Juniper Publishers: Preventing Bladder Injury at Hysterectomy in Post-Cesareans
JUNIPER PUBLISHERS- JOURNAL OF GYNECOLOGY AND WOMEN’S
HEALTH
Journal of Gynecology and Women’s Health-Juniper
Publishers
Authored by Shikha Seth*
Abstract
With the increasing cesarean section rates
gynecologists are facing more number of cases with previously scarred
uterus at the time of hysterectomy. Uterine incision especially of
cesarean section leads to bladder adhesions which poses great problem at
the time of bladder dissection during hysterectomy and sometimes
inadvertently ends up in cystostomy. Greater the number of cesareans,
higher is the chances of adhesions and fibrosis. Both vaginal and
laparoscopic approach can be utilized effectively just taking few
precautions. Urinary bladder if gets injured, one should be able to
diagnose it per operatively so that timely management can be done to
prevent long term squealae. Here few important points are focused which
can help in assessing the difficulty, at risk cases pre-operatively and
surgical options to prevent bladder injury at the time of both vaginal
and laparoscopic hysterectomy.
Abbreviations: CS: Cesarean Section
Introduction
With the modern medicine, equipments, awareness
altogether with the consumer protection act the cesarean section is
facing rising trend ranging from 20-30% deliveries in most of the
centers. Now a days Gynecologist are getting most of the patients of
hysterectomy who have undergone one, two or sometimes even three
cesareans in the past. The problem arises due to post-surgical adhesion
which makes the otherwise normal size uterus hysterectomy technically
difficult vaginally, requiring either the abdominal or laparoscopy
procedure. Previous cesarean section (CS) is a significant risk factor
for urinary tract injury at hysterectomy (odds ratio 2.04; 95% CI
1.2-3.5). Incidental cystostomy at time of abdominal and vaginal
hysterectomy was 0.76 & 1.3% respectively [1].
Mobilization of urinary bladder off the cervix is the
2nd important step after securing the cornual pedicles. In cases of
scarred uterus adhesions are there not only between the bladder and
uterus but also to the anterior abdominal wall which make the dissection
challenging. To avoid complications lateral window technique is the
safest option whether the vaginal, abdominal or laparoscopic mode is
chosen. This mini-review focus on surgical considerations to avoid
bladder complications during hysterectomy in the scarred uterus cases.
During Vaginal Hysterectomy
Conventional procedure of vaginal hysterectomy
describes emptying the bladder before surgery with catheter to avoid
injury, but in cases of previously operated uterus it is preferable to
keep the post void urine to be left in urinary bladder as it better
delineates the boundaries and in case of inadvertent injury results in
gush of urine for intra-operative identification. Urinary bladder extent
ideally be noted by the bladder sulcus (the bladder reflection on the
cervix) and should be confirmed by the bladder sound pushed through
urethral meatus.
Submucousal fluid infiltration is recommended using
100ml saline (0.9%) or antibiotic solution with local anaesthetic
(0.5-1% lignocaine) and 1:2,00,000 adrenaline or 20 units vasopressin
injection, which reduces the blood loss by compressing and constricting
the vessels keeping the surgical field clean for dissection purpose.
Saline takes the path of least resistance and separates the planes, lyse
filmsy adhesions, pushes the bladder up, while anesthetic relaxes the
pelvic floor further.
Traction and counter traction mechanism be used
judiciously to achieve the exposure of vesico-cervical junction for the
incision in vaginal approach. Surgeon pulls the cervix down toward
himself with his left hand while the assistant pushes
the anterior vaginal wall with bladder up and cephalad. Sharp dissection
is preferred while dissecting between the two viscera as it maintains
surgical planes. Blunt dissection in case of previous scar has high
chances of cystostomy. Keep the scissors tip towards the cervix while
dissecting. In cases of nulliparous women and limited intorital opening
“Schuchartd’s incision” (gynaecological episiotomy) can be tried to
improve exposure.
Surgical complication with vaginal hysterectomy in
one or two previous cesearenacses do not differ in hands of experienced
person with proper patient selection [2] and uterine scarring as sequel to cesarean is not a contraindication to vaginal hysterectomy [3].
Restricted mobility, cases with high up cervix which cannot be pulled
even one centimeter on pulling with volsellum, which in draws abdominal
wall with pulling are highly suggestive of abdominal wall adhesions and
should not be tried overzealously by the beginners [4].
For laparoscopy the 10mm central optical port three
5mm accessory ports are placed after creating pneumoperitoneum.
Abdominal wall adhesions are found in midline and are tackled with
cautery or harmonic dissection. Bladder when densely adherent to lower
segment poses difficulty in pushing it down. Safe approach is Lateral
Window Technique.
Lateral window technique: can be used both for vaginal and laparoscopic approach to hysterectomy
This space was first described by Dr. Shrish Sheth
utilizing the utero-cervical broad ligament in post cesarean cases
during vaginal hysterectomy. He described that the lateral area; the two
leaves of broad ligament remains free and allows easy possibility for
entry to dissect whether vaginally or abdominally. In vaginal
hysterectomy cervix is pulled down and bladder cephalad by the assistant
and instead of pushing the bladder up from the center using gauze
covered thumb, sharp dissection using blunt curved Metzenbaum scissors
is done from lateral to medial side keeping the tip of scissors near as
well as towards the cervix. Bladder pillars are incised from lateral to
medial side. 220 vaginal hysterectomies with previous cesarean reported
by Dr Sheth [4] with only 1.5% intra-operative urological trauma vaginally.
In laparoscopic approach after cutting the cornual
pedicles broad ligament is dissected down till the uterine bundle is
identified. Once the uterine vascular bundle is identified the space can
be dissected just above these vessels to reach the lateral margins of
cervix. Any fatty tissue should be moved with the bladder. Uterine
vessels are then tackled by desiccation or ligation. Similar procedure
is done on the opposite side. Once the bladder is completely dissected
and lifted off from the cervix below, midline adhesions of the bladder
and pillars can be gradually separated using sharp dissection or
harmonic ultracision staying near to cervix [5,6].
The lateral approach crates a window which allows a
safe dissection. It is unlikely that the scar of the previous cesarean
would extend laterally with thickness as in the medial portion. In few
cases adhesions may be very dense then intraoperative retrograde
distension of baldder with Methylene blue dye may help in identifying
the borders. This helps in delineate the injury avoiding the need of
cystoscopy [7].
Conclusion
Both Laprascopic and Vaginal hysterectomy are safe
and feasible procedures in patients with previous CS, where laparoscopy
is associated with reduced blood loss and hospital stay, vaginal is
associated with reduced surgery time without abdominal wound [8].
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