83: Technique for retrograde robotic hysterectomy for management of dense bladder adhesions

Abstract

The primary objective is to show a technique for performing retrograde dissection of densely adherent bladder from anterior uterine wall during robotic-assisted laparoscopic hysterectomy. Many women who undergo hysterectomy have a history of prior cesarean sections, which can result in dense anterior uterine adhesions. Significant adhesions between uterus and bladder create a challenge for safe completion of hysterectomy without injury to lower urinary tract. Here, we show a technique for performing a retrograde hysterectomy in which all major blood supply to the uterus is sealed and the colpotomy completed prior to bladder adhesiolysis. Furthermore, we show a technique for retrograde dissection of the bladder from uterine wall starting inferiorly at the level of the cardinal ligaments and working superiorly towards the fundus of the uterus. With this technique, there is early control of vascular supply thus decreasing intraoperative blood loss, direct visualization of ureters thus decreasing risk of injury, and a 360-degree access to bladder adhesions once colpotomy is complete in order to safely perform adhesiolysis. We show dissection of the pararectal and paravesical spaces, bilateral ureterolysis, and sealing of uterine artery at its origin. Performing a retrograde hysterectomy allows early control of blood supply, constant visibility of ureters, and access to inferior bladder adhesions. Performing a retrograde dissection of the bladder can decrease risk of injury to lower urinary tract. These techniques can be used to safely perform robot-assisted laparoscopic hysterectomy in patients with dense uterine adhesions to the bladder.