Prevention and Management of Laparoendoscopic Surgical Complications

Table of Contents IntroductionComplications of Burch Procedure - Comparison of Open to Laparoscopic ApproachContraindications to the Burch ProcedureComplications to the Bladder and Urinary Tract Occurring During Surgery on Other Organ SystemsSummary for Prevention of Bladder Injury During Laparoscopic Surgery

INTRODUCTION

Laparoscopic urinary bladder surgery primarily involves retropubic bladder neck suspension procedures. Because variations of the laparoscopic Burch procedure (Tanagho, Hodgkinson) are most frequently performed, this chapter will focus on the complications of the laparoscopic Burch procedure -  avoidance, recognition, and treatment.

In addition, significant injury to the bladder and the ureters can occur during the performance of laparoscopic procedures such as hysterectomies, ovarian surgery, and treatment of endometriosis. Avoidance, recognition, and treatment of these injuries are outlined along with general principles of management.

Importance of the Burch procedure is highlighted by the presence of = urinary incontinence in 15% to 35% of all women. Genuine stress incontinence is the most common type of incontinence in women.^1,2

To evaluate female incontinence, it is important to check for urge = incontinence, detrusor instability, unstable urethra, vesicle sphincter dyssynergia, and overflow incontinence. In addition urethral pressure should be evaluated, especially in patients over 65 years of age as a low pressure urethra is common in these patients. It is mandatory to perform office urodynamics studies on each patient, and to perform a sophisticated urodynamic study on those in whom a clear cut diagnosis is not developed.^3,4

Ultrasound evaluation of the urethrovesicle junction with stress assists in the diagnosis of patients with stress incontinence. An ultrasound is considered positive when greater than 10 mm movement of the urethrovesicle junction occurs with Valsalva.^5-8

The laparoscopic Burch procedure is best suited for genuine stress incontinence. This incontinence is defined as the involuntary loss of urine that occurs when intravesicle pressure exceeds maximum urethral pressure in the absence of detrusor contraction.^9,10

The laparoscopic Burch procedure can be performed with either a preperitoneal or a transperitoneal approach. The procedure can be effected with sutures,^3,4,11 or staples and mesh.¹²

The more common laparoscopic procedure is a Tanagho modification of the Burch procedure.¹³ Two sutures are placed on either side of the urethra, each 1.5 cm lateral to the urethra. One suture is sited at the midurethral junction and the other near the urethrovesicle junction. These sutures are passed into Cooper's ligament directly above the point of insertion into paravaginal fascia. If staples and mesh are used, the mesh is stapled into place lateral to the urethra approximating positions as previously described. The mesh is stapled into the Cooper's ligament.¹²

If the transperitoneal approach is utilized, bleeding can occur during incision of the urachus. Use bipolar cautery on the urachus prior to incision to secure hemostasis. Dissection is initiated at least 2 cm above the insertion of the bladder. Dissection is carried upward until loose areolar tissue is located, then deepened to the bony pelvis and into the space of Retzius.¹¹

Bleeding can occur during dissection of the bladder and the paravaginal fascia and may be treated with bipolar cautery. Avoid dissection near the urethra or urethrovesicle junction as iatrogenic trauma can occur.¹¹
Complications specific to transperitoneal laparoscopic approach to the space of Retzius include thermal injuries to the dome of the bladder.¹¹ The preperitoneal approach avoids opening the peritoneum near the bladder insertion into the anterior abdominal wall. The likelihood of thermal injury to the dome of the bladder is decreased with a preperitoneal approach. However, in patients with previous surgery, especially Cesarean section, adhesions to the bladder can facilitate balloon dissection iatrogenic trauma to the bladder. It is mandatory to evaluate the bladder by cystoscopy at the end of the procedure to ensure that no staples or sutures have been placed into the bladder and that there is no bladder injury.

Infection

The incidence of reported wound infections and/or hematoma ranges from 2% to 9% in open Burch procedures.

^9,10

Urinary tract infection is not uncommon and has a widely variable incidence ranging from 2% to 45%.

¹⁴

The use of prophylactic antibiotics is helpful in reducing these infections. Extensive irrigation also reduces the risk of infection.

¹⁴

Wound infection and hematoma have = not been reported complications of the laparoscopic Burch procedure. This is likely due to the ability to control bleeding and to irrigate the space copiously.

^3,4,11,12Hemmorrhage

A significant amount of venous bleeding can occur from perforating vessels at the medial edge of the periurethral attachments to the pubic bone.

^9,10

Bleeding from large perivesicle veins can be troublesome and result in rapid blood loss. The incidence of perioperative hemorrhage resulting in transfusion ranges from 1% to 2% of open Burch procedures.

¹⁵

No transfusions have been reported with laparoscopic Burch procedures.

^3,4,11,12

If bleeding occurs use bipolar cautery or clips. Placement of a drain is advisable if significant oozing persists.

Voiding Dysfunction

Patients with severe anterior vaginal wall relaxation, those with preoperative high postvoid residual urine volumes, and those with underactive or areflexic detrusor muscles as demonstrated with pressure flow studies, are at high risk for prolonged voiding dysfunction.

¹⁶

These patients may require preoperative teaching of intermittent self-catheterization.

¹⁶

Patients with evidence of preoperative voiding dysfunction, a peak flow rate of less than 20 mL/second, low or absent detrusor pressure during micturition, and the presence of a large residual urine are likely to have voiding problems after retropubic suspension.

^16,17

Voiding dysfunction following the Burch procedure is a well-documented complication with an incidence ranging from 2% to 25%.

^15,16

Prolonged catheterization greater than ten days and long-term symptoms of prolonged voiding with low peak flow rates and high residual urine volumes constitute postoperative voiding problems. It may be necessary to manage these patients with prolonged catheter drainage and/or intermittent self-catheterization.

Delay of spontaneous voiding following colposuspension may be treated with cholinergic drugs or alpha blocking agents.

¹⁶

In addition, a relationship may exist between postoperative voiding difficulties and the height of bladder neck elevation and/or the degree of approximation of paravaginal tissue to Cooper's ligament. This relationship is one reason for the growing tendency to tie the sutures under less tension. Postoperative voiding difficulties occur with laparoscopic

^3,4,11,12

as well as with open Burch procedures.

^9,10,15,16

However, the use of prolene mesh with staples has occasioned no episodes of urinary retention greater than 24 hours.

¹²

A common question regards how tightly the vagina should be brought up against Cooper's ligament. Urologists in general feel that the value of the Burch procedure lies in fashioning tissue to tissue contact which allows scarring to occur. The procedure therefore is likely to last longer than those procedures that depend on sutures alone to maintain the position of the vagina. Suture can erode through the vagina with time.

In almost all circumstances, the vagina can be lifted to make contact with Cooper's ligament. Where the vagina is less compliant, and the bladder neck too close to the symphysis pubis, place the suture more laterally, away from the bladder neck in the vagina. This will allow correct elevation of the bladder neck with direct tissue to tissue contact. Herniation posterior to the vagina may be secondary to vaginal pressure created by abnormal elevation of the vagina to achieve tissue contact. Varying the position of the sutures laterally can allow tissue to tissue contact without causing undue pressure on the vagina.

A curved ring forceps is used to elevate the vagina lateral to the bladder neck to the level of Cooper's ligament, allowing bladder neck elevation to be seen prior to positioning the first suture in the vagina on each side. A short 20 mm half circle atraumatic needle with 2-0 non-absorbable suture of 36 inch length is used for the sutures. A curved tip needle holder is recommended.

Once the first suture is placed on the patient's right side and tied, a second suture is placed distal to the first, again using the ring forceps to elevate the vagina. The second right hand suture is tied prior to repeating the procedure on the patient's left side. The suture is secured with an extracorporeal knot using a knot pusher, and the tie reinforced with three intracorporeal throws.

After completion of sutures, the vagina is in contact with Cooper's ligament on each side with the bladder neck just behind, but not touching, the pubic symphysis. The peritoneum is closed with a hernia stapler or sutures when using the intraperitoneal approach.

Repair of the support of the bladder neck can also be effected by loosely attaching the paravaginal fascia to Cooper's ligament, leaving a space of 1 to 2 cm. Performance of a paravaginal repair if indicated provides excellent support. This technique of combined paravaginal repair and Cooper's procedure is preferred by many gynecological laparoscopists.

Detrusor Instability

Detrusor instability is a common cause of persistent or recurrent incontinence following surgery for genuine stress incontinence. The postoperative course of detrusor instability is unpredictable as it may persist, worsen, improve, or develop de novo. All patients should be warned preoperatively that they may require anticholinergic medications postoperatively.

^18-20

The occurrence of postoperative detrusor instability in a previously stable urinary bladder is a well-recognized complication of colposuspension and is often cited as the cause of surgical failure. The reported incidence ranges from 3% to 25%.

^9,10,15,16

The majority of these patients will improve with anticholinergic therapy or neuromuscular stimulation treatment. Detrusor instability occurs less often with the laparoscopic approach, reported from 2.8% to 6.0%.

^3,4,11,12Lower Urinary Tract = Injury

Cystotomy can occur during any step of the dissection. In addition, electrosurgery may cause thermal injury to the bladder. With routine use of intraoperative cystoscopy, urinary tract injury should be recognized. If a suture is inadvertently passed into the bladder, it should be removed and passed under direct vision. If evidence of thermal damage is found, the involved area of bladder should be resected with adequate borders, the defect closed and imbricated with suture and the draining catheter left in place at least two weeks.

¹¹

Postoperative fistula formation is rare. The incidence of injury to the bladder and urethra is less than 1%.

