Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

2. General Complications of Pelvic Reconstructive Surgery

Ellen R. Solomon1 and Matthew D. Barber 

(1)

Obstetrics, Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland Clinic Main Campus, Mail Code A81, 9500 Euclid Avenue, Cleveland, OH 44195, USA

Matthew D. Barber

Email: barberm2@ccf.org

Abstract

Before a patient undergoes pelvic reconstructive surgery, the risk of potential complications should be carefully assessed and addressed with the patient. Complications may occur during or after the procedure and it is imperative to recognize high-risk patients and minimize risk from surgery before a patient is brought to the operating room. The lifetime risk of a woman undergoing prolapse or incontinence surgery by the age of 80 is 11.1% [1]. The prevalence of perioperative complications among women undergoing reconstructive pelvic surgery has been reported to be as high as 33% [2]. There are a multitude of factors which are found to increase perioperative risk. A large retrospective cohort study including 1,931 women who had undergone prolapse surgery found an overall complication rate of 14.9% [3]. The complications identified included infection, bleeding, surgical injuries, pulmonary, and cardiovascular morbidity. These complications were associated with medical comorbidities (odds ratio 11.2) and concomitant hysterectomy (odds ratio 1.5). Risk factors for complications after pelvic reconstructive surgery are listed in Table 2.1.

Assessing Perioperative Risk

Before a patient undergoes pelvic reconstructive surgery, the risk of potential complications should be carefully assessed and addressed with the patient. Complications may occur during or after the procedure and it is imperative to recognize high-risk patients and minimize risk from surgery before a patient is brought to the operating room. The lifetime risk of a woman undergoing prolapse or incontinence surgery by the age of 80 is 11.1% [1]. The prevalence of perioperative complications among women undergoing reconstructive pelvic surgery has been reported to be as high as 33% [2]. There are a multitude of factors which are found to increase perioperative risk. A large retrospective cohort study including 1,931 women who had undergone prolapse surgery found an overall complication rate of 14.9% [3]. The complications identified included infection, bleeding, surgical injuries, pulmonary, and cardiovascular morbidity. These complications were associated with medical comorbidities (odds ratio 11.2) and concomitant hysterectomy (odds ratio 1.5). Risk factors for complications after pelvic reconstructive surgery are listed in Table 2.1.

Table 2.1

General risk factors of pelvic reconstructive surgery

Risk factors

Age

Central nervous system disease

Coronary heart disease

Diabetes

Hypertension

Obesity

Peripheral artery disease

Pulmonary disease

Obesity is an increasingly important risk factor for perioperative complications. The prevalence of obesity continues to rise in industrialized countries [4]. With obesity, there is an increase in comorbid conditions including incidence of cardiac disease, type two diabetes, hypertension, stroke, sleep apnea, and some cancers [5]. One study of obese and overweight women found that obese women had significantly increased estimated blood loss and operative time [6]. In a retrospective cohort study from 2007, obese patients who underwent vaginal surgery were matched to patients who were of normal weight and perioperative comorbidities and complications were analyzed. This study found that there was no difference in perioperative complications between obese and nonobese patients; however, there was a higher rate of surgical site infection in the obese population [7].

In obese women undergoing hysterectomy, the abdominal approach results in significantly higher rates of wound infection than those receiving a vaginal hysterectomy [8]. Overall, vaginal surgery appears to be a safer approach for obese women [9]. It is important to assess BMI when planning route of surgery and to consider the increased risks with this population.

Age is also an important factor to consider when assessing perioperative risk. The median age of patients who undergo pelvic reconstructive surgery is 61.5 years [10]. Increasing age corresponds with increasing medical comorbidities including chronic illness, hypertension, coronary heart disease, diabetes, pulmonary disease, and central nervous system disease [11]. A retrospective cohort study of 264,340 women undergoing pelvic surgery found that increasing age is associated with higher mortality risks and higher complication risks. Specifically, elderly women (>age 80) were found to have increased risk of perioperative complications compared with younger women [12]. In this same study, elderly women who underwent obliterative procedures (e.g., colpocleisis) had a lower risk of complications compared to patients who underwent reconstructive procedures for prolapse. In a prospective study of 2-year postoperative survival, survival was worse among 80-year-olds who experienced a postoperative complication [13]. In a retrospective chart review of patients ≥75 years old, 25.8% of patients had significant perioperative complications including significant blood loss, pulmonary edema, and congestive heart failure. Independent risk factors that were predictive of perioperative complications in this patient population included length of surgery, coronary artery disease, and peripheral vascular disease [14]. When choosing to perform a prolapse or incontinence procedure on an elderly patient, it is important to review the patient’s comorbidities.

