Preoperative and Postoperative Complications and Management

Matthew Fagan

GENERAL CONSIDERATIONS

All surgical procedures involve some risk of intraoperative or postoperative complications, anesthetic risk, and the possibility of long-term morbidity, loss of function, or death. Much of the risk to an individual patient is based on the pathology necessitating surgery and her medical comorbidities. Pelvic organ prolapse and urinary and fecal incontinence are disabling conditions with significant burdens of disease and loss of function. They are not, however, fatal diseases. Every consideration must be made to weigh the risks of surgery against the natural history of the disease being treated. Many interventions are available to both assess and reduce an individual patient’s risk of complications during and immediately following surgery. Many of these interventions are backed by sufficient medical evidence that they have been recommended to all surgeons and hospitals. Indeed, agencies such as the Institute for Healthcare Improvement (IHI), Agency for Healthcare Research and Quality (AHRQ), Center for Medicare Services (CMS) and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) have identified certain perioperative practices for universal implementation. Table 19.1 lists eleven practices identified by AHRQ with the best evidence to improve patient safety. Four of these relate directly to perioperative care, and three will be discussed below (1). Additionally, there are some time-honored practices and routines that may actually increase the risk of certain complications. It is every surgeon’s responsibility to remain current on a set of best practices for perioperative care and to advocate for their implementation in an organized fashion by hospital operating rooms and practices.

The goals of perioperative care are to minimize the risk to individual patients and to maximize the likelihood of a successful surgical outcome and return to normal function. Within this framework are the preoperative medical evaluation, immediate preoperative care, and postoperative care. The goals of the preoperative medical evaluation are to maximize the functional status of individual patients with known disease, and to screen based on history and risk factors for subclinical conditions that may affect their response to surgery. A detailed discussion of the preoperative medical evaluation is beyond the scope of this chapter, but all pelvic surgeons should be familiar with this subject. Surgical clearance by an outside provider does not abdicate the surgeon of his or her primary responsibility for the overall care of the patient. Patients undergoing reconstructive pelvic surgery are often older and have a greater number of comorbidities or risk factors that must be addressed prior to surgery.

Surgery for the correction of pelvic floor dysfunction is common. The lifetime risk of surgery for pelvic organ prolapse or urinary incontinence is estimated to be 11%, with 30% of patients seeking reoperation for recurrent symptoms (2). Rates of operative complications and perioperative morbidity are low in benign gynecologic surgery. The VALUE study estimated the overall risk of major complications in hysterectomies for benign indications to be 3% (3). However, pelvic reconstructive surgery involves a substantially higher risk of intraoperative
and perioperative complications than surgery for other benign gynecologic conditions. The reported rates are similar to those observed in gynecologic oncology procedures. Lambrou et al published a retrospective case series of 100 reconstructive pelvic surgery cases. They reported an overall prevalence of complications of 46% (4,5). Patients undergoing reconstructive pelvic surgery are often older, undergo lengthy surgeries, and have histories of prior pelvic surgery (5, 6, 7, 8, 9). All of these are known to increase surgical morbidity and mortality. In addition, patients undergoing reconstructive pelvic surgery often have severely distorted anatomy that also increases the risk of surgical injury.

TABLE 19.1 Interventions Identified by AHRQ with Best Evidence to Improve Patient Safety, 2001

Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk
Use of perioperative beta blockers in appropriate patients to prevent perioperative morbidity and mortality
Use of maximum sterile barriers while placing central intravenous catheters to prevent infections
Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections
Asking that patients recall and restate what they have been told during the informed consent process
Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia
Use of pressure-relieving bedding materials to prevent pressure ulcers
Use of real-time ultrasound guidance during central line insertion to prevent complications
Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications
Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients
Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections

AHRQ, Agency for Healthcare Research and Quality.

This chapter will briefly review some topics in perioperative care, including the use of prophylactic antibiotics, perioperative beta blockers, deep vein thrombosis (DVT) prophylaxis, and urinary catheter use. In addition, specific intraoperative complications and management will be discussed. These include lower urinary tract injury, pelvic hemorrhage and hematoma formation, foreign body/mesh-related complications, and postoperative voiding dysfunction.