²¹

Injury to the bladder occurs with both the laparoscopic and open approach with the same frequency.

Ureteral Injury

Ureteral injury at the time of colposuspension is also rare. Ureteral injury may be associated with performance of the Moskowitz procedure for obliteration of the cul-de-sac.

²²

When ureteral obstruction occurs following colposuspension, it is usually due to ureteral kinking from acute elevation of the anterior vaginal wall rather than obstruction due to suture ligation of the ureter.

^23,24

Ureteral injury should be suspected if the patient develops lumbar pain and fever approximately 48 hours postoperatively. The obstruction may be relieved by a ureteral stent placed cystoscopically and left in place for at least ten days. When cystoscopic stent placement is not possible, percutaneous nephrostomy may relieve the obstruction and facilitate antegrade placement of the ureteral stent.

Confirmation of ureteral patency should be obtained at the time of colposuspension by observing indigo carmine dye flow from the ureteral orifices during cystoscopy. A retrograde ureterograph should be performed if there is concern for ureteral damage. This complication is as frequent with laparoscopic as with the open approach.

^{3,4,9-12,15,16}

Careful cystoscopic examination is essential for both approaches.

Deep Venous Thrombosis

Deep vein thrombosis, pulmonary embolus, and cerebrovascular accidents are particular risks following pelvic surgery and have an incidence of 0.5% following colposuspension. It is important to provide pneumatic compression stockings for antithrombotic prophylaxis. This complication is as likely with laparoscopic as with the open approach.

^{3,4,9-12,15,16}Groin Pain

Some patients may develop groin pain at the suture site through Cooper's ligament. This very occasionally necessitates re-operation to remove the sutures.

²⁴

Initial management, however, should be conservative and consist of reassurance, anti-inflammatory agents and mild analgesics.

Dyspareunia

Dyspareunia is thought to be due to tenting of the posterior vaginal wall. This condition usually improves within two months after colposuspension. It is helpful to instruct patients to wait two months before initiating intercourse.

²⁴

Dyspareunia is as likely with open as with the laparoscopic approach.

Nerve Damage

Nerve damage can occur with colposuspension.

Nerve injury is most commonly related to direct nerve compression against adjacent structures and may result in first-degree injury (neuropraxia) which spontaneously resolves in one to three weeks. Rarely, a second-degree injury (axonotmesis) may occur which takes two to six months to resolve.

²³

The most frequent nerve involved is the common peroneal nerve,

²⁵

but injury to the obturator, sciatic, femoral, or saphenous nerves may occur.

Table 1

lists the nerves which may be injured during suspension procedure, the mechanism of injury, and the clinical presentation. Obturator nerve injury is unlikely with proper suture placement.

^23,24

All of these nerve injuries may occur with either the open or laparoscopic approach to the Burch procedure. Complete familiarity with mechanisms of injury will help the surgeon avoid these problems.

Immediate Postoperative Urinary Incontinence

Immediate postoperative urinary incontinence may occur with both = laparoscopic and open approaches. It may be overflow incontinence, detrusor instability, lower urinary tract fistula, = urinary tract infection, or watery vaginal discharge simulating urinary incontinence.

Persistance Stress = Incontinence

Persistent stress incontinence is most commonly due to failure of the surgical procedure to stabilize and support the bladder neck. This circumstance can be determined by followup urodynamics and ultrasound for evaluation of the urethrovesicle junction movement.

^5-8

Persistent stress incontinence appears to occur less often with the laparoscopic approach.

¹²

Intrinsic sphincter insufficiency (as indicated by a low leak point pressure) may necessitate a sling procedure or periurethral collagen injections.

Postoperative Rectocele, Enterocele, and Uterine Descent

Development of postoperative uterovaginal prolapse, rectocele, enterocele and uterine descent, is a late complication of Burch colposuspension.

²⁶

The incidence of enterocele formation following the Burch procedure is reported to range from 5% to 27%.

²⁶

The presence of a cystocele that extends to the vaginal introitus or beyond is the only preoperative risk factor so far identified.

^10,23-25

The majority of patients do not have identifiable risk factors. It is not clear whether prolapse is due to disruption of the vaginal axis which exposes the vaginal apex in the posterior vaginal wall to a greater degree of intra-abdominal pressure, or to an intrinsic weakness of the pelvic floor.

All patients should be evaluated for evidence of genital prolapse preoperatively and this should be corrected at the time of colposuspension. If there is concern about prevention of rectocele and enterocele, obliterate the cul-de-sac using a Moschcowitz procedure with 2-0 permanent suture through the laparoscope. Attempt to obliterate the channels on either side of the sigmoid colon to prevent enterocele formation. Vaginal prolapse can be treated with a modified laparoscopic McCall procedure using No.1 permanent suture to suspend the posterior wall and tip of the vagina to the uterosacral and cardinal ligaments. A laparoscopic sacral spinous vaginal vault suspension has also been described for Stage III and IV prolapse.

³

Laparoscopic sacracolpopexy is an effective technique for treatment of vaginal vault prolapse.

²⁷

Enterocele may occur with either an open or a laparoscopic approach. Avoiding this complication requires a transperitoneal approach. If the procedure can be completed in a preperitoneal manner which avoids the risks associated with a transperitoneal approach, the risk of genital prolapse may be acceptable.

FAILURES OF THE BURCH PROCEDURE

The return of incontinence following the Burch colposuspension may be due to 1) recurrent or persistent genuine stress incontinence, or 2) urge incontinence secondary to detrusor instability.

Occasionally, patients report a tearing sensation in the groin following exertional straining. This condition may be caused by a pulling of the sutures through either paravaginal fascia or Cooper's ligament, followed by a return of incontinence.

Stress incontinence may recur even with a well-elevated or well-supported bladder neck. This may be due to the presence of a rigid, functionless, drainpipe urethra secondary to postsurgical, postinfection, or postradiation fibrosis.

²⁸

Recurrent or persistent genuine stress incontinence requires either re-operation repeating the same procedure or with a sling procedure to correct the difficulty. Urge incontinence secondary to detrusor instability requires medical therapy for detrusor instability. Both open and laparoscopic approaches are subject to these complications, although the laparoscopic approach may have fewer episodes of detrusor instability.

^11,12

Voiding Disorders

Low-pressure voiding with a maximum voiding detrusor pressure of less than 15 cm of water has been shown to significantly predispose the patient to immediate postoperative voiding difficulties.

²⁸Significant Damage To Urethral Integrity

With significant damage to urethral integrity, retropubic suspension, such as colposuspension, is unlikely to be successful. The maximum intrinsic urethral pressure appears to be at midurethra in the normal continent women and, if this area has been damaged, it may be impossible to provide successful continence surgery with colposuspension.

²⁴Scarred Vagina

A major contraindication for a Burch procedure is the presence of a scarred, foreshortened, and immobile anterior vaginal wall where elevation of the lateral fornices is unlikely.

²⁴Lack of Bladder Neck Mobility

Patients with a well-supported bladder neck aligned behind the symphysis pubis and no mobility on straining are unlikely to achieve any benefit from colposuspension.

^9,10Role of the Burch Procedure In Clinical Practice

The laparoscopic Burch colposuspension has resulted in a very straightforward surgical correction for patients with genuine stress urinary incontinence.

Patients are able to return to their normal activities within one week after surgery provided they avoid heavy lifting or activities that would affect the integrity of the sutures. The incidence of infection, hematoma, and other complications is low. This procedure is a very useful addition to our armamentarium. The complication rate of laparoscopic Burch procedures approximates 10%.

^3,4,11,12

The most common complication after a Burch procedure is an unstable bladder whether performed laparoscopic or open.

^3,4,11,12

The complications from a laparoscopic Burch procedure are not different from the complications of the open procedure, but occur less frequently. As a result, the laparoscopic Burch procedure appears to be an effective and efficient use of minimally invasive techniques for solution of a major gynecologic and urologic problem.

A direct comparison of laparoscopic retropubic urethropexy using prolene mesh compared to classic Burch retropubic suspension showed:

¹²

1) 40 minutes less time in the operating room.

2) 320 cc's less blood loss.

3) 65% performance of laparoscopic Burch procedures in outpatient versus none as outpatient for classic Burch.

4) No urinary retention greater than 24 hours for the laparoscopic Burch approach with 100% urinary retention in the classic approach.

5) Recovery mean time of three days for the laparoscopic approach versus four to six weeks for the classic approach.

6) 2.8% of patients who underwent the laparoscopic approach developed detrusor instability compared to 18% who underwent the open procedure.

7) The cure rate for the laparoscopic approach was 96% compared to 87% with the classic Burch.¹²

A direct comparison of laparoscopic retropubic urethropexy using prolene mesh compared to classic Burch retropubic suspension is shown in Table 2.DISCUSSION

A significant point of discussion concerning the laparoscopic Burch centers around the performance of other supporting procedures, such as the Moschowitz procedure. Performance of the Moschowitz procedure requires a transperitoneal approach for suture placement. Enterocele and rectocele develop in 8% to 15% of patients who have had Burch colposuspension.²¹ Whether all patients should be subjected to additional procedures to protect these 8% to 15%, and whether the performance of additional procedures will protect these patients, has not been evaluated. The simplicity of a preperitoneal approach offers benefits of shorter operating time and decreased morbidity. The preperitoneal procedure does not allow for ready performance of transperitoneal cul-de-sac obliterative procedures. In fact it may prove beneficial to perform the preperitoneal Burch procedure, as is done classically, without performing additional repairs unless those additional repairs are in fact specifically required at the time of the Burch procedure.

