Complication
Prevention
Bleeding
Dissection in correct plane
Avoid retropubic space
Ureteral injury
Cystoscopy with assessment of ureteral patency
Bladder injury
Proper dissection
SUI
Preoperative assessment
Bladder outlet obstruction
Preoperative assessment of voiding function and post-void residual
Avoidance of Kelly plication sutures
Potential anterior compartment repair complications include intraoperative hemorrhage and blood transfusion, genitourinary tract injury, onset of de novo SUI , and postoperative urinary retention. Given the infrequent nature of these complications, there is a paucity of literature focusing on intraoperative and immediate postoperative complications. In this regard, data on the immediate and shorter term complications must be extracted from studies that focus primarily on long-term anatomical and functional outcomes. Utilization of this data is further complicated by the inclusion of concomitant procedures. Women with high-grade anterior compartment prolapse may require a simultaneous vault procedure to adequately address all aspects of pelvic floor support. While these additional procedures often have complication profiles similar to anterior repairs, the complication rates are often higher. This chapter will focus on the complications, and complication rates only for anterior repairs.
Injury to the Lower Urinary Tract
The incidence of lower urinary tract injuries varies based on the type of vaginal surgery, ranging from 0 to 19.5 per 1000 surgeries performed, with injuries occurring more commonly after reconstructive pelvic and incontinence surgery than other gynecological surgeries [3–5]. While injuries are uncommon, the consequences of unrecognized injuries can significantly increase patient morbidity.
Bladder Injuries
Bladder injury at the time of anterior colporrhaphy is very rare. Gilmour and coworkers conducted a systematic review of the literature from 1966 to 2004 and found the rate of bladder injuries during urogynecologic surgery excluding hysterectomies varied from 12.1/1000 surgeries to 16.3/1000 surgeries when intraoperative cystoscopy was performed [3]. Of those studies that performed intraoperative cystoscopy, 95% of bladder injuries were diagnosed and corrected intraoperatively compared to a 43% detection rate when cystoscopy was not performed, underscoring the importance of intraoperative cystoscopy [4].
While the majority of the studies on bladder injuries during urogynecological surgery include multiple concomitant procedures, several report on the rate of bladder injury after anterior colporrhaphy alone. In a study by Kwon and coworkers of 346 women who underwent traditional anterior colporrhaphy , there were no reported bladder injuries [6].
When comparing the rate of bladder injury among traditional anterior colporrhaphy and transvaginal mesh kits, two randomized controlled studies found there to be no difference in the rate of cystotomy with Weber and coworkers reporting no injuries and Hiltunen reporting 1 in the mesh group [7, 8]. A more recent randomized controlled study by Altman and colleagues found there to be a higher rate of cystotomy in the transvaginal mesh group versus traditional anterior colporrhaphy , 3.5% versus 0.5%. However, this did not reach statistical significance (p = 0.07) [9].
Immediate recognition of bladder injury during anterior compartment repairs is essential in reducing postoperative morbidity and potential fistula formation. As cited earlier, intraoperative cystoscopy increases the rate of intraoperative diagnosis and repair. If an intraoperative cystotomy is detected, the injury should be closed in two layers with absorbable sutures. Should the injury be missed, depending on the duration of postoperative catheter drainage and the extent of the injury, the patient is at risk for developing a vesico-vaginal fistula requiring either prolonged catheter drainage or a vesico-vaginal fistula repair.
Ureteral Injuries
Ureteral injuries occur infrequently after routine gynecological procedures (0.5–1.5%), with patients undergoing complex reconstructive procedures for pelvic organ prolapse at an increased risk of ureteral injury [10]. Like bladder injuries, the incidence of ureteral injuries varies depending on the type of urogynecologic surgery, ranging from 2 to 11% [4, 11]. Women with pelvic organ prolapse are at an increased risk of ureteric injury given the anatomic distortion caused by the prolapse itself, with 12–20% of women with symptomatic pelvic organ prolapse having moderate to severe hydronephrosis secondary to chronic obstruction from ureteral kinking [11].
The majority of the studies on ureteral injuries during gynecologic surgery do not separate the rate of injury by procedure. However, a study by Kwon and colleagues looked at the incidence of ureteral injury after anterior colporrhaphy alone [6]. Of the 346 procedures performed, there were seven reported ureteral injuries (2.0%). There was no comment on the POP-Q staging of the women with ureteral injuries. All injuries were recognized at the time of surgery.
