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Special Article

Management of Laparoscopic Bladder Injuries
Kyle J. Wohlrab, MD*, Vivian W. Sung, MD, MPH, and Charles R. Rardin, MD
From the Division of Urogynecology, Department of Obstetrics and Gynecology, Women and Infants’ Hospital, Alpert Medical School at Brown University, Providence, Rhode Island (all authors).

Injuries to the urinary system have been reported in up to 8% ofminimally invasive gynecologic surgeries. Intraoperative recognition of a bladder injury allows for immediate repair and decreased postoperative morbidity rates. Although laparoscopic repair of such injuries requires advanced surgical skills, it affords the patient the benefits of minimally invasive surgery. In addition, laparoscopic visualization of the intravesical anatomy may help to delineate therelationship of the ureters to the bladder injury, thus avoiding further complication. This article will review the techniques and devices used to facilitate laparoscopic cystotomy repair. Prevalence and Risk Factors The female urinary bladder is vulnerable to injury during laparoscopic gynecologic surgery. It is estimated that between 50% and 80% of all surgical complications involving the lowerurinary tract are associated with gynecologic surgery [1]. In fact, most lower urinary tract injuries occur during ‘‘routine’’ benign pelvic surgery. In a retrospective review of all gynecologic surgeries and bladder injuries, Gilmour et al [2] noted rates of injury as high as 1.8%. Even higher rates, up to 8.3%, are reported during laparoscopic pelvic surgery [2,3] Furthermore, when compared withabdominal hysterectomy, laparoscopically aided hysterectomies are associated with a 2.61 increased odds of urinary tract injury [4]. On the other hand, multiple studies have demonstrated decreased hospital stay and decreased need for postoperative narcotic analgesia when gynecologic cases are performed laparoscopically compared with open abdominal incisions [5,6]. Therefore it is imperative thatlaparoscopic surgeons be familiar with recognition and repair of such injuries.
Dr. Rardin is a consultant for Mpathy Medical, Inc. Dr. Wohlrab and Dr. Sung have no financial disclosures. Corresponding author: Kyle J. Wohlrab, MD, 695 Eddy St., Suite 12, Providence, RI 02903. E-mail: kwohlrab@wihri.org Submitted April 21, 2010. Accepted for publication September 9, 2010. Available atwww.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2011 AAGL. All rights reserved. doi:10.1016/j.jmig.2010.09.012

Most bladder injuries occur in patients without identifiable risk factors. However, the potential for injury is increased when there is a distortion of the normal anatomy or when substantial dissection is necessary for adequate surgical exposure. Patient characteristics thatmay increase the risk of lower urinary tract injury include pelvic malignancy, severe genital prolapse, large myomas, previous cesarean section, and inflammatory conditions such as endometriosis or pelvic infection. These conditions are also well suited for minimally invasive techniques. However, laparoscopy and roboticassisted surgery require a complex set of surgical skills with an extensivelearning curve, limitations on retraction and packing techniques, and familiarity with a wide range of instrumentation and available energy sources. Altgassen et al [7] demonstrated that the complication rates of surgeons who had completed 30 or more laparoscopic hysterectomies was nearly half that of their less experienced counterparts. The laparoscopic-assisted vaginal hysterectomy (LAVH) poses aunique risk to iatrogenic bladder injury as dissection of the anterior uterine peritoneum may be accomplished either laparoscopically, vaginally, or both. Kadar and Lemmerline [8] noted that the bladder is exposed to injury most during LAVH when it is dissected laparoscopically but closed vaginally. They point out that the caudal direction of the laparoscopic dissection places the bladder in close...