Cardiac risk factors also impact postoperative morbidity in pelvic surgery. In a retrospective cohort study by Heisler et al. [15], periopera­tive complications were increased in patients with a history of myocardial infarction or congestive heart failure, perioperative hemoglobin decrease greater than 3.1 g/dL, preoperative hemoglobin less than 12.0 g/L, or history of prior thrombosis. In a retrospective analysis of cardiac comorbidities in pelvic surgery by Schakelford et al. [16], hypertension and ischemic heart disease were statistically significant risk factors for perioperative cardiac morbidity. It is important to ensure that a patient’s cardiac status is optimized prior to proceeding with surgery [17]. In a retrospective cohort study of 4,315 patients undergoing elective major noncardiac surgery, predictors of major cardiac complications included high-risk types of surgeries, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and a serum creatinine of ≥2.0 mg/dL [18]. To further decrease cardiac morbidity in patients undergoing surgery, it has also been shown that continuing beta blockers in the perioperative period in patients with chronic beta blockade will decrease cardiovascular mortality [19]. Consultation with the patient’s primary care physician or cardiologist prior to surgery is often warranted in patients with cardiac disease.

In conclusion, when considering pelvic reconstructive surgery, it is important to examine and evaluate the whole patient, including her medical comorbidities in order to appropriately assess her perioperative risk. This knowledge will help determine whether or not surgery is appropriate and, when appropriate, what route of surgery and procedure may be best for the individual patient. In high-risk patients, the vaginal route is often the lowest risk approach. In elderly patients no longer interested in sexual activity, obliterative procedures should be considered because of their quick surgical times and low risk of complications relative to reconstructive procedures.

Venous Thromboembolism

Deep venous thrombosis (DVT) and pulmonary embolism (PE), jointly referred to as venous thromboembolism (VTE), are among the leading causes of preventable perioperative morbidity and mortality. In the perioperative period, the risk of death after VTE is approximately 3–4% [20]. During surgery, the combination of epithelial damage, venous stasis, and hypercoagulability, collectively referred to as Virchow’s triad, increases the risk of any patient undergoing surgery. Many pelvic reconstructive surgeries require the dorsal lithotomy position and steep Trendelenberg; positions that exacerbate the risk of venous stasis. The postoperative risk of VTE may be elevated up to 1 year after the initial procedure has been performed, but is highest in the immediate perioperative period [21].

The risk of VTE has been well studied in the general surgery, urology, and gynecologic oncology population. However, there have been few studies that address the risk of VTE in women undergoing pelvic reconstructive surgery. The data that does exist suggests that the risk of VTE is low after pelvic reconstructive procedures and that sequential compression devices used in the perioperative period are adequate prophylaxis in the majority of patients. In a retrospective cohort study of 1,104 patients who underwent prolapse and/or incontinence procedures by Solomon et al. [22], the incidence of VTE was found to be 0.3% (95% confidence interval, 0.1–0.8). Risk factors assessed for VTE among this patient population included histories of malignancy, breast cancer, hormone replacement therapy, oral contraceptive use, history of tamoxifen use, history of clotting disorder, decreased mobility in the perioperative period, and perioperative central line placement. There were no significant risk factors associated with VTE in this population. The only thromboprophylaxis used in this population were sequential compression devices placed before surgery and used until the patient returned home.

In another retrospective cohort study of 1,356 patients undergoing sling and/or prolapse procedures, the rate of VTE was 0.9% in women who had a sling alone and 2.2% in women who had concomitant prolapse surgery (P  =  0.05) [23]. While this study gives rise to concern of concomitant procedures, it remains unclear if any of the patients received thromboprophylaxis during this study, and therefore it is difficult to assess actual patient risk. In a retrospective review by Nick et al. [24], the incidence of DVT was assessed among patients who underwent laparoscopic gynecologic surgery and found to be 0.7% in this population.

A number of risk factors for VTE have been suggested for women undergoing pelvic surgery. In a retrospective review of 1,232 patients who underwent surgery for gynecologic conditions in Japan, it was found that malignancy, history of VTE, age greater than 50, and allergic-immunologic disease were all statistically significant risk factors for VTE [25]. However, this study only found three episodes of VTE in patients with benign disease making it significantly underpowered for this patient group. In a questionnaire study by Lindqvist et al. [26] that included 40,000 women, it was found that moderate drinkers and women who engaged in strenuous exercise most days were at half the risk of VTE compared to women who were heavy smokers and lead sedentary lifestyles (increased risk of 30%).

