Techniques for difficult dissection of the bladder from the lower uterine segment in a patient with distorted myometrial-endometrial anatomy

Development of the vesicovaginal space in a patient with a history of repetitive abdominal surgery can be difficult. Known risk factors for lower urinary tract injury are previous caesarean section and laparotomy.1 2 Additionally, a laparoscopic approach to hysterectomy has an increased risk of bladder injury.3 In these individuals, preoperative imaging may be helpful for surgical planning. This video demonstrates a safe and reproducible technique for bladder dissection using a robotic-assisted laparoscopic approach in a patient with extensive surgical history. Traditionally, dissection of the bladder is performed in a medial-to-lateral fashion, but we propose a lateral-to-medial approach to minimize the risk of lower urinary tract injury.4