Postoperative pulmonary complications are a frequent cause of morbidity and mortality. Postoperative pneumonia, atelectasis, pneumothorax, and respiratory failure increase length of stay and are more common than postoperative cardiac complications [47]. The incidence of postoperative pulmonary complications in gynecologic patients has been reported to be between 1.22 and 2.16% [48]. There are multiple risk factors that may increase pulmonary complications in the postoperative surgical patient . In a prospective randomized trial of patients who underwent nonthoracic surgery, multivariate analysis showed four risk factors for postoperative pulmonary complications which were age greater than 65, positive “cough test,” perioperative nasogastric tube, and duration of anesthesia (procedures lasting longer than 2.5 h) [49]. A retrospective review of patients undergoing gynecologic laparoscopy found that operative time greater than 200 min and age greater than 65 contributed to hypercarbia. Predictors of the development of pneumothorax included pneumoperitoneum CO₂ pressure greater than 50 mmHg and operative time greater than 200 min [50].

In a retrospective review of 3226 patients who underwent hysterectomy for benign conditions, it was found that the overall incidence of pulmonary complications in the benign gynecologic patient population was extremely low −0.3% (95% CI, 0.17–0.57%) [51].

Surgical approach is also a contributing factor for the development of a postoperative pulmonary complications. A study of patients undergoing abdominal surgery found that age greater than 60, smoking history within the past 8 weeks, body mass index greater than or equal to 27, history of cancer, and incision site in the upper abdomen or both upper/lower abdominal incision were identified as independent risk factors for postoperative pulmonary complications [52].

In a prospective randomized control trial involving 994 patients by Xue and colleagues [53], patients were divided into three groups (1) elective superficial plastic surgery, (2) upper abdominal surgery, and (3) thoracoabdominal surgery. It was found that the incidence of hypoxemia in the postoperative period was closely related to the operative site, where upper abdominal and thoracoabdominal sites gave the greatest risk. When evaluating this study , patients undergoing pelvic reconstructive surgery would most likely fall into the low-risk category similar to elective superficial plastic surgery, with a low risk of hypoxemia in the postoperative period.

Another risk factor associated with postoperative pulmonary complications is smoking. In a prospective cohort study of patients referred for nonthoracic surgery, the risk for postoperative pulmonary complications was increased by age of greater than 65 years or more and smoking of 40 pack-years or more [48]. In a retrospective review performed on 635,265 patients from the American College of Surgeons National Surgical Quality Improvement Program database, current smokers had increased odds of postoperative pneumonia and unplanned intubation [54]. Pulmonary complications significantly decrease after 8 weeks of smoking cessation [55]. Chronic obstructive pulmonary disease patients are at increased risk of having postoperative pulmonary complications. Preoperative pulmonary function tests may help to identify patients with increased pulmonary risk [56]. Patients with COPD were found to be 300–700 times more likely to have a postoperative pulmonary complication in a prospective cohort study [48]. Nasogastric intubation instead of orogastric intubation increases risk of pneumonia in this patient population as well [57].

Sleep apnea is an additional risk factor for postoperative pulmonary complications. Obstructive sleep apnea is defined as partial or complete obstruction of the upper airway during sleep [58]. The prevalence of sleep apnea is around 5% [59]. In an additional study evaluating the prevalence of sleep apnea in the general surgery population, 22% of surgical patients were found to have obstructive sleep apnea [60]. Therefore, we can hypothesize that obstructive sleep apnea is a prevalent and important risk factor for postoperative pulmonary complications in our population as well. In a retrospective cohort study of orthopedic and general surgery patients by Memtsoudis and colleagues [61], 51,509 patients with sleep apnea who underwent general surgery procedures were assessed for postoperative pulmonary complications. It was found that patients with sleep apnea developed pulmonary complications more frequently than their matched controls. Due to relaxation of the pharyngeal muscles from anesthetic agents, sedatives, and opioids, patients with obstructive sleep apnea may have increased airway collapse in the postoperative period [62]. The supine position that occurs during surgery and in the postoperative period may worsen obstructive sleep apnea [63]. Anesthesia may also blunt the hypercapnic and hypoxic respiratory drive as well as the arousal response. In a study performed by Bolden and coworkers [64], the frequency of postoperative hypoxemia was measured in OSA patients in the postoperative period where 16% of the patients studied found multiple measured postoperative desaturations.