In a retrospective review of gynecologic surgery patients, 1,862 patients given VTE prophylaxis with intermittent compression devices alone, the incidence of VTE was 1.3%. The risk factors associated with VTE were diagnosis of cancer, age over 60, anesthesia over 3 h. Patients with two or three of these variables had a 3.2% incidence of developing VTE vs. 0.6% in patients with zero or one risk factor [27].

The question of which thromboprophylactic modality is best in the perioperative period is difficult to answer for women undergoing pelvic reconstructive surgery. As mentioned previously, in the study by Solomon et al. [22], the rate of VTE among patients who underwent pelvic reconstructive surgery was 0.3% where the only thromboprophylaxis used was sequential compression devices placed during the perioperative period. The American College of Obstetricians and Gynecologists [28] follow the recommendations provided by the American College of Chest Physicians from the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy, published in 2004. The recommendations place patients into four risk categories including low, moderate, high, and highest risk (Table 2.2). The ACCP has updated its recommendations for prophylaxis in all surgical patients. Most female pelvic reconstructive surgery patients fall into the “high” risk category; however, because the rate of VTE is so low in this population, it is unknown which form of thromboprophylaxis is the best method to use. In a study performed by Montgomery and colleagues, a prospective randomized trial was performed to assess thromboprophylaxis using SCDs vs. fractionated heparin on urological laparoscopic patients. In both groups, the rate of VTE was 1.2%, but the rate of hemorrhagic complications was significantly higher in the fractionated heparin group (9.3%). As of now, there are no specific guidelines for thromboprophylaxis for patient undergoing pelvic reconstructive procedures. When operating on women who have multiple risk factors for VTE, it would be judicious to consider chemothromboprophylaxis. Otherwise, without inciting risk factors, sequential compression devices may be the only thromboprophylaxis needed.

Table 2.2

American College of Chest physicians risk for venous thromboembolism in patients undergoing surgery

Level of risk

Definitiona

Recommended prevention strategy

Low

Minor surgery

No specific thromboprophylaxis besides early and frequent mobilization

Moderate

Major surgery includes most general, open gynecologic and urologic cases

LMWH, LDUH bid or tid, fondaparinux, or mechanical thromboprophylaxis

High

Major surgery, or patients with additional VTE risk factorsb

LMWH, fondaparinux, oral vitamin K antagonist, or mechanical prophylaxis; alternatively, one may consider combination of chemical and mechanical prophylaxis

Modified with permission from Geerts et al. [97]

Adapted from Solomon [96]

Bid twice daily; LDUH low-dose unfractionated heparin; LMWH low-molecular-weight heparin; tid three times daily; VTE venous thromboembolic events

aDescriptive terms are purposely left undefined to allow individual clinician interpretation

bAdditional risk factors include major trauma or lower extremity injury, immobility, cancer, cancer therapy, venous compression (from tumor, hematoma, arterial anomaly), previous VTE, increasing age, pregnancy and postpartum period, estrogen-containing oral contraceptive or hormone replacement therapy, selective estrogen receptor modulators, erythropoiesis-stimulating agents, acute medical illness, inflammatory bowel disease, nephritic syndrome, myeloproliferative disorders, paroxysmal nocturnal hemoglobinuria, obesity, central venous catheterization, and inherited or acquired thrombophilia

It is essential to be able to recognize the symptoms of VTE in the postoperative patient. While many patients who have VTE may be asymptomatic, the symptoms of dyspnea, orthopnea, hemoptysis, calf pain, complaints of calf swelling, chest pain, and tachypnea may signify a thrombotic event [29]. The physical signs that suggest VTE include hypotension, tachycardia, crackles, decreased breath sounds, lower extremity edema, tenderness in lower extremities, and hypoxia [30]. Although the signs and symptoms of VTE are well known, it is difficult to rule out VTE by clinical diagnosis alone. A systematic review evaluating the D-dimer test used in combination with clinical probability to rule out VTE found that the D-dimer test is a safe and relatively reliable first-line test to use. After a 3-month follow-up, only 0.46% of patients were later diagnosed with PE [31]. However, D-dimer test is not useful in pregnant patients, the elderly, and hospitalized patients due to decreased specificity [32].

