A laparovaginal strategy to avoid bladder injury during laparoscopic-assisted vaginal hysterectomy in cases with ventrofixed uterus following previous cesarean section

Abstract

BackgroundLaparoscopic hysterectomy for benign indications in cases with ventrofixed uterus following previous cesarean section (CS) increases the surgeon’s concern of bladder injury. The present study describes a laparovaginal strategy to avoid bladder injury during laparoscopic-assisted vaginal hysterectomy (LAVH) in cases with ventrofixed uterus following previous CS.MethodsIn a retrospective study conducted in our private general hospital, we included consecutive cases of laparoscopically confirmed ventrofixed uterus associated with previous CS. These were from the cases who underwent LAVH for benign indications. Cases with uterus size >16 weeks of gestation were excluded. Patients’ clinical, intraoperative and postoperative characteristics were studied to evaluate the feasibility of the described laparovaginal strategy to prevent bladder injury during LAVH in cases with ventrofixed uterus.ResultsA total of 35 cases with ventrofixed uterus underwent LAVH during the study. Six (17.14%) cases had a history of one CS, while 29 (82.86%) cases had a history of previous two or more CSs. A supravesical loose fatty tissue plane (supravesical space) indicating reach to the bladder wall during laparoscopic lysis of the uterus from the anterior abdominal wall was successfully demonstrated in all the cases. The bladder flap preparation was avoided. Uterovesical adhesions were dissected by posteroanterior approach during vaginal phase of LAVH in all the cases. LAVH was successfully performed in all the cases. None of the cases had bladder injury, laparotomic conversion or other major complications. Mean operating time for LAVH was 149.71±38.36 minutes (70–200 minutes). Mean uterine specimen weight was 162.85±92.57 g (60–500 g). Mean postoperative hospital stay was 2.42±0.73 days (2–5 days).ConclusionIn spite of severe adhesions in cases with a ventrofixed uterus following previous CS, bladder injury can be avoided during LAVH by the described laparovaginal approach in the present study.Short synopsisThe described laparovaginal approach may avoid bladder injury during laparoscopic-assisted vaginal hysterectomy in cases with a ventrofixed uterus following previous cesarean section.

Cesarean scar perforation in laparoscopic hysterectomy for endometrial cancer: a case report

“…Filling the bladder with saline is another technique utilised to clarify the boundary with the uterus, which may be cause for concern [18]. Several reports in the literature aimed to decrease these serious urological complications by for example dissecting from the vaginal rout [19] or laterally to the adhesions [20]. Although Shellhaas and colleagues (2009) [18] did not detect a statistically significant beneficial effect of filling the bladder with saline, shorter operation times, shorter postoperative hospital stays, and fewer bladder injuries were noted in patients whose bladders were filled.…”

Outcomes of Hysterectomy in Women with Prior Cesarean Section: Retrospective Analysis of Non-Descent Vaginal Hysterectomy (NDVH) Versus Abdominal Hysterectomy (TAH) in Benha University Hospital

“…Given the high prevalence of both CS and HR, a lot of women who have had a previous CS will need HR later in their life [1,2,3] . Previous pelvic surgeries, including CS's, may lead to formation of significant intra-abdominal adhesions, especially along the previously dissected bladder [5,6] . Previous CS has been found to be associated with an increased odds of surgical complications in women undergoing HR later in their life [7] .…”

“…Women were included if they had all the following criteria: (1) women with prior ≥ one CS, (2) non-descent uteri ≥ second degree uterine descent even under anesthesia, (3) patient's age ≥18 years old (4) execution of general or spinal anesthesia, (5) the execution of hysterectomy via vaginal or abdominal route, (6) benign uterine diseases, (7) clinical follow-up until completely cured or≥ 30 days postoperatively.…”