PERIOPERATIVE CARE

Prophylactic Antibiotics

The use of antibiotics to prevent surgical site infections such as cuff cellulitis and pelvic abscess in hysterectomy patients is well established (10). Moreover, antibiotic prophylaxis is also recommended to prevent surgical site infections in abdominal wounds. Surgical site infections are the second most common source of nosocomial infection in the United States. (11). Their prevention and the appropriate use of prophylactic antibiotics have received much attention in recent years. The Institute for Patient Safety, JCAHO, Centers for Disease Control and Prevention, and CMS have all contributed to new guidelines and performance standards aimed at reducing the incidence of surgical site infections (12). Recent studies indicate significant variation from recommended practices and the need for ongoing efforts to improve compliance. In a review of 34,133 Medicare patients at 2,965 hospitals in the United States, only 55.7% of patients received a dose of antibiotics within 1 hour before incision, and prophylaxis was discontinued within 24 hours of surgery end time for only 40.7% of patients. This study included patients undergoing vaginal and abdominal hysterectomy as well as other general and thoracic surgical procedures (13).

Current guidelines recommend that prophylactic antibiotics be administered within 60 minutes of incision time and be discontinued within 24 hours of surgery. The antimicrobial agent chosen should be active against the likely infectious organisms to be encountered in the surgery performed and should have an appropriate safety profile for the patient (11). For gynecologic surgery, cefazolin and cefotetan are endorsed as appropriate choices for nonallergic patients. For patients unable to tolerate cephalosporins, clindamycin with or without gentamicin or aminoglycosides are recommended regimens. These recommendations are for patients undergoing hysterectomy. Recommendations by the American College of Obstetricians and Gynecologists do not endorse prophylaxis for laparoscopy, urodynamics, and
exploratory laparotomy not involving hysterectomy or bowel surgery (10). There is also evidence that antibiotic prophylaxis is not required for office cystoscopy and for urodynamics (14). A study by Cundiff et al demonstrated no difference in the rate of postprocedure urinary tract infection (UTI) between nitrofurantoin and placebo in patients undergoing combined cystourethroscopy and urodynamics.

Several issues related specifically to reconstructive pelvic surgery are not addressed in the literature. Clearly, any patient having reconstructive surgery involving a hysterectomy should receive antibiotic prophylaxis. However, current guidelines do not address abdominal reconstructive operations not involving hysterectomy or vaginal procedures involving neither hysterectomy nor colpotomy. Several examples include abdominal sacral colpopexy, vaginal cystocele and rectocele repairs, midurethral sling operations for urinary incontinence, and the newer minimally invasive total mesh repairs for uterine and vaginal prolapse. In addition, little information in the literature exists regarding the appropriateness and duration of antimicrobial prophylaxis for surgery involving synthetic and biomaterial implants. Most surgeons would favor the use of antibiotic prophylaxis in these cases; however, the question has yet to be studied in a rigorous manner. It has been our practice to use prophylactic antibiotics in all reconstructive procedures, albeit with little evidence to guide our practice. The history of surgical innovation has many stories of time-honored practices failing to show benefit after undergoing scientific study. Given the risks of unnecessary antimicrobial usage, perhaps these issues will receive scrutiny as the discipline of female pelvic medicine and reconstructive surgery continues to mature and develop its scientific base.

Beta Blockers

Beta blockers have been demonstrated to reduce cardiac morbidity and mortality in patients undergoing major noncardiac surgery (15, 16, 17). Perioperative cardiac events occur in 1% to 5% of all patients undergoing noncardiac surgery (15). The exact risk in women undergoing reconstructive pelvic surgery is unknown. Lambrou et al reported a 2% rate of cardiac complications in a series of 100 reconstructive pelvic surgery cases, and Waetjen reported a 1.1% rate based on analysis of data from the National Hospital Discharge Summary (4,18). Toglia reported three cases of myocardial infarction in 54 women aged 70 to 85 (5). Although this topic may seem remote from the purview of the gynecologic surgeon, it is important to remember that the operating surgeon is the lead person in the team responsible for patient safety throughout the perioperative period. Furthermore, several patient safety organizations, including AHRQ, have identified perioperative beta blockade as an intervention with sufficiently strong scientific evidence to support implementation (1).

