BLEEDING

Problematic bleeding is undoubtedly the most feared problem that a surgeon encounters during or immediately after a surgical procedure. During the procedure, intraoperative bleeding compromises the surgeon’s ability to adequately complete the task at hand. The reported incidence of bleeding during vaginal surgery varies by specific procedure, and to some degree, reported rates of hemorrhage depend on the investigator’s definition of excessive blood loss. Most surgeons consider the need for blood transfusion a reliable definition of excessive surgical bleeding, but less blood loss can still interfere with surgical outcome and prolong hospitalization. Reported rates of such intraoperative hemorrhage are between 0% and 2% for most vaginal procedures, but these rates likely underestimate the incidence of problematic bleeding.

Several investigators have reported low transfusion rates even when multiple vaginal reconstructive repairs, including hysterectomy and pubovaginal slings, are performed during the same operation. One of the largest series of patients undergoing multiple vaginal prolapse and incontinence procedures was reported by Shull and colleagues.¹ Three hundred and two patients underwent a uterosacral vault suspension in combination with other support defects involving the urethra, bladder, posterior cul-de-sac, or rectum. The mean intraoperative blood loss for all patients in this study was 243 mL, and the blood transfusion rate was 1%. Other studies have reported similarly low rates of blood transfusion and blood loss between 200 and 350 mL when performing multiple vaginal prolapse repairs with a uterosacral vault suspension.²^–⁵ In one report looking at a series of patients undergoing vaginal reconstructive procedures, each of which included uterosacral vault suspension, the investigator found that when he compared blood loss between those having a hysterectomy at the time of repair with patients having only reconstructive procedures, hysterectomy did not significantly increase operative blood loss or the risk of significant bleeding.³ One of the attractive features of the uterosacral vault suspension for apical prolapse is its low incidence of troublesome bleeding. However, most published data are reported by experts in the field and may not accurately reflect the experience of the generalist surgeon.

Although the reports cited found major intraoperative blood loss to be uncommon even when an apical prolapse procedure was performed, correction of the vaginal apex with a sacrospinous ligament fixation has been often associated with the potential for increased bleeding. This procedure, originally described by Richter,⁶ has been studied repeatedly in the past decade with regard to surgical complications in general and bleeding in particular. The incidence of excessive bleeding reported in most series has been between 0.5% and 3.5%.⁷^–⁹ An important aspect of these statistics, however, is that maneuvers to control bleeding in this area have been reported to promote injury to adjacent structures, including the rectum and nerves. Nieminen and Heinonen⁹ reported a higher transfusion rate (28% of 25 women) when performing a sacrospinous ligament fixation in a population of patients older than 80 years.

In an attempt to define the optimal surgical strategy for controlling intraoperative hemorrhage associated with sacrospinous ligament fixation, Barksdale and coworkers.¹⁰ conducted an anatomic study with 10 female cadavers to map the vascularity in the region of the sacrospinous ligament and propose surgical strategies for controlling hemorrhage. Their report detailed various combinations and permutations of vascular anastomoses in the area of the sacrospinous ligament (i.e., superior gluteal, inferior gluteal, internal pudendal, vertebral, middle sacral, lateral sacral, and external iliac by way of the circumflex femoral artery system). They concluded that because of the vascular anastomoses, the heroic approach of laparotomy with surgical ligation of the internal iliac artery was unlikely to be of significant benefit. They also determined the inferior gluteal artery to be the most likely artery responsible for hemorrhage related to the sacrospinous ligament fixation. Based on anatomic considerations, bleeding from the inferior gluteal artery is optimally controlled by any combination of packing and vascular clips by means of the vaginal approach or arterial embolization by invasive radiology techniques. We have become less hesitant to employ surface hemostatic factors, such as FloSeal (Baxter International, Deerfield, IL).

Very few studies have evaluated factors associated with increased blood loss during vaginal surgery, such as surgeon skill level, surgical techniques, obesity, and the impact of prior pelvic surgery. Coates and associates ¹¹ reported surgical outcomes in 289 women undergoing a vaginal prolapse repair. In 154 of these operations, the senior staff member was the primary surgeon (mean blood loss, 248 mL), and in the remaining 135 procedures, a senior gynecology resident was the primary surgeon (mean blood loss, 234 mL). The difference in operative bleeding between the senior staff surgeon and the surgical trainee was not clinically or statistically significant. One retrospective review of surgical outcomes in obese women (i.e., body mass index [BMI] > 30 kg/m²) compared surgical complications in 189 subjects undergoing abdominal hysterectomy and in 180 women having a vaginal hysterectomy.¹² Both groups of obese women had a mean change in hemoglobin of 1.7 g and a 13% transfusion rate, which established obesity as risk factor for hemorrhage in female pelvic surgery, regardless of the chosen surgical approach.

