Bladder injury can result from the perforation of the undrained bladder by an insufﬂation needle or trocar, or it may occur while the bladder is being dissected from adherent structures or from the anterior uterus (127,128). The frequency of injury is difficult to estimate and varies with the procedure. Estimates of the frequency of unintentional cystotomy associated with laparoscopic hysterectomy range from 0.4% to 3.2% and appear to be more frequent in the context of a previous cesarean section (129,130). The injury may be readily apparent by direct visualization. If an indwelling catheter is in place, hematuria or pneumaturia (CO2 in the catheter drainage system) may be noticed. A bladder laceration can be confirmed by injecting sterile milk or a diluted methylene blue solution through a transurethral catheter. Thermal injury to the bladder, however, may not be apparent initially and, if missed, can present as peritonitis or a fistula.
Routine preoperative bladder drainage usually prevents trocar-related cystotomies. Separation of the bladder from the uterus or other adherent structures requires good visualization, appropriate retraction, and excellent surgical technique. Sharp mechanical dissection is preferred, particularly when relatively dense adhesions are present.
Very small-caliber injuries to the bladder (1 to 2 mm) may be treated with bladder catheterization for 3 to 7 days. If repair is undertaken immediately, catheterization is unnecessary. When a larger injury is identified, it can be repaired laparoscopically (127,128,131). If the laceration is near to or involves the trigone, an open procedure should be used. The mechanism of injury should be taken into consideration in making this evaluation because electrical injuries often extend beyond the visible limits of the apparent defect. If a coagulation-induced thermal injury occurred, the coagulated portion should be excised.
For small lesions, closure may be performed with layers of absorbable 2-0 to 3-0 sutures.
Postoperative catheterization with either a transurethral or suprapubic catheter should be maintained for 2 to 5 days for small fundal lacerations and for 10 to 14 days for injuries to the trigone. Cystography should be considered before the urinary catheter is removed.
One of the most common causes of ureteral injury during laparoscopy is electrosurgical trauma (113,132,133). Ureteral injury can occur after mechanical dissection, including linear cutting and stapling devices (133–135). Although intraoperative recognition of ureteral injury is possible, the diagnosis is usually delayed (132,133). Ureteral lacerations may be confirmed intraoperatively, visually, or following the intravenous injection of indigo carmine. Thermal injury presents up to 14 days after surgery with fever, abdominal or ﬂank pain, and peritonitis. Leukocytosis may be present, and intravenous pyelography shows extravasation of urine or urinoma. Mechanical obstruction from staples or a suture may be recognized intraoperatively by direct visualization. Cystoscopy following the intravenous injection of indigo carmine may be used to confirm failure of the dye to pass through the ureter. Abdominal ultrasound may be helpful, but a CT urogram can more precisely identify the site and degree of the obstruction. Unrecognized ureteral obstruction may present a few days to 1 week after surgery with ﬂank pain and often fever (136).
Discharge or continuous incontinence is a delayed sign of ureterovaginal or vesicovaginal fistula.