Techniques for difficult dissection of the bladder from the lower uterine segment in a patient with distorted myometrial-endometrial anatomy

Development of the vesicovaginal space in a patient with a history of repetitive abdominal surgery can be difficult. Known risk factors for lower urinary tract injury are previous caesarean section and laparotomy.1 2 Additionally, a laparoscopic approach to hysterectomy has an increased risk of bladder injury.3 In these individuals, preoperative imaging may be helpful for surgical planning. This video demonstrates a safe and reproducible technique for bladder dissection using a robotic-assisted laparoscopic approach in a patient with extensive surgical history. Traditionally, dissection of the bladder is performed in a medial-to-lateral fashion, but we propose a lateral-to-medial approach to minimize the risk of lower urinary tract injury.4

By prioritizing a lateral-to-medial approach and carefully developing the vesicovaginal space with controlled dissection, surgeons may reduce the risk of lower urinary tract injury in complex hysterectomy cases. This technique provides a strategy for patients with significant scarring or distorted anatomy and may enhance operative safety in individuals with a history of multiple uterine or abdominal surgeries.

We present a patient with a history of four caesarean sections undergoing a robotic-assisted laparoscopic hysterectomy. Preoperative MRI was remarkable for a pelvic mass (suggestive of a leiomyoma) that replaced the whole anterior endometrium and myometrium, extending to the posterior wall of the bladder but without any invasion. Intraoperatively, a prolapsing uterine mass was visualized anteriorly, exerting pressure against the bladder and further obscuring the normal anatomic planes. Following dissection, the border of the tumor was clearly demarcated and seen abutting the bladder, as demonstrated by the arrowheads (figure 1).

The dissection began by dissecting the lateral attachments between the lower uterine segment and the posterior bladder wall. After these attachments were safely divided, the vesicovaginal plane was developed from lateral-to-medial using a combination of cold sharp scissors and gentle traction-countertraction to expose the tissue planes. Electrosurgery was used judiciously to maintain hemostasis while helping to develop the tissue planes. The progression of dissection, management of the prolapsing mass, and development of the vesicovaginal plane are demonstrated in video 1. Please see online supplemental file 1 for a list of the robotic instruments that were utilized and a summary of operative techniques.