Diagnosis of Ureteral Injuries
Intraoperative Diagnosis
If a ureteral injury does occur, the ability to identify the injury at the time of the initial operation is paramount to avoid the permanent damage associated with unrecognized injuries. The single most controllable factor adversely affecting the outcome of ureteral injuries is delayed diagnosis. Studies have shown that intraoperative recognition and repair of ureteral injuries decreases postoperative morbidity, minimizes loss of renal function and need for nephrectomy. Early recognition also decreases the incidence of ureterovaginal fistulas as compared to postoperative diagnosis with delayed repair [12].
If a ureteral injury is suspected during abdominal surgery, direct inspection of the ureter is recommended. However, during vaginal surgery, direct visualization of the ureter is usually not feasible. Therefore, intraoperative cystoscopy has been recommended as a means to identify ureteral injuries during vaginal surgery while obviating the need for an abdominal incision. Prior to cystoscopy, indigo carmine, methylene blue, or fluorescein should be administered allowing for assessment of ureteral patency.
If fluoroscopy is available, another method of assessing ureteral patency is retrograde ureterography. If fluoroscopy is not available, a one-shot excretory urogram can be obtained 10 min after the administration of intravenous contrast material (1 mL/pound of body weight). Fluoroscopically, ureteral injuries present as urinary extravasation or high-grade obstruction.
Delayed Diagnosis
Most ureteral injuries are unsuspected and diagnosed postoperatively [13]. In a study by Meirow and coworkers, the mean delay to diagnosis of patients sustaining ureteral injuries after gynecologic surgery was 5.6 days [14]. Undiagnosed ureteral injuries are associated with significant morbidity, the formation of ureterovaginal fistulas and potential loss of renal function [15]. The majority of patients present with fever, flank pain, continuous incontinence, pyelonephritis, ileus, peritonitis, or anuria. However, 5% of patients remain asymptomatic and are diagnosed at a later date secondary to a nonfunctioning or hydronephrotic kidney [13]. Delayed diagnosis is most often (66–76%) made by CT pyelography, excretory urography, or retrograde ureterography [16].
General Principles of Management
Immediate Intraoperative Management
The management of ureteral injuries depends on the time of diagnosis, location, nature, and extent of the injury. Injuries recognized intraoperatively must be treated immediately. Inadvertent ligation or kinking of the ureter should be treated by suture removal and repeat cystoscopy to ensure ureteral efflux. Typically, if recognized immediately, ureteric damage is minimal as these injuries include other tissue in the ligature [12]. If the extent of the ureteral injury is in question, at minimum, ureteral stent placement is warranted [12]. For more severe injuries, when ureteral viability is unlikely, exploration and direct visualization of the ureter is recommended [17]. The involved ureter should be primarily repaired or resected, debrided, and re-anastomosed over a stent. If the diagnosis of an intraoperative ureteral injury is made during retrograde ureterography, an attempt at retrograde stent placement should be made.
Delayed Management
The type of repair and the timing of delayed-recognition injury repair are controversial. Postoperatively noted suture entrapment can be managed conservatively with immediate attempt at placement of a double-J ureteral stent or nephrostomy tube drainage if the suture is absorbable [18]. However, placement is only possible in 20–50% of patients [16]. In a study by Ghali, only 2 of 21 (19%) iatrogenic ureteral injuries identified postoperatively were able to be stented [16]. When stent placement is possible, as many as 73% of patients will not require open surgery.
If the diagnosis is delayed, the traditional recommendation is that repair of iatrogenic ureteral injuries after urogynecologic surgery should not be undertaken for 3–6 months [19]. However, more recent studies suggest similar outcomes after immediate and delayed repairs [19]. Given that most injuries after vaginal surgery occur to the distal one-third of the ureter, intervention often involves ureteral reimplantation or ureteroneocystostomy. Ureteroneocystostomy is used to repair distal ureteral injuries close to the bladder or in the intramural tunnel.
Hemorrhage
Hemorrhage is a rare complication of anterior compartment repair. During a traditional suture plication repair, proper dissection between the vaginal epithelium and the underlying vaginal muscularis (often called pubocervical fascia) will minimize blood loss and reduce the risk of postoperative hemorrhage . Judicious use of electrocautery during the anterior vaginal wall dissection can also be used to maintain hemostasis. A recent randomized controlled trial by Altman and colleagues included 389 women who underwent isolated anterior compartment repair [9]. Women with stage ≥ 2 prolapse were randomized to a repair using trocar-guided transvaginal mesh (n = 200) or a traditional colporrhaphy (n = 189). The two treatment groups did not differ significantly in terms of POP-Q stage or previous anterior compartment repairs. The traditional colporrhaphy group had a significantly lower mean estimated blood loss (EBL) (35.4 ± 35.4 mL) compared to the trocar-guided transvaginal mesh group (84.7 ± 163.5 mL, p<0.001). The study reported five cases (1.3%) of clinically significant intraoperative blood loss with all five patients having undergone trocar-guided transvaginal mesh placement: four patients (1.0%) had an EBL greater than 500 mL and one patient (0.3%) had an EBL greater than 1000 mL and a subsequent retropubic hematoma. The authors did not provide data on transfusion rates. Due to its focus on anterior compartment repairs without concomitant pelvic floor procedures, the Altman study is a valuable addition to the limited body of literature that addresses the complications of isolated anterior compartment repairs.
Studies that included concomitant pelvic floor procedures also provide data regarding the low incidence of hemorrhage associated with anterior compartment repair [8, 20–22]. Weber and colleagues who performed the very first randomized study of anterior compartment repairs, comparing standard plication, plication with mesh and ultra-lateral anterior colporrhaphy [7]. Subjects were excluded if they underwent any anti-incontinence procedure other than a suburethral plication. Subjects undergoing additional procedures for prolapse were included. Of the 109 women undergoing anterior compartment repair with concomitant pelvic floor procedures, one patient (0.9%) in the standard anterior colporrhaphy group required transfusion rate.
A randomized controlled trial by Hiltunen and colleagues, comparing anterior colporrhaphy with and without tailored mesh, included 201 women with pelvic organ prolapse [8]. Subjects were excluded from the study if they had gynecologic malignancies , apical prolapse mandating apical fixation, SUI , or their main symptomatic compartment was the posterior vaginal wall. Women could be included if they underwent concomitant vaginal hysterectomy, reduction of an enterocele, culdoplasty, or posterior colporrhaphy without mesh. Women were randomized to traditional anterior compartment repair (n = 97) or anterior compartment repair reinforced with mesh (n = 104). A total of 29 patients (14%) underwent an isolated anterior compartment repair with no concomitant procedure. There was no difference in rates of previous vaginal surgery or concomitant hysterectomy between groups. All patients had vaginal packing in place for 20 h postoperatively. Although the mean EBL in the traditional repair group (114 ± 109 mL) was less than the mean EBL in the mesh group (190 ± 23 mL), the difference was not statistically significant (p = 0.004). There was no statistically significant difference is clinically significant blood loss (EBL >400 mL) between the groups (3.1% vs. 9.6%, p = 0.07). Two patients in total (1.0%), it was not specified in what group, required blood transfusions.
Careful attention should be paid during dissection of anterior vaginal wall and muscularis to minimize blood loss. Hemostasis can typically be attained using electrocautery. If electrocautery is insufficient, a figure-of-eight stitch with a 2-0 or 3-0 Vicryl suture can be used to over sew a small vessel. When closing the anterior vaginal wall incision, great care should be taken to achieve a secure closure. A tight closure can provide an additional degree of hemostasis by allowing tamponade within the closed anterior compartment.
The low incidence of clinically significant blood loss affects our routine postoperative care pathway. Given that hemorrhage is a rare complication of anterior compartment repair; our practice is to not obtain routine postoperative lab work. If the patient undergoes a pelvic floor reconstruction that includes a concomitant hysterectomy, then we will obtain routine postoperative blood work and admit the patient for overnight observation. A vaginal pack is placed at the completion of the anterior compartment repair and removed after 1 h in the recovery room . If the patient is admitted for observation due to a concomitant pelvic floor procedure, then the vaginal packing is removed in the early morning of postoperative day one. Vaginal packs are commonly used as a means to reduce postoperative hemorrhage , despite the lack of evidence in the literature. An abstract from Thiagamoorthy and colleagues reported the results of a randomized controlled trial assessing the effect of vaginal packing after a vaginal hysterectomy and/or pelvic floor repair [23]. The women were randomized to receive a vaginal pack (n = 86) or no vaginal pack (n = 87). A total of five patients were withdrawn from the no packing group due to intraoperative bleeding. The study demonstrated no significant difference in mean postoperative hemoglobin on the first postoperative day (11.75 g/dL vs. 11.94 g/dL, p = 0.061) and 6 weeks postoperatively (12.55 g/dL vs. 12.49 g/dL, p = 0.884) between the packing and the no packing group. Although the packing group had fewer postoperative hematomas (n = 4) compared to the no packing group (n = 9), the difference was not significant (p = 0.098). Despite the lack of statistical significance, all three clinically significant complications related to bleeding were in the no packing group. One patient returned to the operating room from the recovery room for hemorrhage and two patients required repeat admission for intravenous antibiotics to treat an infected pelvic hematoma. The data presented in the abstract support our continued use of vaginal packing until additional data are available to influence our care pathway.
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