Bladder

The urinary bladder can be injured during operations on other organ systems. The urinary bladder can sustain thermal and mechanical injuries. Thermal injuries can occur from bipolar and = unipolar electrocautery, use of laser energy, and from endothermic devices. Mechanical injuries can occur from trocar placement and as a result of blunt and sharp dissection with graspers or scissors. Prevention of urinary bladder injuries during laparoscopic surgery requires adherence to basic principles of safety that govern use of = thermal and mechanical laparoscopic devices.

Serious urinary complications occurred during operative laparoscopy in 1.6% of cases.²⁹ These complications included bladder injuries, urinary fistulas, and ureteral injuries. The major operative laparoscopic procedures included hysterectomy, adnexectomy, treatment of tubal pregnancy, ovarian cystectomy, and ablation-fulguration of severe endometriosis (Stage IV). Of the 15 injuries in a series of 953 patients, 4 were ureteral injuries, 3 bladder fistulas, and 8 bladder perforations. Eight cases were recognized during the original surgery (1 ureteral injury and 7 bladder injuries) and repaired at that time. Laparotomy or additional major surgery was performed in seven patients (3 ureteral injuries, 2 bladder fistulas, and 2  bladder perforations). The rate of urinary tract injuries in major abdominal gynecologic operations is 1.5% with bladder perforations, vesicovaginal fistulas, and ureteral injuries all reported.³⁰

Puncture injuries with the Veress needle or trocar, primary or secondary, can be prevented by following basic safety principles at time of introduction:

1) Drain the bladder prior to beginning the operation.

2) Insert the Veress needle intraumbilically so that the Veress needle has the smallest amount of tissue to traverse before entering the peritoneal cavity.

3) Elevate the lowest portion of the umbilicus with clamps which elevate skin, fascia, and peritoneum as a unit.

4) Insert the Veress needle in a perpendicular fashion for a very short distance through the elevated umbilicus. The distance from the skin of the umbilicus to the peritoneum is rarely more than 0.75 cm. Open the valve to allow atmospheric pressure to push air into the peritoneal cavity as the tip of the needle enters.

5) Check the position of the Veress needle with installation of normal saline and then aspirate the saline to verify intraperitoneal placement or use the hanging drop technique.

6) Insufflate to 15-25 mm Hg for the placement of the primary trocar. The use of a transient pressure of 25 mm Hg will provide a more tense surface against which to place the first trocar.

7) Insert the primary trocar for a = short distance in a near vertical position with elevation of the abdominal wall and then direct the trocar toward the pelvis.

Part II

If the dome of the bladder is entered during placement of the primary  or secondary trocar and the injury is preperitoneal, this injury may be treated with drainage for 1-2 weeks. If this injury  pierces the bladder through both the surface of the space of Retzius and intraperitoneal vesicle wall, then the  peritoneal side of the laceration should be repaired. This repair has been performed laparoscopically for a 2 cm  laceration.³¹ Laparoscopic needle holders were inserted through a third lower-quadrant puncture site on  the left between the umbilicus and the pubic hair line. A 4-0 polydioxanone (PDS, Ethicon, Summerville, NJ)  purse-string suture was placed to close the bladder muscularis, after which no leakage was discernible. A second figure of  eight stitch was placed through the anterior abdominal wall peritoneum and bladder muscularis.³¹

The use of a 45° angle thrust through an infraumbilical location in  obese patients carries the risk of perforation to the dome of the urinary bladder.³² In two cases of  unintended cystotomy one injury occurred after multiple attempts at entry with the primary trocar and the second  occurred when the primary trocar was placed in a non-catheterized patient.³³ Eight cases of bladder injury  were reported with 4 cases being due to Veress needle perforation, 2 cases due to primary trocar perforation,  and 2 cases due to secondary trocar perforation.³⁴ The Hasson technique for open laparoscopy may reduce these types of  injuries.³⁵

Injury to the bladder can occur from the distal tip of the uterine  cannula if it perforates the uterus, is incorrectly placed or becomes disconnected. In this type of injury, a layered  transvaginal repair may be performed with ureteral catheter placement and intermittent cystoscopy.³⁶ Previous  surgery increases the risk for inadvertent cystotomy by placing the bladder on traction close to the umbilicus or  because adhesions place it in the path of a secondary trocar. In addition, previous surgery can result in  adhesion formation which obliterates the position of the bladder.³⁷ Adhesions can form in the area of the  cervicovaginal junction as a result of previous cesarean sections and extend the attachment of the bladder beyond the  lower uterine segment.³⁷ When injury is to the dome of the bladder, debride damaged tissue and appose  in two layers using interrupted 4-0 polydioxanone sutures.³⁷

Bladder injuries occur during resection of endometriotic implants  overlying or penetrating into the bladder as well as during adhesiolysis procedures.³⁷ Injuries to the  dome of the bladder remote from the ureters created by blunt or sharp dissection can be repaired by excising the  damaged tissue with scissors, everting bladder mucosa and closing with interrupted 4-0 polydioxanone (PDS, Ethicon,  Summerville, NJ) endocorporeal sutures. The bladder muscularis is then reapproximated without tension using 4-0  polydioxanone. Urinary drainage is maintained for seven days postoperatively.³⁷

For nonthermal urinary bladder injuries, the decision whether to await  spontaneous healing with 10-14 days of in-dwelling catheter or to perform primary repair by endoscopic techniques followed  by drainage of 7-10 days relies on the surgeon's judgment and the extent of the injury.

