Bladder injury can be sustained when developing the space of Retzius and dissecting the bladder off the pubis, especially in the presence of scarring from prior anti-incontinence procedures. Inadvertent bladder injuries can be minimized by dissecting directly on the pubis, just lateral to the insertion of the rectus muscle bodies. Sharp dissection may be required to develop this retropubic space especially when there is scarring. Bladder injuries which occur during the retropubic dissection should be identified and repaired, as these injuries tend to be large.

Bladder injury can also occur when instruments are introduced into the retropubic space to deliver the sling sutures from the vaginal incision to the abdominal incision. We typically use a long, curved clamp with a fairly sharp tip (Crawford clamp ) for this maneuver. At the time of passage, the clamp is kept in direct continuity with the back of the pubis at all times, and a finger is positioned within the ipsilateral aspect of the vaginal incision, adjacent to the urethra. This allows for direct tactile control as the instrument tip is passed through the endopelvic fascia, and minimized the degree of “blind” passage. As recommended by the AUA Guidelines, we perform cystoscopy after passage of the instruments to rule out injury to the urinary tract [3]. Use of a 70° lens allows for a thorough evaluation of the entire bladder and urethra with minimal angling of the cystoscope. If a clamp is noted to be in the bladder, it is withdrawn and repositioned, and repeat cystoscopy is performed. Injuries from clamp passage do not require formal repair although it may be prudent to maintain bladder drainage with a Foley catheter for a few days postoperatively.