To avoid hypoxemia in OSA patients, it is necessary to encourage patients to bring with them their home continuous positive airway pressure (CPAP ) machines, or to order home CPAP settings for CPAP hospital machines. Careful evaluation of the patient is essential to preventing postoperative complications. If a patient is suspected to have OSA but has not been diagnosed, it is useful to place the patient under continuous pulse oxygen saturation monitoring for the first 24 h after surgery [58].

Atelectasis and hypoxemia are common after surgery especially surgeries that involve the abdomen or thorax. Early on, atelectasis may result from soft tissue edema from the upper pharynx due to intubation and tongue manipulation. Later, especially in patients who have undergone abdominal surgery, there is decreased ability to take in deep breaths or cough due to postoperative pain. Postoperative patients have decreased functional residual capacity [65]. These factors lead to hypoventilation. Diagnosis of atelectasis may be made clinically and/or via imaging tests. Atelectasis may present as postoperative fever, decreased breath sounds at the lung bases, and can be found on chest-X-ray or CT.

Pre- and postoperative incentive spirometry is the most common prevention and treatment intervention for atelectasis. Incentive spirometry used in the perioperative period enhances postoperative functional residual capacity and reminds patients to continue to take in large breaths. If the patient becomes hypoxic from atelectasis, bronchoscopy may be performed to remove secretions from the airway [66]. Continuous positive airway pressure (CPAP ) can be used in the postoperative period and has also been shown to decrease intubation in patients who are at high risk of hypoxemia from atelectasis after abdominal surgery [67].

Postoperative pneumonia is a common postoperative pulmonary complication. Hospital-acquired pneumonia refers to pneumonia that develops after 48 h in the hospital. Diagnosing postoperative pneumonia can be difficult. Infiltrates from atelectasis, pulmonary edema, and acute lung injury can all look identical to pneumonia on chest X-ray. Diagnosis should be suspected if patient has new onset fever, purulent sputum, leukocytosis, hypoxemia, and infiltrate on chest X-ray (American Thoracic Society, 2002) [68]. In a prospective case series of patients presenting with postoperative pneumonia within 14 days of surgery, 61% of patients developed pneumonia within the first 5 days postoperatively. The most common etiologic agents were Staphylococcus aureus, Streptococci, and Enterobacter [69].

Treatment of postoperative pneumonia should begin with broad-spectrum antibiotics given the polymicrobial nature of hospital-acquired pneumonia. Recommendations by the American Thoracic Society and the Infectious Disease Society of America include coverage for aerobic bacteria as well as anaerobic coverage. Most hospitals have guidelines for treating hospital-acquired pneumonia based on regional microbial infection.

Urinary tract infections (UTIs) are one of the most common infections seen in the postoperative period. The incidence of UTIs rises with increasing age. Eighty percent of UTIs are caused by bladder instrumentation, with catheter-associated UTI (CAUTI) being most common [70]. The rate of bacteruria after undergoing an anti-incontinence procedure has been estimated to be between 17 and 85% [71]. Reconstructive pelvic surgery almost always involves bladder instrumentation via cystoscopy and/or catheter placement, thereby increasing the risk of UTI in these patients. Additional risk factors for UTI include inefficient bladder emptying, pelvic relaxation, neurogenic bladder, asymptomatic bacteriuria, decreased ability to get to the toilet, nosocomial infections, physiologic changes, and sexual intercourse, all seen commonly in the reconstructive pelvic surgery population [72]. Development of a fever in the postoperative period after female pelvic reconstruction should warrant a urinary tract evaluation; however, it is rare that lower UTI causes fever in itself .

There have been multiple trials evaluating risk of UTI after urogynecological procedures including the SISTEr trial of Burch vs. autologous sling for treatment of stress urinary incontinence, where the reported rate of UTI was 48% in the sling cohort and 32% in the Burch cohort during the first 24 months of follow-up [73]. In the TOMUS trial , retropubic midurethral slings were associated with significantly more UTIs than transobturator slings in the first 6 weeks after surgery (13% vs. 8%, p = 0.3) and after 24 months follow-up (21% vs. 13%, p = 0.02) [74]. In a case–control study of women undergoing surgery for stress urinary incontinence and/or pelvic organ prolapse, 9% of women developed UTI and the risk of UTI was significantly increased by previous history of chronic or multiple UTIs, prolonged duration of catheterization, and increased distance between the urethra and anus [75].

