Transcript Management of intra-operative complications of SUI and POP

Complications associated with
SUI and POP surgery
Ju Tae Seo, MD
Department of Urology
Cheil General Hospital
Kwandong University College of Medicine
Introduction
• Women have an 11% lifetime risk of one operation for
POP or SUI
• Midurethral sling for SUI
1) retropubic MUS ; TVT, SPARC, IVS, TVA, Iris, Serapren
tape, Advantage, T-sling, Continence, Safyre, Seratom
2) transobturator MUS ; TVT-O, TOA, MONARC, TOT,
CM-sling, Osiris, Lynx
3) New slings ; TVT-Secur, MiniArc
• Mesh for POP surgery
; Prolift, Apogee, Perigee
The incidence of major complications
may be underreported.
• A significant discrepancy between scientific
reports and FDA/MAUDE reports
1) reports may understate complications
2) surgeons with higher complication rates do
not answer questionnaires
3) differences exist between high- and lowvolume surgeon
4) Complication rates accounted for by surgeons
who manage the complication
Co-morbidities increase the incidence
of complications
• Diabetes and vascular lesion
; a 2-fold increase in the risk of major Cxs
(sepsis, pulmonary failure, MI and thromboembolic events)
• Obesity (BMI≥35kg/㎡)
; increase technical difficulty and Cx rates
(deep vein thrombosis, arrhythmia, pneumonia)
• Previous radiation for pelvic cancers
Complications after midurethral sling
procedure and POP surgery
• Intra-operative complications
: clinically significant bleeding & hematoma
: bladder, urethral, vaginal wall perforation
: bowel, nerve injury
• Postoperative complications
: UTI
: Mesh erosion (vaginal & urethral)
: De novo urgency
: postoperative voiding dysfunction
Operative complications of
procedure
MUS
Bleeding and hematoma
• Highly vascular venous space of Retzius(pelvic floor vein,
epigastric vessel) or obturator or iliac vessels
• Mean distance from TVT trocar to the major vessels is 3.2
to 4.9 cm and vascular injuries involving large arteries(ext.
iliac, femoral, obturator, epigastric, inf. Vesical) are rare
• Minor bleeding in retropubic procedure may related to the
close positioning of dorsal vein of clitoris under the
inferomedial aspect of pubic bone
• Risk is high in patients with previous surgery in Retzius
space
• In TVT
; significant blood loss from 1.1 to 2.3%
; retropubic hematoma from 2.0 to 4.1%
• In TOT
; 1-2% of the cases
- heavy intraoperative bleeding, pelvic, retropubic
hematoma, and perineal, labial, or thigh hematoma
• Management depend on extent of bleeding
: transfusion
embolization
hematoma drainage
laparotomy
• Most retropubic venous bleeding
- managed with observation only
- two finger or gauze compression for 5 minutes
just after surgery
Bladder perforation
• More common in retropubic sling (0.7~24%), lower
in transobturator sling(0~1%)
• Risk factors ; previous anti-incontinence surgery, pelvic
surgery, surgeon’s experience
• Austrian TOT tape registry comprising of 2,541 cases
- 10 bladder and 2 urethral perforation
• A retrospective study by Barber et al of 390 patients
treated with TOT
- 2 bladder and 2 urethral injuries were reported
• Careful and circumferential cystoscopic examination of
distended bladder
 trocar is removed and repassed
 cystoscopy is repeated with each pass of the trocar
Bladder and urethral injury
• Tips in difficult situation
- injection of normal saline behind the pubic bone in the intended path
of needle
- passing the needle from the suprapubic incision to the vaginal tunnel
• Recommendation of universal intra-operative cystoscopy in cases of
previous extensive pelvic surgery and difficulty of needle passage
• No need any further therapy except catheter drainage for 2-4 days
• Undiagnosed bladder & urethral injuries
- hematuria, pain(suprapubic/urethra), recurrent UTI, stone, voiding
dysfunction, fistula
• The mesh must be removed completely.
• The earlier a misplaced tape is explanted, the fewer the scar, the
less inflammation will develop, and the easier complete removal
will be.
Urethral perforation by TOT procedure
Vaginal wall perforation
• majority occurred in the transobturator slings
(2.3~12.9%)
• Especially in pts without lateral defect of
cystocele ( high position of lateral sulcus), risk
of vaginal wall perforation is increased.
• Careful vaginal wall inspection just after trocar
or introducer passage (inside-out & outside-in)
• Management – repositioning of trocar and
simple suture of vaginal wall
Bowel injury
• A rare complication documented in case report
• A greater risk in patients with Hx of previous
abdominal or pelvic surgery
- adhesion in the Retzius space
• No data on bowel injury with transobturator
approach
• Rectal perforation is not rare in post.
transvaginal mesh repair (4~5%)
: simple suture and NPO for 5~7 days
Rare cases of major complications
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Bowel, vascular, and nerve injuries
Necrotizing fasciitis
Ischiorectal, obturator abscess
Sepsis
Patient deaths
Extremely uncommon (86/11,800 cases)
- 32 vascular, 33 bowel injuries
- 8 patients death after TVT placement
• Major complications might be underrepoted
in the literature.