Recognition, proper management by closure and drainage of the bladder,  and careful intra-operative and postoperative evaluation are the key factors for uncomplicated healing of these types  of injuries.

Evaluate bladder injuries cystoscopically to ensure the integrity of  the ureters. For extraperitoneal bladder injury, catheterization with Foley catheter for 10-14 days is adequate. For  large extraperitoneal bladder injury, a mini-laparotomy incision followed by a standard two layer repair of the bladder with  absorbable sutures and 10-14 days catheterization is appropriate.³⁸

For an intraperitoneal bladder laceration of less than 1 cm, two layer  purse-string suture with 2-0 absorbable suture may be used. The first purse-string suture is used for securing  the muscularis and mucosa; the second includes the serosa and muscular layer.³⁸

If the laceration is more than 1 cm, the bladder is mobilized to ensure  the suture site is free from tension. A standard two layer closure is performed using 3-0 delayed absorbable  suture for the first layer of closure which includes the muscularis-mucosal portion of the bladder approximated  with continuous running stitches. Afterwards, instill 250 cc's of indigo carmine dye into the bladder to ensure a  water-tight seal. Repair any leaking site with figure of eight suture. The second layer of closure should include the  serosal-muscular portion of the bladder with 2-0 delayed absorbable suture either with interrupted or  continuous stitches without undue tension. The bladder is drained for 10-14 days.

To establish a diagnosis of inadvertent bladder injury, instill indigo  carmine dye in the bladder and observe for leakage. Cystoscopic examination may be necessary to detect injury and  is essential in cases in which extensive electrosurgery has been performed around the bladder.³⁸

While injury to the dome of the bladder diagnosed at the time of  surgery can be repaired in a straight-forward manner, injury at the base of the bladder is more difficult to diagnose  and can result in significant postoperative complications.³⁹ These injuries may occur during  laparoscopic-assisted vaginal hysterectomy with vaginal closure of the cuff.³⁹ Because of the proximity of the  ureters at the base of the bladder and sensitivity of the trigone area to injury, great care must be taken in evaluating  this area for damage. Unrecognized injury due to ligation of the ureter at the ureterovesical junction has  resulted in ureteric fistula³⁹ requiring ureteric re-implantation. There also has been reported a case of  vesicovaginal fistula requiring abdominal closure and ipsilateral ureteric re-implantation because of the proximity of  the fistula to the ureteric orifice.

Care must be taken during closure of the vaginal cuff to ensure that  suture does not penetrate the bladder or encompass the ureter. It may be helpful to perform cystoscopic examination after  every case which has involved dissection of extensive adhesions or removal of large uteri.⁴⁰ To avoid  injury during laparoscopic hysterectomy, the vesicouterine fold should be identified and divided transversely  with scissors. The vesicocervical ligament should be cut in the midline and bladder dissected toward the vagina.  The placement of counter traction against the vaginal apex by use of a ring forceps with a 4x4 provides an  additional margin of safety. The use of the Koh Colpotimizer (Cooper Surgical, Chicago, IL) assists with this  dissection. Coagulation of the bladder pillars on both sides of the cervix with bipolar forceps should precede sharp  transection. Be sure that the bladder is dissected off the upper part of the vagina where the vaginal opening is to be  made to ensure avoiding injury during closure of the vaginal cuff.⁴¹

Instillation of indigo carmine dye assists identification of bladder  boundaries as well as identification of bladder injuries. Injury to the base of the bladder is likely to result from  blunt dissection of the bladder off of cervical-vaginal tissue in patients with previous surgical scars. The safest technique  is to use sharp dissection without unipolar cautery. Unipolar cautery may cause thermal burn through the bladder  wall which is difficult to recognize. Injury at the base of the bladder should be repaired with cystoscopic and  laparoscopic visualization. The first layer of closure may be a continuous suture including both muscularis and  mucosal layers placed without undue traction but water-tight. Cystoscopic evaluation of the repair will ensure  nonencroachment of the ureteric orifices. Leakage is corrected with interrupted figure of eight sutures. A second layer  of interrupted figure of eight stitches through the bladder, peritoneum, and muscularis is placed overlying the first  suture line and a Foley catheter left in place for 14 days.^40-41 Transvaginal repair of laparoscopic  injuries to the base of the bladder can also be performed in a standard two layer closure with standard  instruments.