Signs and symptoms of UTI in women are varied. Common cystitis symptoms include frequency, urgency, nocturia, dysuria, suprapubic discomfort, hematuria, and occasional mild incontinence. Fever, chills, general malaise, and costovertebral angle tenderness are associated with upper UTI [71]. There are multiple ways to diagnose UTI. Urine dipstick testing can detect the presence of leukocytes, bacteria, nitrates, and red blood cells. It also measures glucose, protein, ketones, blood, and bilirubin. In the office, the dipstick test can be used as a rapid diagnostic test . It can measure leukocyte esterase nitrates, hematuria, and pyuria. In the setting of leukocytosis, and/or nitrites and hematuria, the sensitivity to detect UTI is 75%, but the specificity is 66% with a positive predictive value of 81% and a negative predictive value of 57% [76]. The most important predictor of UTI measured by microscopy is leukocytosis; however, leukocytosis alone is not sufficient to diagnose UTI [77]. The gold standard to diagnosing UTI is a urine culture. The traditional diagnosis of UTI by culture is greater than 100,000 colony forming units/mL (CFU); however, many women may have asymptomatic bacteriuria. In a study performed by Schiotz [78], 193 women who underwent gynecologic surgery and had a Foley catheter for 24 h were assessed for bacteriuria; 40.9% of patients had asymptomatic bacteriuria, while only 8.3% of patients actually developed UTI. In contrast, those with fewer than 100,000 CFU but symptoms of UTI can also be appropriately diagnosed as having a UTI.

The most common pathogen causing complicated and uncomplicated UTI is E. coli. The definition of complicated UTI is associated with a condition that increases the risk of acquiring infection or failing first-line treatment. Many patients with pelvic floor disorders with UTI may fit into the complicated category because they are status/postcatheterization and procedures [79]. Other uropathogens include Klebsiella, Pseudomonas, Enterobacter, Enterococcus, and Candida. The initial therapy for treatment of UTI traditionally has been Trimethoprim–Sulfamethoxazole (TMP–SMX) if the resistance in the population is less than 20%. However, due to empiric treatment of UTIs in the past, resistance for TMP–SMX and amoxicillin is high and has been reported to be up to 54% for TMP–SMX and 46% for penicillins. Nitrofurantoin has been well studied and is an additional agent used frequently to treat UTIs. It is a cost-effective agent that may be used in the setting of fluoroquinolone and TMP–SMX resistance [80]. When treating a postoperative reconstructive patient, it is important to evaluate the antimicrobiogram in the specific hospital setting and to prescribe accordingly.

It is clear that patients who undergo female pelvic reconstructive procedures require antibiotics prophylaxis at the time of the procedure [81]. The American Urologic Association Best Practice Guidelines [82] recommend antibiotic prophylaxis for vaginal surgery to prevent both postoperative UTI and postoperative pelvic infection (Table 4.2). A prospective randomized trial by Ingber and coworkers [83] found that patients who were given single-dose antibiotic therapy for midurethral slings had a low rate of postoperative UTI (5.9%). Clinical trials have been mixed about whether multiple doses of antibiotics in the perioperative period decrease UTI rates beyond single-dose therapy [84]. What is also unclear is the need for prophylactic antibiotics beyond the perioperative period in patients who will require prolonged catheterization. In a randomized, double-blind controlled trial by Rogers and coworkers [81], 449 patients who underwent pelvic organ prolapse and/or stress urinary incontinence surgery and had suprapubic catheters placed were given either placebo or nitrofurantoin monohydrate daily while the catheter was in place to assess rate of UTI. The study found that there was a significant decrease in positive urine cultures, as well as symptomatic UTI at suprapubic catheter removal with nitrofurantoin prophylaxis; however, there was no difference in symptomatic UTIs at the 6–8 week postoperative visit. A similar trial evaluating nitrofurantoin daily prophylaxis in patients with prolonged transurethral catheterization after pelvic reconstructive surgery found that daily nitrofurantoin during catheterization did not reduce risk of postoperative UTI [85].