Operative complications of POP
surgery
Complications
 Intraoperative
 Hemorrhage
 < 2% with injuries (Ureteral, bladder, urethral, gastrointestinal )
 During and after surgery
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Infections (cuff cellulitis, abscess)
Bleeding
Urinary retention, bowel obstruction
Rectal injury, bladder injury
Mesh erosion, infection, vaginal granulation
Fistulas (ureterovaginal, vesicovaginal)
Ileus
Recurrence
Leg pain (esp, transobturator approach)
Persistent dyspareunia, pelvic pain, vaginal stenosis
Voiding dysfunctions
New Pelvic Symptoms after
Reconstructive Pelvic Surgery
Thythy Pham et al. Am J Obstet Gynecol 2009;200:88.e1-e5.
A Long-Term Treatment Outcome of
Abdominal Sacrocolpopexy
 57 women who underwent ASC with mesh for symptomatic uterine
or vault prolapse
 The median follow-up was 66 months (range 60-108)
Jeon MJ et al. Yonsei Med J 2009;50: 807-13.
Meshes and trocars for POP surgeries
Ant. and Post. mesh(Prolift) for POP surgery
Prolift System for Repair of Pelvic Organ
Prolapse
• Early outcome results from a retrospective study of 687 pts in
7 centers of France
: Intra-operative and short-term post-operative complication
rates ranged from 0.15% to 1.75%
: Mesh erosion rates ranged from 0% to 13.3%
: Cure rate at 10 months – 95%
• US based study including 350 pts
: Cure rate at 14 months – 91%
: Mesh erosion rates were <2%, conservative treatment or “in
office” surgical correction
: Intra-operative complications ranged from 0.3% to 2.6%
(cystotomy - most common Cx)
: Post-operative de novo OAB, voiding dysfunction, and SUI
were seen in 4%, 2% and 3% of pts, respectively
Mechanism or Hypothesis
 Postoperative voiding dysfunction may be caused by
– Detrusor instability
– Urethral obstruction
– Recurrence of the cyctocele
 Factors related to the development of urinary retention
following SUI surgery
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Pre-operative Qmax
Decreased detrusor pressure
Straining during voiding
Bladder neck elevation during surgery
Mechanism or Hypothesis
 Increased amount of blood loss is associated with
postoperative urinary retention
- First, more blood loss may result in hematoma formation acting as a nonfunctional, obstructive sub-urethral mass
- Second, more blood loss may be related to more extensive damage to the
innervation of the detrusor muscle when surgery gets more complicated
 Disturbed pelvic floor relaxation due to post-operative pain,
intrinsic damage to the innervation of the bladder and BOO can
contribute to the development of urinary retention following
vaginal prolapse surgery
 These hypotheses will be tested in future prospective studies.
Robert A et al. Neurourology and Urodynamics 2009;28:225–8.
Postoperative voiding dysfunction
 Resolution of preoperative urgency in ≥63% of
patients
 De novo detrusor instability in 5%
 Prolonged urinary retention in <1% of women
Nguyen et al. J Urol 2001;166:2263-6.
Postoperative voiding dysfunction
 New urge incontinence was the most commonly cited reason
for patient dissatisfaction 1 year after surgery
Mahajan ST et al. Am J Obstet Gynecol 2006;194:722-8.
 Patients dissatisfied after retropubic midurethral slings were more
likely to report urinary leakage, overactive bladder symptoms,
Davis TL et al. Am J Obstet Gynecol 2004;191:176-81.
and voiding dysfunction
 Development of new pelvic symptoms after reconstructive pelvic
surgery can adversely affect patient satisfaction, symptom
improvement, and quality-of-life measures
Thythy Pham et al. Am J Obstet Gynecol 2009;200:88.e1-e5.
Stress urinary incontinence after
transobturator mesh for cystocele repair
 Cystocele repair can lead to de novo SUI or exacerbate preexisting SUI
 93 patients after a transobturator mesh procedure
 57 women had not undergone a concomitant anti-incontinence
procedure
 Median follow-up: 9 months
 87.5% (21/24) of patients with preoperatively SUI reported
cure/improvement
 one patient (4.2%) reported worsened SUI
 21.2% (7/33) complained of de novo SUI
 Transobturator mesh for cystocele repair appears to have a net
positive effect on SUI.
Shek KL et al. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:421-5.
Conclusions
 High rates of new symptoms after MUS &
reconstructive pelvic surgery were reported
 These symptoms are associated with decreased selfreported improvement and satisfaction despite
objective cure
 Patients should be counseled carefully prior to
surgery