There are several compelling reasons why patients undergoing reconstructive pelvic surgery may be likely to benefit from perioperative beta-blocker therapy. Reconstructive surgery is often performed in older patients who, based on age and other comorbidities, are at increased risk for cardiovascular events perioperatively. Secondly, patients seeking surgery for pelvic floor disorders may have better functional status than age-matched patients undergoing nonelective surgery by other specialties and therefore may not undergo the same in-depth preoperative evaluation as acutely ill patients. Patients with known cardiac disease are usually triaged and treated in a manner to minimize their potential for complications. Undiagnosed, and thus untreated, cardiac disease may represent a large risk in our patient population. Furthermore, cardiac symptoms do not receive the same evaluation in women as they do in men. Cardiac disease is underdiagnosed and undertreated in the female population. Cardiac disease presents with atypical symptoms in women (19). All of these factors may leave our patients especially vulnerable to morbidity or mortality from undiagnosed cardiac disease that comes to light only during the physiologic stress of surgery.

Risk-based algorithms have been devised to identify patients likely to benefit the most from perioperative beta-blocker use. The two algorithms quoted commonly in the literature are in Table 19.2. Based on 1997 data, 42% of patients undergoing surgery for prolapse are over age 60 and 22% are over age 70 (18). Based on age alone, patients undergoing abdominal repairs of pelvic organ prolapse represent a population likely to benefit from intervention.

Metoprolol and atenolol are the two most studied beta blockers used in the perioperative period. Some studies suggest the greatest benefit if started prior to surgery, while others looked at the effects of starting beta blockers at the time of induction of anesthesia. All interventions looked at variable time periods of postoperative treatment (days to 1 month). There are several randomized trials in the literature with some heterogeneity regarding patient populations, medication, intervention, and follow-up periods. However, some conclusions can be
made. Perioperative beta blockers benefit high-risk patients (Revised Cardiac Risk Index above 2) and are likely to benefit to moderate-risk patients (Revised Cardiac Risk Index above 1) with a low chance for harm. A recent meta-analysis found a benefit for perioperative cardiac mortality (number needed to treat [NNT] = 20), long-term overall mortality (NNT = 11), long-term cardiac mortality (NNT = 10), myocardial infarction (NNT = 14), and myocardial ischemia (NNT = 6). Results of a recent cohort study showed similar results for overall in-hospital mortality. Interestingly, this study also showed that women were less likely than men to receive beta blockers perioperatively (15). A large, well-designed randomized controlled trial with strict inclusion criteria and patients representing the spectrum of noncardiac surgery is needed. Until then, prophylaxis against cardiac events, cardiac mortality, and overall mortality with perioperative beta blockers is recommended for moderateto high-risk groups, and the criteria in Table 19.2 are reasonable. Patients undergoing reconstructive pelvic surgery are a potentially high-risk group.

TABLE 19.2 Indications for Beta-Blocker Use

Beta blockers for any TWO of the following:
	Age >65
	Hypertension
	Current smoker
	Serum cholesterol >240
	Non-insulin-dependent diabetes
Revised Cardiac Risk Index (RCRI)
	One point for each of the following:
	Intraperitoneal procedure
	History of ischemic heart disease
	History of cerebrovascular disease
	Insulin-dependent diabetes
	Serum creatinine >2.0

DVT Prophylaxis

The risk of DVT following major gynecologic surgery in patients not receiving prophylaxis is estimated to be between 15% and 40%. Risk factors include increasing age, previous venous thromboembolism, and surgery for gynecologic malignancy (20,21). In addition, major reconstructive pelvic surgery should be considered a risk factor. In 2001, Geerts presented a risk stratification model and recommendations that are endorsed by the American College of Chest Physicians and adopted by the Center for Medicare Services as part of the Surgical Care Improvement Project. These were revised again in 2004. Based on this model, patients between age 40 and 60 undergoing major surgery are at moderate risk and patients over age 60 undergoing major surgery (or age 40 with additional risk factors) are at high risk. Without prophylaxis, moderate-risk patients have a 10% to 20% risk for calf DVT, a 1% to 2% risk of pulmonary embolism (PE), and a 0.5% risk for fatal PE; high-risk patients have a 20% to 40% risk for calf DVT, a 2% to 4% risk for PE, and a 1.0% risk of fatal PE (21). A group-specific model of prophylaxis has been recommended. Individual patients are assigned a group (moderate or high risk) based on age, procedure, and risk factors and appropriate prophylaxis is instituted based on recommendations for that risk group.

