Retrograde Bladder Dissection for Prevention of Bladder Injury during Robotic-Assisted Laparoscopic Hysterectomy

Study Objective To demonstrate a technique for retrograde bladder dissection in a patient with extensive adhesive disease of the pelvis. Design Step-by-step video demonstration of retrograde bladder dissection during robotic-assisted hysterectomy. Setting Academic tertiary referral center. Patients or Participants 38-year-old gravida 3, para 2 with history of two prior Cesareans and tubal ligation, presented with long-standing abnormal uterine bleeding, dysmenorrhea as well as chronic pelvic pain. She was referred to minimally invasive gynecology for definitive surgical management. Preoperative pelvic ultrasound revealed uterus measuring 10.1 × 4.9 cm and was otherwise unremarkable. Interventions Patient was taken to the operating room for robotic-assisted hysterectomy and bilateral salpingectomy. After general anesthesia was administered, patient was placed in dorsal lithotomy position. Intraoperatively, the anterior cul-de-sac was obliterated due to her prior surgeries. The bladder was densely adherent to the entire length of the uterine arteries bilaterally, starting at their origin. The retroperitoneum was entered medially, then paravesical and pararectal avascular spaces were dissected bilaterally. The uterine artery was ligated at the origin to decrease pulse pressure of uterine circulation. Ureterolysis was performed bilaterally. The bladder was carefully dissected and mobilized caudally, in a lateral-to-medial and inferior-to-superior fashion to avoid injury, following the anatomical landmarks. After the bladder was mobilized, hysterectomy was safely completed without complications. Measurements and Main Results The patient had an uneventful postoperative course and was discharged home on the day of surgery. Pathology was benign and revealed adenomyosis as well as endometriosis in right fallopian tube. The patient was symptom-free at her 4-week postoperative visit. Conclusion Retrograde bladder dissection is a useful technique to safely restore anatomy in patients with dense adhesive disease and obliterated anterior cul-de-sac. Knowledge of anatomical landmarks is essential for this technique.