Vesicophobia During Vaginal Hysterectomy – Too Superficial Dissection

Author Information

Raut DP *, Parulekar SV**.
(* First Year Resident, ** Professor and Head, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)


Vaginal hysterectomy is much more difficult to perform than an abdominal hysterectomy. The surgeon has to be well trained in vaginal surgery, or there can be serious complications during the performance of the operation, including injury to the urinary bladder. Lack of expertise and a fear of injuring the bladder can lead to dissection in a wrong plane. Dissection into the fascia over the detrussor and the detrussor itself is a not uncommon error. We present such a case becuse the management of this error has not been documented well in the literature.


The space available for operating is limited while performing a vaginal hysterectomy.[1] The anatomy is also a little difficult to understand, as conventional education of human pelvic anatomy is through cadeveric dissection, which is done by the abdominal route. Without adequate training and operative experience, the operating surgeon can experience difficulty in finding correct tissue planes and performing the correct steps.[1] Finding the uterovesical fold of peritoneum  and opening it is an important step, which may be associated with a fear of injuring the bladder. This may result in dissection in a plane that is too superficial, passing into the fascia over the detrussor and the detrussor itself. We present such a case and discuss methods of diagnosing the condition and managing it.

Case Report

A 40 year old woman, married for 20 years, multipara, presented to the outpatient department with complaints of menorrhagia for 2 years.  She has soakage of 3-4 pads per day and passage of clots for 8 days, without any dysmenorrhea. She had come with similar complaints 5 days back to the emergency section and was started on norethisterone and tranexemic acid to stop the bleeding. However this treatment failed to control the bleeding. She had undergone a rapid cervical dilatation and endometrial curettage 1 month back for abnormal uterine bleeding. The histopathology report was suggestive of bleeding endometrium. The patient was operated for anal hemorrhoids 22 years ago and tubal ligation was done 6 years ago. There was no other significant medical or surgical history. On examination her vital parameters were stable. Speculum examination showed a hypertrophied cervix. Bimanual pelvic examination showed bulky, retroverted, midposed uterus and free and nontender fornices. Ultrasound examination of the pelvis showed a bulky uterus measuring 9.4 x 4.0 x 6.6 cm and endometrial thickness of 12 mm. Malignancy was screened for by Pap smear which showed severe inflammatory cell changes and endometrial aspiratyub xytology which showed no malignant cells.
The patient was posted for a vaginal hysterectomy. She was being operated on by a resident doctor, assisted by a junior consultant. She was put in lithothotomy position under spinal anaesthesia. After making an incision into the anterior vagina near the portio vaginalis, anterior pouch dissection was started. Blunt dissection  was done to open the plane between the supravaginal cervix and the bladder. There was a significant amount of bleeding. The uterovesical fold could not be identified. At this stage we were called for help.
The findings are shown in figure 1. The detrussor was torn in the midline and the bladder mucosa was seen pouting throgh it. The plane between the bladder and the supravaginal cervix was identified after dividing the fibers of pubovesicocervical fascia between the two. It was a smooth, white surface which had no bleeding from its surface. The bladder was retracted with Landon’s retractor.Dissection was continued upward in this plane until the uterovesical fold of peritoneum was reached. It was held with two hemostats and cut. Subsequent hysterectomy was carried out by the conventional technique. The detrussor injury was repaired with a continuous suture of No. 3-0 polyglactin. The patient made an uneventful recovery and was discharged after 5 days.

Figure 1. Cut edges of detrussor are shown by arrows.

Figure 2. The cut edges of the supravaginal cervix (yellow arrows) are held with two Allis’ forceps. The correct plane of dissection is shown by white arrow.


Abdominal hysterectomy permits visualization of the pelvic structures clearly prior to performing any pelvic surgery, unless the anatomy has been distorted by pelvic adhesions or tumors. The uterovesical fold of peritoneum can be held easily, confirmed to be the uterovesical fold by its looseness over the supravaginal cervix and isthmus, and then cut with scissors. It is quite different in a vaginal hysterectomy.[1] After making an incision in the anterior vagina near the portio vaginalis, the pubovesicocevical fascia has to be dissected in the correct plane that can be identified only with experience, and then the peritoneal fold can be reached. [2,3,4,5,6,7] The fascial fibers which stand out as the divided vaginal edge is elevated held by two Allis’ forceps have to be identified. The peritoneal fold can be reached after cutting these. It is confirmed to be the fold by putting a finger over it and rolling it from side to side. It rolls very easily over the smooth anterior surface of the corpus. When caught with two hemostats, it stands out as a thin translucent fold. If the dissection is carried out more superficially, it passes into the fascia over the bladder and then the bladder wall. Injury to the detrussor is suspected when there is significant bleeding during the sharp dissection. Detrussor injury is more likely to occur when the dissection is done bluntly, with finger pressure. Injury to the bladder wall is suspected when there is leak of watery fluid into the operative field, hematuria, visualization of the catheter through the dissected area, and leak of methylene blue solution into the operative field when it is instilled into the urinary bladder through Foley’s catheter.[2,8] The correct plane has to be found posterior to the dissected area. The correct plane has a number of diagnostic features. The smooth, white surface of the supravaginal cervix is seen posterior to the plane. When in doubt, a bladder sound can be passed into the bladder to define the limits of the bladder, so that dissection can be done beyond the bladder wall. In case all of these methods fail, the posterior peritoneal pouch can be opened first.[2,8] Then a finger can be passed behind and then over the top of the uterus to reach the uterovesical fold of peritoneum from above. Then it can be opened over the finger seen through it. But this is not possible if the uterus is large. Passing more superficially and hence into the bladder wall is much more serious than passing too deep into the cervical tissue. However both of these situations must be avoided by following meticulous technique, so that morbidity is kept low.


A resident doctor or a consultant not trained in vaginal surgery may experience difficulty while opening the uterovesical fold of peritoneum, and being afraid of injuring the urinary bladder, may go in a wrong plane. Adequate training, experience, and adopting the techniques described in this article should help overcome this difficulty and fear.


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Raut DP, Parulekar SV. Vesicophobia During Vaginal Hysterectomy – Too Superficial Dissection. JPGO 2014 Volume 1 Number 12 Available from: