15 Avoiding and Managing Vaginal Surgery Complications—A Series of Case Discussions
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This chapter reviews a variety of potential complications that can occur during or as a result of vaginal surgery. Most of the cases have an accompanying video clip demonstrating the technical aspects of managing the complications.
Case #1: Intraoperative Management of Ureteral Obstruction During a Vaginal Prolapse Repair
A 56-year-old woman with symptomatic pelvic organ prolapse underwent a vaginal prolapse repair that involved anterior colporrhaphy as well as vaginal vault suspension to the uterosacral ligaments. After the anterior colporrhaphy was completed and the apical stitches were tied to suspend the vaginal vault, 5 mL of indigo carmine was administered intravenously and cystourethroscopy was performed to confirm ureteral patency. There was prompt efflux of dye from the right ureter; however, there was no efflux from the left ureter 15 minutes after dye administration. Close visualization of the ureter revealed peristalsis of the intravesical part of the ureter.
This is a typical example of a ureteral kink or obstruction occurring secondary to a prolapse repair. The obstruction is caused either by the stitches placed through the uterosacral ligament on the patient’s left side or by one of the stitches placed for the anterior colporrhaphy. Although options to address this problem include attempting to pass a stent and performing a retrograde study, in our opinion the next step of management should be to identify the suture causing the obstruction, cut it, ensure ureteral patency, and then, if appropriate, replace the suture. In this particular case, the offending suture was from the anterior colporrhaphy, and once the suture was cut, dye was visualized immediately. The suture was replaced, ureteral patency was confiirmed, and the procedure was completed. (See Videos 15-1 and 15-2 for demonstrations of techniques for addressing ureteral obstruction during and after a vaginal prolapse repair.)
Case #2: Vaginal Mesh Erosion After Prolapse Repair Using a Trocar-Based Total Vaginal Mesh Kit
A 59-year-old woman had recurrent pelvic organ prolapse as well as erosion of a large piece of mesh into the upper part of the anterior vaginal wall. She had undergone prolapse repair using a trocar-based total vaginal mesh kit 6 months before presentation. Her current symptoms included a feeling of recurrent prolapse, significant dyspareunia related to the mesh erosion, and vaginal bleeding and discharge. Examination revealed apical prolapse with descent of Pelvic Organ Prolapse Quantification point C to +1 as well as recurrent prolapse of the upper part of the anterior vaginal wall (point Ba was at 0). The patient underwent vaginal surgery for excision of the eroded mesh and suture repair of her apical prolapse and cystocele.
This erosion most likely occurred due to bunching up of the mesh in the anterior vaginal wall (Video 15-3). The fact that a patient experiences erosion and failure of prolapse repair after a mesh kit procedure does not exclude the patient from undergoing a subsequent traditional suture repair. During dissection of the anterior vaginal wall the peritoneum was entered and a high uterosacral vaginal vault suspension was accomplished to adequately suspend the prolapsed cuff. The mesh was sharply excised, and the recurrent cystocele was corrected with an anterior colporrhaphy (see Video 15-3).
Case #3: Midurethral Sling in the Urethra
A 36-year-old woman had recurrent urinary stress incontinence. One year previously she had undergone a sling placement procedure using the Gynecare TVT Secur system (Ethicon Women’s Health and Urology, Somerville, NJ), which resulted in minimal to no improvement in her stress incontinence. Subsequently she had two injections of a urethral bulking agent, which again failed to improve her incontinence. On physical examination she was noted to have urethral hypermobility (urethral angle of 60 degrees with straining on the Q-Tip test). Urodynamic studies confirmed recurrent urinary stress incontinence with leak-point pressure measurements of approximately 50 cm H2O. Cystourethroscopy was undertaken, and the edge of the previously placed synthetic sling was seen transecting the lower left edge of the midurethra. The patient gave consent for exploration of the anterior vaginal wall with excision of the previously inserted sling and urethral reconstruction with placement of a fascial sling at the bladder neck.