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(1) Bleeding
Most cases of bleeding that one experiences during
transvaginal surgery are self corrected. Clearly,
identification of those patients at risk for bleeding
complications (e.g. aspirin use, non-steroidal
anti-inflammatory drug use (NSAID), coumadin and those
who have a history of bleeding diathesis should be
screened and possibly corrected prior to surgery.
Nonetheless, significant bleeding can be encountered
intra operatively, especially if one dissect into the
wrong tissue planes and structures. Bleeding encountered
intra operatively can be controlled with judicious use
of electrocoagulation and/or suture ligatures. This
should be performed cautiously if done in the anterior
vaginal wall or retropubic space in order to avoid
ureteric injury. Most cases of mild bleeding subside
with packing or placement of a tampon.
Alternatively, intra vaginal inflation of a foley
catheter with 50 to 60 ml of water can help tamponade
bleeding. In the event bleeding become severe or the
patient becomes unstable, the source of bleeding may be
extraperitoneal or retroperitoneal. Appropriate
resuscitative measures should be taken in these cases.
Persistent or postoperative bleeding may require
re-exploration or even a laparotomy. If the bleeding
area can not be identified, one may consider selective
angio- embolization or if necessary, bilateral
hypogastric artery ligation.
(2) Infection
Since bacteria potentially contaminate the vagina, it is
a frequent site of infections in the postoperative
period. This can be avoided with judicious use of
broad-spectrum antibiotics administered preoperatively
along with a careful and thorough vaginal preparation
and scrub prior to incision and proper draping of the
surgical field such that the rectum/ anus is out of the
area of the operation. Additionally , preoperative urine
culture & sensitivity testing may be indicated in
patients at risk for recurrent urinary tract infection (UTI)
or those with abnormal urinalyses (e.g. presence of
leukocytes, nitrites, and blood). Therefore, prevention
again is the key of helping avoid complications in the
postoperative period.
Infections may affect the vaginal incisional areas,
suprapubic incisions (suspension cases), retropubic
spaces, or urinary tract. Incisional infections or
vaginal cuff infections occur more commonly after
hysterectomy and may be from retained secretions or
inadequate cleansing of the vaginal apex. Nonetheless,
these infections may drain spontaneously , or require
antibiotics and daily gentle digital examination of the
vagina. Prevention of this complication requires
thorough cleansing of the entire vagina prior to surgery
and during closure of the cuff, avoidance of dead space
where fluid and bacteria may collect . Retropubic
infections may occur from similar mechanisms and may
require open drainage with a penrose or other drain type
to assure the collection resolves. Suprapubic infections
and infected sutures may occur if bacteria become
entrapped and transferred to the suprapubic incision.
Again, copious antiseptic irrigation helps avoid this
problem as does antibiotics preoperatively. If this area
becomes infected, one must judge whether or not the
infection requires open drainage or simply antibiotic
and compresses. Additionally if the sutures are painful
to the patient, they may be infected and can be removed
suprapubically. Often there may be sufficient scar
formation inferiorly to allow for adequate bladder neck
support despite removal of the suspending sutures.
Sutures or synthetic material erosion in the vagina
leads to vaginal drainage, bleeding and pain. They must
be removed in most of the cases.
Urinary tract infections may be problematic as they may
cause an exacerbation of incontinence symptoms after the
catheters are removed. Therefore, one must always
realize that an infection may be present in the setting
of postoperative incontinence or urge symptoms.
Avoidance of long term urethral foley catheter and
postoperative antibiotics help reduce the incidence of
UTI’s. We attempt to utilize suprapubic catheters in the
post operative period as they lessen the likelihood of
bacterial contamination of the urinary tract. Rarely,
the cystitis may result in a pyelonephritis requiring
hospitalization and intravenous antibiotics.
(3) Osteomyelitis
Osteomyelitis of the pubic bone is an infrequent
occurrence, however, with the increasing use of bone
anchors in vaginal sling surgery, one must be aware of
this complication . routine use of intravenous broad
spectrum antibiotics preoperatively as well as copious
antibacterial irrigation during surgery with meticulous
surgical technique can help prevent this problem.
Proper recognition helps prevent a delay in therapy. One
may complain of difficulty in walking bone pain,
low-grade fevers and erythema or tenderness over the
anchor area. Plain film radiography may demonstrate the
anchor in the retropubic space, out of the bone
secondary to inflammation. CT scanning , MRI and bone
scanning may demonstrate the infection even better.
Proper management includes antibiotic therapy,
anti-inflammatory agents and possibly orthopedic
consultation. If partial resection of the pubic
symphysis is required in severe cases, clearly , the key
to prevention of long term sequelae is early recognition
and therapy.
(4) Bladder Injury (Perforation)
Injuries to the bladder may occur during dissection
of the vaginal epithelium off of the underlying
perivesical fascia and bladder or during suture passage
in cystocele repair or anti-incontinence procedures. A
routinely placement of urethral foley catheter or a
suprapubic tube to allow proper identification and
drainage of the bladder. The urethral foley allow
palpation of the urethra, bladder neck and bladder
easily. The catheters are plugged during surgery;
therefore, if bladder entry occur , one may notice urine
extravasation in to the operative field. In the course
of dissecting tissue flaps of vaginal wall off the
perivesical fascia, one must stay very superficial in
the dissection on the side of the wall in order to
prevent bladder entry. Another area in which bladder
injury may occur is during entry in to retropubic space.
Using the curved Mayo scissors, pointed towards the
ipsilateral shoulder with entry at the level of the
bladder neck and urethropelvic ligaments prevents
bladder injury . If one enters too proximal towards the
bladder base, a higher chance of bladder injury is
encountered. When bladder entry is suspected,
instillation of indigo carmine dye/ betadine into the
foley catheter can be helpful in identifying the entry
site and subsequent confirmation of repair. Lack of
recognition of an intro-operative bladder injury will
lead almost invariable to a vesico-vaginal fistula.
Suture perforation of the bladder may occur in the
course of trans vaginal surgery and incontinence
procedures, this may be easily identified with use of
intra operative cystoscopy and should rarely be
problematic. If one discovers a bladder entry, the
sutures are simply removed. We have decreased this
occurrence with dissection into the retropubic space
that allows the surgeon’s fingers to be placed into the
space freely . Subsequent suture passage from the
suprapubic incision can then be performed under
fingertip guidance with use of a ligature carrier. Other
important prevention steps for bladder entry at this
time include emptying the bladder of accumulated urine
prior to retropubic space dissection and proper entry in
the lateral fornix and not through the levator fascia
laterally or too medially into the bladder.
If the bladder entry is encountered, a multi layer
repair using absorbable sutures is recommended. The
initial layer re approximates the mucosal surface with
fine absorbable sutures while the outer layer (perivesical
fascia) is closed with interrupted absorbable sutures.
Cystoscopy is performed and indigo carmine may be
instilled through the catheter to ensure a watertight
closure. If ureteric injury is contemplated, intravenous
indigo carmine dye is administered and visualization
cystoscopically from each ureteric orifice. Extensive
bladder injury may require use of a fibro fatty labial
flap (Martius flap) as an added layer of protection from
future fistula formation. Finally, the vaginal
epithelium is advanced over the repair such that none of
the suture lines are overlapping. Long-term catheter
drainage is required for at least one or two week and a
voiding cystourethrogram should be performed to confirm
healing and absence of extravasations. |
