Redefining Bladder Dissection in Robotic Hysterectomy with Previous Cesarean Section: A "Head-On Approach"

Intraoperative adhesions, particularly between the bladder and cesarean scar, as well as between the uterus and anterior abdominal wall, are commonly encountered in patients with a history of cesarean sections. These adhesions substantially elevate the risk of severe intraoperative complications, including bowel or bladder injuries, during hysterectomy. The incidence of bladder complications is significantly lower in patients with one or two prior cesarean sections compared to those with three or more. Moreover, the likelihood of inadvertent cystotomy is several times higher in patients with three or more cesarean sections than in those with no prior cesarean sections. Here, we report a simple, safe, and reproducible Head-On approach for bladder dissection. This innovative technique, developed by us, is particularly effective when the lateral window cannot be identified. With the rising incidence of cesarean sections, surgeons are increasingly encountering dense bladder adhesions during hysterectomies. The Head-On technique was developed specifically for bladder dissection in such cases to minimize the risk of urogenital tract injuries.