Infection complicating pelvic surgery can occur in three different settings: (1) fever of unknown origin, (2) operative site infection, and (3) infection remote from surgery. The pathological source of most surgical site infections is from bacteria located on the skin or in the vagina. Skin flora is usually aerobic gram positive cocci, but may include gram negative, anaerobic, and/or fecal flora if incisions are made near the perineum and groin [86]. Pelvic reconstructive surgery almost always involves the vagina and perineum and therefore places all of our patients at increased risk for surgical site infections. Other patient comorbidities that may increase the risk of surgical site infections include advanced age, obesity, medical conditions, cancer, smoking, malnutrition, and immunosuppressant use [87, 88]. Other risk factors for surgical site infection include poor hemostasis, length of stay, length of operative time, and tissue trauma. Specific risk factors for obese patients include increased bacterial growth on skin, decreased vascularity in the subcutaneous tissue, increased tension on wound closure due to increased intra-abdominal pressure, decreased tissue concentrations of prophylactic antibiotics, and a higher prevalence of diabetes with poor glucose control and longer operating time [89]. In a retrospective chart review of patients who underwent midline abdominal incisions, patients with increased subcutaneous fat were 1.7 times more likely to develop a superficial incisional infection [90]. In a prospective study of 5279 patients who underwent hysterectomy, it was found that obese patients who underwent abdominal hysterectomy were five times more likely to have wound infection. Route of surgery was an additional risk factor for infection with the highest risk in patients who underwent abdominal hysterectomy. Patients who underwent laparoscopic or vaginal hysterectomy were more likely to have remote pelvic infections compared with abdominal hysterectomy [88]. In a large retrospective study of over 22,000 patients undergoing hysterectomy, the rate of surgical site infection overall was 2.04% and it was found that β-lactams given prior to incision were associated with the lowest rate of surgical site infections [91]. It is therefore advised that patients with penicillin allergies should be questioned on their reaction thoroughly and may necessitate penicillin allergy testing prior to surgery to avoid alternate antibiotics if possible. In another large retrospective study of over 55,000 patients undergoing hysterectomy, it was found that compared with those of normal BMI, women with BMIs 40 or higher had five times the odds of wound dehiscence, five times the odds of wound infection, and 89% higher odds of sepsis [13]. Women should be counseled of these findings prior to undergoing hysterectomy.

Use of synthetic mesh may be an additional risk factor for surgical site infection. There have been multiple case studies describing mesh infection. In one retrospective case study of patients who had undergone abdominal sacrocolpopexy, 27% of patients who underwent hysterectomy at the time of sacrocolpopexy became infected requiring mesh removal vs. 1.3% of patients in the same study that had undergone sacrocolpopexy alone [92]. In an additional case series of 19 women who had undergone intravaginal slingplasty with synthetic mesh, six women had infected mesh that had to be removed [93]. In randomized trials comparing native tissue vaginal repair to transvaginal mesh placement using wide-pore [94] polypropylene, the risk of infection appears to be low in some trials and elevated in others [95]; however, many of these studies are small and are not adequately powered to detect differences in infectious morbidity.

Diagnosis of surgical site infection includes pain and tenderness at the operative site and fever. Fever is defined as a temperature of greater than 38 °C on two or more occasions occurring at least 4 h apart [96]. Skin erythema, induration, and/or drainage of purulent or serosanguinous fluid may be visualized on examination. On pelvic exam, there may be pelvic, vaginal cuff, or parametrial tenderness. There may be a leukocytosis on complete blood count [95]. If pelvic abscess is suspected, ultrasound, CT scan, or MRI may be used for diagnosis. Ultrasound is a cost-effective way to image a patient with a suspected abscess. The sensitivity and specificity of pelvic ultrasound to look for pelvic abscess is 81% and 91%, respectively [97]. Computed tomography may be used to diagnose pelvic abscess when the diagnosis by ultrasound is equivocal. However, computed tomography increases exposure to ionizing radiation which may be problematic in younger patients.

Patients with superficial wound cellulitis may be treated with oral therapy. If there is evidence of a wound seroma or hematoma, a small portion of the wound may be opened and/or evacuated. It is important to probe the wound to insure the fascia is intact [98]. It may be necessary to remove staples and sutures in the infected area. Admission is recommended if a patient is febrile, has signs of peritonitis, has failed oral agents, has evidence of a pelvic or intra-abdominal abscess, is unable to tolerate oral intake, or has laboratory evidence of sepsis [95]. Patients requiring admission should receive broad-spectrum parenteral antibiotics. Pelvic abscess may need drainage via opening of the vaginal cuff, CT, or ultrasound-guided drainage [99]. A vaginal cuff abscess may necessitate opening part of or, in some cases, the entire cuff to allow for sufficient drainage. If mesh has been placed, it may need to be removed if directly involved with the infection in order to achieve adequate resolution.