Injury To The Bladder

Cystotomy is the most common urinary tract injury (Table 2).

Dissection of the bladder off the lower uterine segment, cervix, and upper vagina is necessary for a total hysterectomy. Less dissection is needed for a suprac-ervical hysterectomy and not surprisingly results in a lower rate of cystotomy (37). Cystotomy is also a common injury during the dissection for laparoscopic retropubic colposuspension (40).

When bladder injuries are not recognized intraoperatively they often lead to significant morbidity, including postoperative urinomas, bowel obstructions, infections, and fistula (41). Observation of gas in the Foley bag or bubbles at the time of cystoscopy is a common intraoperative sign of bladder injury during laparoscopy.

When an intraoperative injury is suspected, consultation with urologist and evaluation of the lower urinary tract are recommended. Typically this involves intravenous injection of Indigo carmine (5 cc) and cystoscopy. The bladder and both ureters should be evaluated in all cases.

Energy sources such as monopolar and bipolar electrocautery, CO2 laser, and the ultrasonic scalpel can all be associated with injuries to the bladder or ureter. These energy sources were evaluated in an animal model to determine the accuracy of clinical assessment of the injuries and the extent of lateral spread. Laparoscopic assessment is as accurate as gross assessment of the injured tissue (42). Monopolar cautery has the greatest risk of lateral spread (43).

Small injuries to the dome of the bladder can often be managed with prolonged bladder drainage. When surgical repair is required, this can often be accomplished with laparoscopic suture techniques. If injury occurs at the time of hysterectomy, transvaginal repair is also an option.

The route chosen for repair should reflect the surgeon's ability and experience. A closed pelvic drain should be considered if the repair is not watertight.

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