Based on 1997 data from the National Hospital Discharge Summary, 42% of patients having surgery for pelvic organ prolapse were over age 60, and an additional 18% were between 50 and 60 years old. The mean age was 55 years (18). Therefore, based on age criteria alone, at least 40% of patients undergoing reconstructive pelvic surgery are in the high-risk category for venous thromboembolism. The above estimates of risk are based on routine benign gynecologic surgical procedures. There is evidence that reconstructive pelvic surgery has a higher inherent risk of complications than routine gynecologic surgery. Lambrou et al showed that reconstructive surgeries have complication rates similar to gynecologic oncology surgeries. Specific to venous thromboembolism risk, they showed a 3% PE rate in their series of patients receiving venous thromboembolism prophylaxis in a university hospital setting. This is 10 times the risk observed in the CREST study of patients undergoing gynecologic surgery for benign disease (4). Based on these considerations, it should be clear that patients undergoing surgery for pelvic floor disorders are at high risk for venous thromboembolism and that the risk estimates for major gynecologic surgery likely represent the lower end of the true risk estimate range.

The American College of Chest Physicians recommends the use of anticoagulant-based prophylaxis, with mechanical prophylaxis being used only in patients considered to be at high risk of bleeding. Anticoagulant prophylaxis for moderaterisk patients includes unfractionated heparin 5,000 U twice per day or low-molecular-weight heparin daily. For higher-risk patients, including reconstructive surgery patients, heparin 5,000 U three
times per day or low-molecular-weight heparin with or without sequential compression devices are acceptable choices (21). Continued venous thromboembolism prophylaxis following hospital discharge is largely untested in gynecologic surgery patients and should be considered only in patients who are undergoing cancer surgery and who are over 60 years of age or have previously experienced a venous thromboembolism. Prophylaxis should continue for 2 to 4 weeks after hospital discharge in these highest-risk groups (22).

Catheter Use

UTIs account for about 40% of hospital-acquired (nosocomial) infections, and about 80% of these are associated with urinary catheters (23). Nearly all patients having reconstructive pelvic surgery will have a urinary catheter inserted sometime during their hospital stay. There are no absolute guidelines for catheter care, and often care must be individualized based on specific patient factors and functional status. However, some general principles apply, including aseptic insertion techniques, maintenance of a closed drainage system, and minimizing the duration of catheter usage postoperatively.

With a properly maintained closed drainage system, the risk of infection is between 5% and 10% per day, and up to 50% of patients will remain free of infection after 7 days (24). Management is often complicated in patients undergoing surgery for advanced pelvic organ prolapse or urinary incontinence because of the risk of postoperative urinary retention and the need for voiding trials following surgery. However, early voiding trials are now the norm following reconstructive pelvic surgery, with most patients beginning voiding trials by the second postoperative day. In modern practice, it seems that the majority of patients will be catheterized for less than 2 days. Patients requiring long-term catheterization are best managed with clean intermittent self-catheterization, although suprapubic catheterization remains an option in selected cases.

Investigators have examined several issues related to catheter usage in adults and their potential to reduce the incidence of UTI, including the type of catheter material, the method of catheterization (indwelling transurethral and suprapubic, or intermittent), the duration of catheterization, and the use of prophylactic antibiotics. This topic has also been the subject of several recent Cochrane group reviews (23,25).

With regards to catheterization method (suprapubic versus indwelling urethral versus intermittent urethral), the Cochrane group concluded that there was evidence that suprapubic catheters have advantages over indwelling urethral catheters in terms of bacteriuria, recatheterization, and discomfort (23). However, the clinical significance of bacteriuria in these cases is not clear. Furthermore, there was no information about possible complications or adverse effects during catheter insertion. Severe complications from suprapubic catheter insertion have been reported and include major vascular and bowel injuries. There is limited evidence that the use of intermittent catheterization carries a lower risk of bacteriuria than indwelling urethral catheterization. No clear consensus exists in the literature, especially as it applies to reconstructive pelvic surgery (25). It seems that any benefits in terms of reduced infection rates from the routine use of suprapubic catheters are outweighed by possible complications related to insertion and maintenance. Intermittent clean catheterization is the preferred method of bladder drainage from an infectious standpoint; however, its use is limited in the immediate postoperative period because of cost and patient discomfort. In patients requiring long-term bladder drainage, an attempt should be made to teach intermittent self-catheterization. The balance between risks and benefits favors continuous transurethral bladder drainage for short-term use in the postoperative period in routine cases, with suprapubic catheters reserved for specific situations in individual patients.

