••• Chapter 37^ Lower Urinary Tract Injuries During Gynecologic Surgery^371
❍ At what times during an abdominal hysterectomy is the bladder at greatest risk?
(1) Incising the parietal peritoneum
(a) Failure to drain the bladder before entering the peritoneal cavity increases this risk.
(2) Entering the vesicouterine fold
(b) If the fold is entered too low, the dome of the bladder may be injured.
(3) Separating the bladder from the uterine fundus, cervix, or upper vagina
(c) Adhesions from previous surgery, endometriosis, irradiation, or pelvic inflammatory disease can cause the
bladder to be densely adherent to the lower uterus and upper vagina. Sharp dissection with Metzenbaum
scissors pointed away from the bladder will decrease this risk.
(4) Entering the anterior vagina and suturing the vaginal vault
(d) Vagina or grasping the edges of the vaginal cuff in preparation for repair will prevent bladder injury here. In
addition, suturing the vaginal cuff in an anterior to posterior direction will decrease the risk of bladder injury.
❍ Where is the most common location of a bladder injury during entry into the peritoneal cavity?
Bladder dome.
❍ What is the most common location of a bladder injury during vaginal hysterectomy?
Supratrigonal portion of the bladder base.
❍ How is the correct plane between the bladder and the cervix recognized during vaginal hysterectomy?
Firm downward traction on the cervix with gentle countertraction of the bladder with a right-angled retractor
should reveal the correct plane, which is white and relatively avascular.
❍ Once a bladder injury is suspected, how is it diagnosed?
Use a Foley catheter to instill 400 to 600 cc of sterile milk or sterile water and methylene blue into the bladder and
watch for this colored fluid in the surgical field.
❍ How should a bladder injury be repaired?
The bladder can be damaged at the trigone, the base, or the dome. The size, nature (thermal, sharp laceration,
or crush), and location of the injury will determine the most appropriate management. Careful assessment of the
extent of injury with intraoperative cystoscopy should be performed. Intravenous (IV) indigo carmine should be
administered to assure ureteral patency and absence of damage to the ureters. Several key surgical principles must
be followed to ensure a successful repair; the repair should be tension free, water tight, and hemostatic. Adequate
mobilization in order to achieve a tension-free closure must be performed. Repair should include a multilayer
closure with delayed absorbable sutures (typically 3-0) because permanent suture may cause stone development.
Small perforations of <1 cm, such as those following trocar injuries, usually require no repair. Prolonged bladder
drainage may be useful in cases of injury over dependent areas of the bladder and ureteral catheterization could be
required if the injury involves the trigone or is in close proximity to the ureteral orifices.
❍ What should the postoperative management of a cystotomy repair include?
Bladder decompression for 7 to 10 days. Consider prophylactic antibiotic suppression. Performing a voiding
cystourethrogram to assure that the bladder is completely healed prior to removing the indwelling catheter is
recommended by some authors; however, care should be taken as to not over distend the bladder during the study.
Ureteral catheterization is not necessary for injuries at the dome that do not involve the ureters.