Early recognition is key in preventing signicant morbidity or even death of a bleeding patient. Ideally, any signicant bleeding is identied and managed intraoperatively.

saline solution for washout and identication of bleeding is helpful. Blood products should be replaced as needed, either traditionally or with blood salvage techniques.

The risk of urinary tract injury is 1–2% for all gynecologic surgery [11]. The rates of cystotomy at the time of hysterectomy vary by approach. In a randomized trial of 1300 hysterectomies, blad­der injury occurred 1% in the abdominal approach, 2.1% in the laparoscopic approach, and 1.2% in vaginal approach [11, 12]. This rate does vary amongst studies, and some report blad­der injury more commonly occurring in vaginal hysterectomy with injury on anterior cul-de-sac entry.

To avoid bladder injury, some surgeons choose to continuously drain the bladder with a Foley catheter, intermittent drainage with an in and out catheter, or backll the bladder with normal saline or sterile milk to delineate planes in patients with previous cesarean sections or dif­cult anatomy [13]. If identication is difcult, inserting a cystoscope can illuminate the bladder base. On abdominal entry, it is important to enter the peritoneum as cephalad as possible to avoid inadvertent bladder injury [14]. Proper use of assistants and retractors to help keep important structures out of the operative eld is essential. In abdominal and laparoscopic/robotic surgeries, cephalad traction of the uterus helps to delineate the vesicouterine plane and mobilize the bladder away from the uterine arteries [15]. During abdominal hysterectomy, this can be accom­plished with the use of Kocher clamps on the bilateral cornua and upward traction by the sur­geon or assistant. In laparoscopic or robotic sur­gery, this can be achieved with the use of a uterine manipulator or the use of traction from a laparo­scopic or robotic instrument from above. In vagi­nal hysterectomy, manual traction on the incised vaginal epithelium allows for easy dissection along the cervix and into the anterior cul-de-sac. Once the plane is achieved and caudad traction on the cervix is maintained, the use of an anterior Deaver retracts and protects the bladder.

Although an area of controversy, the authors advocate for universal cystoscopy with hysterec­tomy as it increases the absolute recognition of

Postoperatively, suspicion of a bladder injury should be elevated with leakage of uid from the vagina, oliguria or anuria, hematuria, abdominal pain/distension, fever, abdominal ascites with elevated uid creatinine, and postoperative ileus. An easy diagnosis of cystotomy postoperatively is to backll the bladder with 300ccs of normal saline and measure how much returns through the Foley catheter. No uid return indicates extrava­sation of the uid through a cystotomy [14]. Imaging can also be useful to identify a cystot­omy and includes a CT cystogram.

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Postoperatively, the bladder should be decompressed with an indwelling Foley cathe­ter. For a signicant injury, we typically leave a catheter for 2–3 weeks, although there is no consensus on duration and this can range from 7days to 3weeks. Earlier removal decreases the risk of urinary tract infection and likely has sim­ilar cure rates. No prophylactic antibiotics are needed for short-term catheter use, although some studies suggest a dose of antibiotic at the time of catheter removal may decrease urinary tract infections [19]. There is controversy regarding the postoperative use of CT cysto­gram prior to Foley catheter removal [13]. In our experience, if it was an uncomplicated intra­peritoneal repair, the Foley can be removed by the patient at home, but if there is any concern for healing it can be removed after ensuring no extravasation on CT cystogram.