Compression ultrasonography is a noninvasive, easy, and cost-effective procedure for the diagnosis of DVT in the lower extremities. The sensitivity and specificity for detecting DVT using compression ultrasonography in symptomatic patients is 89–96%, although the sensitivity is decreased in patients with calf DVT or asymptomatic patients [33]. Compression ultrasonography may also be used in conjunction with other diagnostic tests if PE is suspected [34]. If compression ultrasound is negative but patient remains symptomatic, venography may be used to further rule out DVT [35].

Indicated imaging for patients presenting with signs and symptoms of PE include ventilation perfusion scanning (V/Q), computed tomography (CT) pulmonary angiography, and spiral CT of the chest. The V/Q scan was the imaging modality of choice for decades; however, due to lack of ease of use and potential for indeterminate testing, CT has become the modality of choice [33]. CT angiography has specificity of 96% as well as 83% sensitivity [29]. This has become the gold standard for PE diagnosis. CT looking for PE may vary across centers due to type of CT used and radiologist’s ability to make the diagnosis.

It is important to start anticoagulation immediately once VTE has been diagnosed; furthermore, if there is high suspicion for PE, anticoagulation may be started even before the diagnosis is confirmed. Acute PE should be treated initially with a rapid onset anticoagulant which may be followed by treatment with a vitamin K antagonist for at least 3 months [31]. For rapid onset anticoagulation, patients may be started on IV unfractionated heparin, subcutaneous unfractionated heparin, subcutaneous low molecular weight heparin, and subcutaneous fondaparinux. The American College of Chest Physicians recommends using subcutaneous low molecular weight heparin for the initial treatment of acute, nonmassive, PE. If the patient has decreased kidney function, morbid obesity, or is pregnant, IV unfractionated heparin may be used due to its shorter duration and titratability [36]. Once anticoagulation therapy has been established, the patient may continue on subcutaneous therapy or can be bridged to warfarin for at least 3 months. Warfarin may be more acceptable to patients because of its oral route and ease of use; however, warfarin requires continuous monitoring and titration [37]. If the patient has contraindications to anticoagulation therapy, an inferior vena cava (IVC) filter can be considered.

Pulmonary Complications

Postoperative pulmonary complications are a frequent cause of morbidity and mortality. Postoperative pneumonia, atelectasis, pneumothorax, and respiratory failure are postoperative complications that increase length of stay and are more common than postoperative ­cardiac complications [38]. The incidence of ­postoperative pulmonary complications in ­gynecologic patients has been reported to be between 1.22 and 2.16% [39]. There are multiple risk factors that may increase pulmonary complications in the postoperative surgical patient. In a prospective randomized trial of patients who underwent non-thoracic, on multivariate analysis four risk factors for postoperative pulmonary complications were age greater than 65, positive “cough test”, perioperative nasogastric tube, and duration of anesthesia (procedures lasting longer than 2.5 h) [40]. 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 [41].

Surgical approach is also a contributing factor for the development of a postoperative pulmonary complication. 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 [42].

In a prospective randomized control trial involving 994 patients by Xue et al. [43], 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 [39]. 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 [44]. Pulmonary complications significantly decrease after 8 weeks of smoking cessation [45]. 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 [46]. Patients with COPD were found to be 300–700 times more likely to have a postoperative pulmonary complication in a prospective cohort study [39]. Nasogastric intubation instead of orogastric intubation increases risk of pneumonia in this patient population as well [47].

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 [48]. The prevalence of sleep apnea is around 5% [49]. 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 [50]. 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 et al. [51], 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 [52]. The supine position that occurs during surgery and in the postoperative period may worsen obstructive sleep apnea [53]. Anesthesia may also blunt the hypercapnic and hypoxic respiratory drive as well as the arousal response. In a study performed by Bolden et al. [54], 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 in their home continuous positive airway pressure (CPAP) machines or to order home CPAP settings for the 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 [48].

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 [55]. 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 are 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 patient becomes hypoxic from atelectasis, bronchoscopy may be performed to remove secretions from the airway [56]. 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 [57].

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) [58]. 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 aureasStreptococci, and Enterobacter [59].

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 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 [60]. The rate of bacteruria after undergoing an anti-incontinence procedure has been estimated to be between 17 and 85% [61]. 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 bacteruria, decreased ability to get to the toilet, nosocomial infections, physiologic changes, and sexual intercourse, all seen commonly in the reconstructive pelvic surgery population [62]. 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 [63]. 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 [64].