Dissection of the bladder caudally is performed by many practitioners  of laparoscopic hysterectomy. Some, however, have raised concern that this maneuver places the bladder and distal  ureter in harms way.^28,39 During abdominal hysterectomy the bladder is dissected caudally off the cervix  and the vaginal cuff closed proximal to the bladder. During vaginal hysterectomy the bladder is dissected  cephalad and the cuff closed distal to the bladder. During laparoscopic hysterectomy followed by transvaginal closure of  the vaginal cuff, the bladder is dissected caudally and the cuff closed distal to the bladder.

To alleviate this concern^29,39 an appropriate approach would  be to perform the entire operation laparoscopically, including closure of the vaginal cuff, or avoid laparoscopic dissection  of the bladder altogether if the cardinal and uterosacral ligaments are to be divided vaginally.³⁹  Division of the bladder peritoneum is worthwhile because in the absence of uterine descent, the white line of the  anterior cul-de-sac can be high and difficult to reach, particularly if the subpubic arch is narrow.³⁹  

Whether the surgical procedure is laparoscopic hysterectomy, bowel  resection, or lysis of extensive adhesions of the bladder, the types of bladder injury may be categorized as either  thermal or mechanical.

MECHANICAL INJURIES

Mechanical injuries to the urinary bladder may occur during sharp  scissors or blunt dissection of adhesions or scar near the dome of the bladder. Examples may be adhesions from  previous infection or surgery relating to the bowel, appendix, or peritonitis. Base of bladder injuries occur in  patients who are undergoing hysterectomy after previous cesarean sections, infections, and treatment for  endometriosis. Mechanical trauma to the dome of the bladder can also occur during insertion of the umbilical or secondary midline  suprapubic trocar.

The first report of laparoscopic repair of bladder injury demonstrated  that bladder perforation by a 5 mm trocar can be repaired with laparoscopic suturing.³¹ Incidental  cystotomy due to primary trocar insertion has also been reported in an obese patient evaluated for infertility in  which three attempts were made at entry into the peritoneum and the patient presented 24 hours later with voiding  difficulties. Cystography revealed a bladder laceration which was repaired by laparotomy.³³ An additional  incident occurred during diagnostic laparoscopy for amenorrhea during which the bladder was not drained preoperatively.  The injury was recognized when bladder mucosa instead of peritoneal cavity was visualized with the  laparoscope. The injury was subsequently repaired by laparotomy.³³ Additional cases of bladder perforation by the  primary trocar have been reported but details surrounding the injuries and their repair were not given.³⁴  Primary trocar insertion into the bladder occurred in a 103 kg patient placed in dorsal lithotomy position whose  bladder was emptied preoperatively with a straight catheter and in whom a 10 mm disposable trocar was inserted  through a peri-umbilical incision at a 45° angle. The trocar was placed after Veress needle insufflation. This  injury was not repaired at surgery but allowed to heal with Foley catheter drainage for five days.³² In  another case a 72 kg 45 year old female underwent diagnostic laparoscopy for chronic pelvic pain and the same technique  was used with a long Veress needle inserted along a 45° angle. Pneumoperitoneum was established and a 10 mm  disposable trocar inserted at the same 45° angle while elevating the peri-umbilical abdominal wall. The  laparoscope was inserted and found to be in the bladder. Repeat attempt at entry with a method of open laparoscopy entered the  bladder for a second time. At this point the case was terminated and a catheter was left in place for one week  and removed with no evidence of subsequent complications to the bladder.³²

Injury due to insertion of the Veress needle into the bladder has been  reported.³⁴ The bladder has also suffered penetrating injury due to a disconnected Rubin cannula which  required layered transvaginal repair with placement of a left ureteral catheter and intermittent cystoscopy  because of the very close proximity of the injury to the left ureter.³⁶THERMAL INJURIES

Thermal injuries to the bladder require careful debridement to the  point of healthy tissue. A two layer closure and up to three weeks drainage with Foley catheter are required. Deep  thermal injury to the bladder may appear as only a lightened area at cystoscopy and may not be evident in the  intra-abdominal portion of the bladder peritoneum. For this reason cystoscopy is recommended for all major laparoscopic  operations which require use of significant electrical cautery. In order to avoid this injury, use of unipolar  cautery in proximity to the bladder surface should be avoided.

Bladder injury can occur during total laparoscopic  hysterectomy.⁴² A risk factor for bladder injury is the presence of surgical scar which makes dissection of the  vesicovaginal cul-de-sac difficult. In order to recognize this type of injury, inject 250 ml of methylene blue into the  bladder catheter. If the injury is small and located some distance away from the trigone portion of the bladder  it can be repaired laparoscopically. Use a two layer closure with delayed absorbable suture material and check  that the bladder is water tight by injecting 300 ml of methylene blue via the bladder catheter.