Besides patient characteristics and surgical experience, surgical equipment may also impact the occurrence of unacceptable bleeding. Good surgical exposure and lighting is paramount to achieving surgical goals and avoiding and controlling bleeding. The Lonestar retractor (Lone Star Medical Products, Stafford, TX) is invaluable in this regard because it retains an open introitus and allows the surgeon to maintain visualization of the vaginal apex. The use of a surgical headlight or a cool lighting system that is adherent to the retractor and placed within the pelvis (LightMat, Lumitex, Strongsville, OH) provides sufficient light for operating in a deep body cavity.

In addition to the traditional ways of controlling bleeding, such as suture ligation and electrocautery, other user-friendly techniques have been introduced. In the United Kingdom, Hefni and colleagues ¹³ randomized 116 patients to vaginal hysterectomy with traditional suture ligation (n = 59) or to vaginal hysterectomy with the LigaSure (Valleylab, Boulder, CO) vessel sealing system (n = 57).¹³ Mean intraoperative blood loss was 100 mL in both groups, but perioperative bleeding complications in the suture ligation group neared statistical significance (P = .0571).

More than other approaches to surgery, the transvaginal approach may be technically challenging in the setting of previous surgery. Boukerrou and coworkers ¹⁴ reported surgical outcomes of 741 women undergoing vaginal hysterectomy. Seventy-one (9.58%) of their subjects had undergone previous cesarean section, and the remaining 670 (90.41%) had not. Mean blood loss was 181.69 mL in the group of patients with previous cesarean section and 145.96 mL in the control group (P = .05). Among women with a history of cesarean section, 11.3% had intraoperative hemorrhage (i.e., blood loss in excess of 500 mL), compared with only 2.5% of women without a history of previous cesarean section. It is intuitive to surgeons that prior procedures in the same area render subsequent operations more difficult and prone to complications such as bleeding, but few articles report this conclusion.

In addition to vaginal prolapse procedures, transvaginal incontinence procedures, such as pubovaginal slings, may also cause intraoperative bleeding. Even though the traditional bladder neck pubovaginal slings required more extensive transvaginal surgical dissection, including digital and usually blind dissection of the retropubic space, several large pubovaginal sling series have demonstrated rare intraoperative bleeding complications.¹⁵^–¹⁸ The increasingly popular minimally invasive or midurethral sling is placed by passing a trocar blindly through the retropubic or obturator space. Although there are rare reports of iliac artery injuries published on the MAUDE database, most case series report a 1% to 3% increased bleeding rate resulting in pelvic or perineal hematomas. Abouassaly and associates¹⁹ reviewed 241 patients who had undergone placement of a tension-free vaginal tape. These patients, recruited from six medical centers, had an intraoperative hemorrhage rate of 2.5% (16 patients). Four patients (1.9%) developed a pelvic hematoma within the first 24 hours after surgery. In another series, Krauth and colleagues²⁰ described 604 patients undergoing placement of a minimally invasive suburethral sling by the transobturator approach. They reported a 0.8% incidence of intraoperative hemorrhage and postoperative development of two (0.33%) perineal hematomas, one of which resolved without intervention, and the other, believed to be associated with a concomitant prolapse repair (not the transobturator sling), required revision surgery.

In summary, surgeons are wise to consider each patient’s individual risk factors for operative bleeding before surgery. Intuitively, obese women and women with a history of prior pelvic surgery may have an elevated risk for excessive surgical bleeding, and extra precautions should be taken in the operating room (e.g., good surgical assistants and exposure, blood products available on short notice). We evaluate bleeding time and platelet function for patients who provide us a history of prior intraoperative or postoperative hemorrhage. Any medication that can affect bleeding should be stopped 7 to 10 days before surgery when this can be safely accomplished. Surgeons who are managing patients who require some level of anticoagulation, such as a patient with a history of heart valve replacement or atrial fibrillation, are wise to obtain hematologic advice for the perioperative management of anticoagulation agents.

INJURY TO THE URINARY TRACT

Operating in the vagina places the surgeon close to the urinary tract, and great care must be taken to avoid its injury. As with any effort to avoid surgical complication, a sound surgical plan and good exposure are important, as is a thorough understanding of the anatomy within the surgical field. It is encouraging to consider that most injuries to the urinary tract during vaginal surgery are problematic only if unrecognized.