There is no evidence to support the use of antibiotics to reduce the incidence of UTIs in postoperative patients requiring transurethral catheterization. The use of prophylactic antibiotics in patients requiring bladder drainage beyond 24 hours does reduce the rate of microbiologic isolates recovered in the urine; however, there is no evidence that this results in fewer clinical UTIs when compared to patients not receiving antibiotics (23,25). Patients managed with clean intermittent catheterization do not require antibiotics. There is evidence that patients managed with suprapubic catheterization may benefit from prophylactic nitrofurantoin, with reduced rates of UTI at catheter removal. In patients managed by suprapubic catheterization, antibiotic prophylaxis may be warranted (26).

The choice of catheter material has also been studied as an intervention to reduce UTI rates in hospitalized patients. Silver alloy-impregnated catheters have been shown to have several benefits, including reducing the incidence of bacteriuria and symptomatic UTI in adults requiring short- and long-term catheterization. Some analyses have also demonstrated a cost savings with the
use of such catheters. These catheters are not yet in routine use in most institutions (23).

There is much work remaining to be done to address optimal methods for postoperative urinary catheterization in reconstructive pelvic surgery. The basic principles of a closed drainage system inserted under sterile conditions that remains in place for the shortest duration possible seems the basis standard for appropriate care. Questions regarding optimal method of voiding trial and the timing for the initiation of voiding trials have yet to be answered by high-quality research studies (25).

INTRAOPERATIVE COMPLICATIONS

Lower Urinary Tract Injury

Injury to the bladder or ureter can occur during any pelvic operation. Anti-incontinence procedures and reconstructive surgeries for advanced prolapse increase the risk of such injuries. Unrecognized lower urinary tract injury in gynecologic surgery represents a source of permanent disability to patients and significant litigation risk for hospitals and surgeons (27). The overall incidence rates for urinary tract injury in reconstructive pelvic surgery are difficult to estimate, and only a few studies have looked at such procedures separate from other gynecologic surgery and hysterectomy. A recent review article cited a range of 2% to 12% in surgeries for advanced pelvic organ prolapse (28). The rates of injury for individual procedures vary widely but have been reported as follows: tension-free vaginal tape (TVT) 4% (bladder) (29,30), Burch urethropexy 3% to 6% (bladder, urethra) (31,32), traditional bladder neck slings 3% to 7% (bladder) (33), abdominal sacral colpopexy 3% to 4% (bladder or urethra) (34), sacrospinous suspension 3% to 4% (bladder), and high uterosacral suspension 11% (ureter) (35). Bladder injuries are more common than ureteral injuries. All surgeons performing these procedures must be well trained in techniques necessary for the prevention, detection, and repair of lower urinary tract injuries.

Injury to the bladder can occur at any point during surgery, such as during peritoneal access, during dissection of the vesicovaginal space during abdominal or vaginal surgery, during open retropubic dissection, or during the passage of trocars when performing minimally invasive mid-urethral slings. In a recent study of the long-term follow-up of bladder perforation by Armenakas et al, two thirds of bladder injuries were localized to the anterior wall or dome of the bladder and one third to the base. Risk factors for bladder perforation include prior cesarean section, large fibroid uterus, and laparoscopic hysterectomy (36). The risk of bladder injury can be minimized by careful attention to hemostasis, sharp dissection, and high entry into the peritoneal cavity during laparotomy. In some cases, intentional high, extraperitoneal cystotomy can be used to facilitate further dissection of the bladder and avoid an unintentional or difficult-to-repair injury to the bladder (37). In the past, some authors have advocated the universal use of such a technique in all open retropubic operations. Distention of the bladder can also facilitate identification of the correct tissue planes during difficult dissection. This is easily accomplished by retrograde filling of the bladder transurethrally through either a three-way or conventional Foley catheter. The distention medium is either sterile water or preferably dyed irrigation fluid or sterile infant formula. The use of opaque media also allows for identification of possible small perforations in addition to identification of the correct dissection plane.

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