Vesicovaginal fistula can occur following operative laparoscopy. If the  uterus is detached from the bladder using unipolar or bipolar cautery, excessive coagulation may be responsible  for thermal bladder necrosis. Thermal necrosis may become apparent only in the postoperative period when a  vesicovaginal fistula occurs. Fistula can also occur if the bladder is taken up when the vagina is sutured from below.  Injection of methylene blue via a bladder catheter will confirm the diagnosis of vesicovaginal fistula. This complication  requires thorough evaluation with intravenous pyelography and retrograde cystography. Spontaneous healing may occur  in small lesions by draining the bladder with a large gauge urinary catheter for three to six weeks. If the  injury is large, surgical repair may be attempted. This repair may be carried out via the vaginal route or by  laparotomy.⁴²

Laparoscopic repair of a vesicovaginal fistula has been reported twelve  weeks after extensive surgery which required removal of a 2 cm portion of the posterior bladder wall.⁴³  Simultaneous cystoscopy was performed and both ureters were catheterized. The fistula was identified in the  posterior bladder wall superior to the trigone. A ureteral catheter was withdrawn through the fistula and into the  vagina to facilitate identification during excision. The bladder was severely adherent to the vagina over the apex. An  opening was made in the vagina away from the bladder and rectum. An inflated glove in the vagina helped maintain  pneumoperitoneum. The anterior vaginal wall was elevated using grasping forceps. The bladder was filled with water  and, using a CO2 laser, cystotomy was performed above the fistula. Water was evacuated and the bladder distended by  pneumoperitoneum from the cystotomy. Under direct observation the vesicovaginal space was developed  laparoscopically. The bladder was freed posteriorly from the vaginal wall. The bladder fistula was identified and excised with  CO2 laser. Both the vagina and the bladder were closed laparoscopically. The 1.5 cm vaginal wall opening was  repaired with one layer of interrupted polyglactin suture. The bladder was then repaired with one layer of interrupted 1-0  endoknot vicryl sutures (Ethicon, Summerville, NJ) using extracorporeal knotting. A peritoneal flap was used to  separate the vesicovaginal space and secured with two interrupted vicryl sutures.

Vaginal repair of a fistula should follow Latzko's  technique⁴³ and the abdominal approach should be used for the following indications:

1) Inadequate exposure because of a  high or retracted fistula in a narrow vagina.

2) Proximity of the fistula to the  ureter.

3) Associated pelvic pathology.

4) Multiple fistulas.

The following steps are  critical:

1) The bladder should be emptied  prior to surgery. It is not necessary to leave the Foley catheter in the bladder during surgery, especially in  complicated laparoscopic surgeries which require extensive uterine or vaginal manipulation from below by an assistant.  The catheter may inadvertently be pulled or pushed by the assistant while manipulating the uterus or vagina,  thereby bruising the trigone area of the bladder with the balloon tip of the catheter. Routinely instill 15-30 cc of  concentrated indigo carmine dye into the bladder after it is emptied prior to surgery. This facilitates early detection  of bladder injury during surgery.

2) Insert all secondary trocars under  direct visualization. This is especially important when anatomyis distorted due to infection, severe endometriosis,or  previous major pelvic surgery.

3) Separate the bladder from the low  uterine segment by using sharp dissection. Never dissect the bladder bluntly. This too is important in the case of  previous surgery, such as C-section, infection, or endometriosis.

4) Make sure the bladder is not inside  the jaw of the laparoscopic stapling device before firing it.

5) Avoid excessive electrosurgery  around the bladder.³⁸

The signs to recognize bladder injuries  intraoperatively include the following:⁴⁴

1) CO2 in the urinary catheter bag  during insufflation,
2) Bladder appears to be pushed by the  accessory trocar as it is advanced through the abdominal wall,
3) Blood in the urine,
4) Urine drainage from an accessory  trocar incision,
5) Postoperative urinary retention,  particularly if the amount of urine obtained during catheterization is less than anticipated,
6) Postoperative signs of peritonitis,  and
7) Leakage of indigo carmine from the  injured site.

The particular approach to the repair of bladder injuries is dependent  upon 1) whether the injury is thermal or mechanical, 2)  whether the injury is at the base or dome of the bladder and 3) the proximity of  injury to the trigone and ureteric openings.

Table 1. Nerve  Injuries During Burch Procedure.
09

Table 2.2  Comparison of laparoscopic retropubic urethropexy and classic Burch retropubic suspension.

09

References:

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©Society of Laparoendoscopic Surgeons, 1999

Reprinted with permission from the Society of Laparoendoscopic = Surgeons.

Carter JE, Schuessler WW. Laparoscopic urinary bladder surgery. In = Kavic MS, Levinson CJ, Wetter PA, eds. Prevention and Management of Laparoendoscopic Surgical Complications. Miami: = Society of Laparoendoscopic Surgeons; 1999:207-219.

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