting separation from the bladder might decrease the chance of severe hemorrhage. Alternatively, attainment of vascular control at the lower uterine segment by ligation before developing the vesicouterine space might prove beneficial in this endeavor as well. In addition, in some situations, it might be reasonable to preemptively open the bladder adjacent to the uterine attachment.

This would allow for direct visualization of the trophoblast invasion of the bladder. The previously described almost techniques are useful in that they can be carried out in the hands of a skilled obstetrician. However, a recent analysis of PP with bladder involvement looked at timing of urology consultation relative to outcome. In this series, 2 of 5 cases of PP with bladder invasion underwent preoperative urology consultation, which resulted in no urinary complications in this group. The remaining 3 cases underwent urology consultation during or immediately after surgery and represented 3 bladder injuries and 1 ureteral injury.5 It is our opinion that early urologic consultation and operative assistance will decrease the incidence and/or severity of urinary complications during surgical management of PP with bladder involvement.