Bladder flap creation during cesarean delivery. A systematic review and meta-analysis of randomized controlled trials

The aim of the study is to compare the risks and benefits of bladder flap creation and omission during cesarean delivery. The databases search from inception to August 2025 included PubMed, Scopus, Embase, Web Of Science, Cochrane library, and clinicaltrials.gov registration using the keywords cesarean delivery AND bladder flap and their MesH terms yielded 13 studies with 3663 participants. All studies were evaluated through risk of bias assessment, and the quality of evidence was assessed through GRADE analysis. Microscopic hematuria was evaluated in 6 studies with 2738 participants and revealed an Odds Ratio (OR) of 3.23 with 1.10, 9.42 95% Confidence Interval (CI), P value = 0.04, I2 = 94%. Intraoperative blood loss was evaluated in 3 studies with 609 participants and revealed a mean difference (MD) of 46.75 with -123.50, 217.00 95% Confidence Interval (CI), P value =0.59, I2 =89%. Hemoglobin drop was evaluated in 7 studies with 2953 participants and revealed a MD of 0.15 with -0.05, 0.35 95% Confidence Interval (CI), P value =0.13, I2 =99%. Total operative time was evaluated in 9 studies with 3170 participants and revealed a MD of 7.93 minutes with 3.21, 12.66 95% Confidence Interval (CI), P value =0.001, I2 =97%. Incision to delivery time was evaluated in 8 studies with 3131 participants and revealed a MD of 0.52 minutes with 0.45, 0.58 95% Confidence Interval (CI), P value <0.001, I2 =99%. Duration of hospitalization was evaluated in 4 studies with 2574 participants and revealed a MD of 0.33 days with -0.28, 0.95 95% Confidence Interval (CI), P value =0.28, I2 =100%. Pain VAS score was evaluated in 5 studies with 1150 participants and revealed a MD of 0.88 with 0.20, 1.55 95% Confidence Interval (CI), P value =0.01, I2 =94%. The risk of bladder injury was evaluated in 5 studies with 1188 participants and revealed an OR of 2.11 with 0.48, 9.20 95% CI, P value =0.32, I2 =0%. Postoperative complications were evaluated in 4 studies with 1101 participants and revealed an OR of 1.44 with 0.55, 3.75 95% CI, P value =0.46, I2 =0%. Time to first defecation was evaluated in 3 studies with 356 participants and revealed a MD of 0.46 days with 0.02, 0.91 95% Confidence Interval (CI), P value =0.04, I2 =99%. Omission of bladder flap creation during CD is associated with significant shortening of the operative time (high evidence) and incision to delivery time (high evidence) and a significant reduction in microscopic hematuria (low evidence), postoperative pain score (low evidence) and time to 1st defecation (moderate evidence) compared to women subjected to bladder flap creation. CRD42022306980