Injuries to the urethra, bladder, or ureters that are identified at the time of surgery and primarily repaired most often heal without incident or further significant consequence to the patient.²¹ For this reason, we rarely perform vaginal surgery without a cystoscopic evaluation of the lower urinary tract and confirmation of bilateral ureteral spill after the administration of intravenous indigo carmine. In addition to absent ureteral spill, other abnormalities sought are suture transfixation or sling penetration of the bladder and surgical entry to the bladder, each of which would necessitate re-exploration for removal or repair. We also look for bladder wall ecchymosis, which may suggest the need for a longer period of postoperative catheterization. Several published studies have confirmed the importance of intraoperative cystoscopy when pelvic reconstructive procedures, including incontinence procedures, are performed. Harris and associates²² reviewed the records of 224 consecutive patients undergoing urogynecologic and reconstructive pelvic surgery. Based on a 4% rate of injury to the urinary tract, which would have been unrecognized without intraoperative cystoscopy, they concluded that cystoscopy should be included in all incontinence and pelvic reconstructive procedures. Another large, prospective study, in which intraoperative cystourethroscopy was performed universally on 471 women undergoing hysterectomy, documented a 7.6% rate of injury to the urinary tract.²³ Of the patients in this report, 144 (31%) had a vaginal hysterectomy. Among those patients having vaginal hysterectomy, 11 (7.6%) experienced an injury to their urinary collecting system; 6 of the 11 had concurrent prolapse surgery. Of the 11 injuries, 2 were ligated ureters, 7 were cystotomies, 1 was a suture in the bladder, and 1 was bladder abrasion. Concurrent prolapse surgery was therefore found to be an independent risk factor for injury to the urinary system. When controlling for prolapse and incontinence surgery, there was not a significant increase in the risk of urinary tract injury based on route of hysterectomy, age, BMI, race, blood loss, uterine size, and history of previous cesarean section. However, the standard of care in community practice is to not routinely perform cystoscopy at the end of hysterectomy or pelvic organ prolapse surgery.

Transvaginal vault suspensions, specifically uterosacral vault suspensions, have been associated with urinary tract injuries, especially injuries involving one or both ureters. Because this vault suspension involves placement of sutures intraperitoneally above the level of the ischial spines, the ureter is near the suture placement. A cadaveric study by Buller and colleagues ²⁴ demonstrated the strength of the uterosacral ligament at various locations in the pelvis and its proximity to the ureter at the site of customary suture placement. Based on their findings after necropsy of 11 female cadavers, the ureter is, on average, 2.3 ± 0.9 cm from the uterosacral ligament at the level of the ischial spine. This finding led Buller and his colleagues to claim, “The proximity of the ureter to the distal uterosacral ligament warrants concern during vaginal vault repairs that use the ligament.”²⁴

Several surgical series of uterosacral vault suspension have reported a 0% to 11% incidence of injury to the ureter.¹^–⁵ In each of these series, the injuries were identified at the time of surgery after confirming an absence of ureteral spill on cystoscopic evaluation. Management usually involved removal of the uterosacral suspensory sutures with or without ureteral stent placement; however, some injuries, presumably transections, required ureteroneocystotomy. In these reports, all injuries were detected by intraoperative cystoscopy at the time of surgery, and as a result, none of the patients had permanent or long-term urinary tract sequelae. In addition to ureteral injury, cystotomy may occur during transvaginal surgical entry into the peritoneal cavity and may be repaired and the operation continued in most circumstances.⁴

Aronson and colleagues ²⁵ reported the ureteral injury rate using a modified “deep” Mayo-McCall uterosacral ligament plication for vaginal vault suspension. The technique for placement of suture through the uterosacral ligament described by the investigators resulted in a uterosacral anchoring point much more dorsal and posterior than previously described. In this retrospective report of 411 consecutive patients, they observed three ureteral injuries, only one of which was attributable to the vault suspension procedure (0.24% [range, 0.01% to 1.35%]).

Injury to the lower urinary tract is not uncommon in vaginal procedures designed to treat stress urinary incontinence, and the data depend on the procedure used. Factors such as anesthetic technique (i.e., regional or local versus general anesthesia) and the use of hydrodissection in the retropubic space were previously thought to affect bladder injury rate, but a report from Ghezzi and coworkers ²⁶ disputes these assumptions.

The minimally invasive techniques for placement of midurethral slings are associated with the highest rate of bladder injury, with some articles describing cystotomy rates greater than 10%.²⁷^–²⁹ However, in one study that surveyed members of the American Urogynecologic Society and members of the Society for Urodynamics and Female Urology, only 10% to 15% of those surveyed from both groups admitted to cystotomy rates higher than 5%. More than 90% of the members in both societies would replace the trocar at the time of surgery, and more than 80% of the members in both societies would drain the bladder transurethrally for at least 24 hours if a cystotomy was made with the trocar.³⁰

Some investigators have described risk factors associated with inadvertent cystotomy. Bodelsson and associates ²⁷, in their series of 177 patients undergoing a tension-free vaginal tape procedure, were able to show a statistically and clinically significant difference in the occurrence of cystotomy and urethrotomy among surgeons with different levels of experience. Another potential contributing factor to operative morbidity, including urinary tract injury, is obesity. However, Rafii and colleagues²⁹

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