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If there is any concern about the previous bladder sugery (which there is) I would make a vertical incision and avoid a low transverse incision. This is not based on data, just based on common sense. Cosmesis is not a concern when someone has had complex surgery that is working well.

I agree with vertical incision but whee rt paramedian or lt as it ll be difficult to put it in midline

I don't lnow with certain, because I never had a similar case. However, a vertical incision with bladder exploration seems the best logical option.

Do one-shot IVP preoperative or request for cystoscopy before, incise above in the lower part of upper segment .

I agree with vertical incision.

The mitrofanoff was made by using the appendix or part of the small intestine? Why CS is the only option? I agree with the vertical paramedian incision.

Do Midline Skin Incision and Classical Uterine incision and avoid the bladder at all cost

A vertical incision is certainly better. But with an echography just before the CS (full bladder) you certainly hace a good idea concerning the postion of the adhesion

Although midline seems to be adequate, a (high) Joel-Cohen incision could do the trick, depending on the location of the abdominal opening of the Mitrifanoff. Retrograde inspection (flexible cystoscope) or perhaps sonographic imaging (e.g. ultravist®) prior to surgery might help in planning a midline or parasagital incision (left or right of the Mitrifanoff?). Insert a catheter during surgery to protect the appendix. What about vaginal birth? Plan surgery nonetheless. Good luck.

Mitrofanoff was done by appendix

Vaginal route after the bladder plastic surgery is preferable. In case of urgent indications for the SC vertical incision should be performed .

I agree with vertical incision. we used it in 2 cases uneventfully.

I delivered 4 patients with transverse incision higher up, not in lower segment I did not touch bladder peritoneum even. There was not much blood loss & easy to repair. If there is no space & bad adhesions then one have to go higher up with vericle incision in upper segment.

DR. MH MODIBBO Murtala Muhd Specialist Hospital Kano.

If vaginal delivery is contraindicated, classical incision will be the solution. Then the second delivery should be by another c/s @ 35 weeks gestation.

dear Dr_Shagufta_Tahir

what do u mean by transverse incision higher up which level? below umbilicus or above it.

I have done a case earlier higher transverse incision can be done and the peritoneum is avoided

if the adhesion are more then vertical incision can be done

A rare case. Preoperatively, the localization of the bladder can be determined by ecography. The trajects of the blood supply, to both the sigmoid segment used for augmentation and appendix used for Mitrofanoff, would be unknown, but in any case they will be located anterior to the lower segment. Careful dissection - both of the bladder and of the vascular pedicles of the two segments of digestive tract used to reconstruct the lower urinary tract - may be needed to gain access to the lower segment. Should this dissection be risky or impossible, a classical incision on the uterus may be needed, and the decision will be taken intraoperatively. It is therefore more sensible to perform a longitudinal (i.e. vertical) incision of the abdominal wall, from the onset. A midline incision would probably be safe if the cutaneous stoma of the appendix is in the right iliac area, but if it is at the umbilicus, a left paramedian incision may be safer and should still offer sufficient exposure. The catheterization of the appendix , after emptying the bladder, helps. In 29% of cases there will be an associated uterine malformation, which should have been documented at the time of the cystoplasty.

Nice answer dr valentine. Thanks

If you go to CS, of course recomendations by dr Stefan are meaningful, as well as other collegues such us dr Kasapoglu!

I would suggest midline incision for better exposure and to avoid incidental injuries..

No midline

Dear Mohamed,

it would be very interesting for all contributers to get some information on the outcome of Your patient. Hope it all went well.

Is an extra-peritoneal approach feasible Dr.Valentin Stefan?

Now question to Elsawy:

What was a solution in your case?

Could you breafly describe it?

The situation is complicated

I think the middle is preferable to access

what result?

tell us

Old CS performed with vertical incision.