11 Surgery for Pelvic Organ Prolapse

Avoiding and Managing Complications

Mickey Karram, MD, Christopher F. Maher, MD

 Video Clips online

11-1 Intraoperative Management of Ureteral Kink during Vaginal Repair of Prolapse

11-2 Postoperative Management of Ureteral Obstruction after Vaginal Prolapse Repair

11-3 Vaginal Repair of Cystotomy

11-4 Laparoscopic View of Cystotomy and Ureteral Injury after Laparoscopic-Assisted Vaginal Hysterectomy

11-5 Recurrent Prolapse with Mesh Erosion after Trocar-Based Vaginal Mesh Kit

11-6 Vaginal Mesh Erosion Managed with Surgisis Biodesign

11-7 Recurrent Vaginal Mesh Erosion Managed with Surgisis Biodesign

11-8 Excision of Synthetic Mesh from the Rectum

11-9 Laparoscopic Evaluation and Management of Postoperative Bowel Dysfunction

11-10 Vaginal Repair of Vesicovaginal Fistula with Removal of Biologic Graft from the Wall of the Bladder

11-11 Techniques of How to Take Down Distal Iatrogenic Vaginal Constriction

11-12 Technique of How to Take Down Constriction with the Use of a Postoperative Vaginal Mold

11-13 Vaginal Excision of Mesh Causing Postoperative Vaginal Pain and Dyspareunia

11-14 Laparoscopic Excision of Mesh from the Bladder

11-15 Vaginal Removal of Mesh from the Bladder

This chapter reviews a variety of potential complications that can occur during or as a result of surgical repair for pelvic organ prolapse. All cases and discussions have one or more accompanying video clips that demonstrate the technical aspects of managing the various complications.

Case 1: Intraoperative Management of Ureteral Kink during a Vaginal Prolapse Repair

 View: Videos 11-1 and 11-2

A 56-year-old patient with symptomatic pelvic organ prolapse undergoes a vaginal prolapse repair, which involves an anterior colporrhaphy and a vaginal vault suspension to the uterosacral ligaments. After completing the anterior colporrhaphy and tying of the apical stitches to suspend the vaginal vault, 5 ml intravenous indigo carmine is administered and a cystourethroscopy is performed to ensure ureteral patency. Prompt efflux of dye is observed from the right ureter; however, no efflux is observed from the left ureter 15 minutes after administering the dye. Close visualization of the ureter reveals peristalsis of the intravesical part of the ureter.

Case Discussion

This example of a ureteral kink or obstruction is typical of one that has occurred secondary to a prolapse repair. Either the stitches placed through the uterosacral ligament on the patient’s left side or one of the stitches placed for the anterior colporrhaphy has caused the obstruction. Options to address this obstruction could involve attempting to pass a stent or performing a retrograde study. However, in the author’s 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 is from the anterior colporrhaphy; once the suture is cut, immediate visualization of dye is noted. The suture is replaced, and ureteral patency is again ensured; the procedure is completed. (See Video 11-1, “Intraoperative Management of Ureteral Kink during Vaginal Repair of Prolapse,” and Video 11-2, “Postoperative Management of Ureteral Obstruction after Vaginal Prolapse Repair,” for demonstrations of how best to address a ureteral kink during and after a vaginal prolapse repair. )

Case 2: Management of Inadvertent Cystotomy during Vaginal Prolapse Repair

 View: Video 11-3

A 65-year-old woman has recurrent vaginal prolapse, mostly secondary to a large cystocele. The patient has consented for a mesh-augmented repair of her recurrent cystocele. During the anterior vaginal wall dissection of the bladder off the vaginal wall, an inadvertent cystotomy occurs. (See Video 11-3, “Vaginal Repair of Cystotomy.” ) The dissection proceeds, and the cystotomy is completely mobilized off the vaginal wall to allow a tension-free closure. A vaginal sponge or packing is placed in the vagina to maintain a relatively watertight seal, and the cystoscopy is undertaken to view the ureteral orifices and to determine the distance from the cystotomy to the ureters to ensure that a safe closure can be accomplished without compromising either ureter. If the cystotomy is in close proximity to one or both ureteral orifices, then the authors recommend the placement of ureteral catheters during the repair of the cystotomy. The catheters may have to be maintained in place if postoperative edema or swelling is a concern. The cystotomy is then closed in layers with a fine delayed absorbable suture. The authors recommend either 3-0 Vicryl or chromic sutures. The authors prefer to interrupt the first layer, which should involve a mucosa-to-mucosa closure with a second layer imbricating the muscularis over the first layer. The mesh augmentation portion of the procedure is abandoned as a result of the concerns about the mesh being in contact with the cystotomy, which could create a potential infection, the breakdown of the cystotomy, or an erosion of the mesh into the bladder. The authors recommend proceeding with a vaginal suture repair of the cystocele to correct the anterior vaginal wall prolapse. The remainder of the repairs is performed as initially planned. The bladder is continuously drained with an indwelling Foley catheter for 10 to 14 days, depending on the size and location of the defect. A cystogram that confirms an intact bladder is recommended before removing the catheter. A voiding cystogram also ensures that the patient is able to void spontaneously in an efficient fashion when the catheter is removed.

Case 3: Laparoscopic View of Cystotomy and Ureteral Injury after Laparoscopic-Assisted Vaginal Hysterectomy

 View: Video 11-4

A 46-year-old woman with mildly symptomatic uterovaginal prolapse and some uterine fibroids undergoes a laparoscopic-assisted vaginal hysterectomy. A urogynecologic consultation is obtained to address a large cystotomy that occurred during the laparoscopic dissection of the bladder off the lower uterine segment. During the laparoscopic assessment of the cystotomy, a large defect is noted; in addition, no efflux of urine or dye is observed spilling from the right ureteral orifice. An attempt at passing a ureteral catheter is unsuccessful. After administering intravenous indigo carmine, intraperitoneal dye confirms a right ureteral injury. (See Video 11-4, “Laparoscopic View of Cystotomy and Ureteral Injury after Laparoscopic-Assisted Vaginal Hysterectomy.” ) Urologic consultation is obtained to perform a ureteral reimplantation procedure.

Discussion of Cases 2 and 3

These two cases depict how best to manage intraoperative injuries to the lower urinary tract that can occur during pelvic reconstructive surgery. Identifying and addressing any injury intraoperatively whenever possible are extremely important. Although an injury might be noted only in the bladder, one should not assume that an injury to one or both ureters has not also occurred. A full assessment of ureteral patency and bladder integrity should be undertaken whenever any concern exists that the lower urinary tract might have been compromised during pelvic reconstructive surgery.

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