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 [61]. 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 leukesterase, 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% [65]. The most important predictor of UTI measured by microscopy is leukocytosis; however, leukocytosis alone is not sufficient to diagnose UTI [66]. 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 bacteruria. In a study performed by Schiotz [67], 193 women who underwent gynecologic surgery and had a Foley catheter for 24 h were assessed for bacteruria; 40.9% of patients had asymptomatic bacteruria, 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 [68]. Other uropathogens include KlebsiellaPseudomonasEnterobacterEnterococcus, and Candida. The initial therapy for treatment of UTI traditionally has been Trimethoprim-Sulfamethozole (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 fluroquinolone and TMP-SMX resistance [69]. 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 [70]. The American Urologic Association Best Practice Guidelines [71] recommend antibiotic prophylaxis for vaginal surgery to prevent both postoperative UTI and postoperative pelvic infection (Table 2.3). A prospective randomized trial by Ingber et al. [72] found that patients who were given single-dose antibiotic therapy for midurethral slings had a low rate of postoperative UTI (5.9%). An additional prospective randomized control trial found that patients who received multiple doses of antibiotics in the perioperative period had decreased postoperative febrile morbidity and significantly decreased hospital stays than patients who did not receive antibiotics [73]. What is 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 et al. [70], 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. Little data exists on the role of prophylactic antibiotics for patients with postoperative indwelling transurethral catheters.

Table 2.3

American Urological Association recommended antimicrobial prophylaxis for urologic procedures

Procedures

Organisms

Antimicrobials of choice

Alternative antimicrobials

Duration of therapy

Vaginal surgery and/or slings

E. coliProteus sp., Klebsiella sp., Enterococcus, skin flora, and Group B Strep.

First/second-generation cephalosporin

Aminoglycoside  +  metronidazole or clindamycin

Ampicillin/sulbactam

Fluroquinolone

≤24 h

Modified from AUA Best Practice Guidelines [71]

Surgical Site Infections

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 [74]. 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 [7576]. 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 [77]. 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 [78]. In a prospective study of 5,279 patient 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 [76].

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 [79]. In an additional case series of 19 women who had undergone intravaginal slingplasty with synthetic mesh, 6 women had infected mesh that had to be removed [80]. In randomized trials comparing native tissue vaginal repair to transvaginal mesh placement using wide-pore [81] polypropylene, the risk of infection appears to be low in some trials and elevated in others [82]; 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 [83]. 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 [82]. 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 [84]. 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 [85]. 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 [82]. 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 [86]. 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.

Prevention of wound infection is paramount to the practice of reconstructive pelvic surgery. Good surgical technique, hemostasis, and gentle tissue handling may decrease risk of infection [84]. There have been multiple studies that suggest perioperative cleansing the vagina with saline increases infection rate [8788]. Currently, there is no evidence to suggest that cleansing the vagina with any preparation reduces postoperative infection.

The use of prophylactic antibiotics is an imperative strategy for lowering surgical site infection. Antibiotics should be given within 30 min of incision time to allow for the minimal inhibitory concentrations (MIC) of the drug to be in the skin and tissues at time of incision. Recommendations for prophylactic antibiotic regimens from the AUA and ACOG are listed in Tables 2.3 and 2.4. Cephalosporins are commonly used in pelvic surgery because of their broad antimicrobial spectrum with Cefazolin, the most commonly used agent [73]. Patients who are morbidly obese with BMI greater than 35 should receive increased dosing of antibiotics [74]. Procedures lasting longer than 3 h and blood loss greater than 1,500 cc require redosing of antibiotics.

Table 2.4

Recommended antibiotic prophylaxis by American College of Obstetrics and Gynecology

Procedures

Antibiotic

Dose (single dose)

Hysterectomy, female pelvic reconstructive procedures, procedures involving mesh

Cefazolina

Clindamycin plus gentamicin or quinolone or aztreonam

Metronidazole plus gentamicin or quinolone

1 or 2 g IV

600 mg IV with 1.5 mg/kg or 400 mg IV 1 g IV

500 mg IV with 1.5 mg/kg or 400 mg IV

Modified from ref. [74]

IV intravenously; g grams; mg milligrams

aAlternatives include cefotetan, cefoxitin, cefurtoxime, or ampicillin-sulbactam

Nerve Injury

Intraoperative nerve injury is a preventable iatrogenic complication. Injury to nerves in the upper and lower extremities, while uncommon, may occur during laparotomy, robotic, laparoscopic, and vaginal procedures. In a prospective cohort study of women who underwent elective gynecologic surgery, the overall incidence of postoperative neuropathy was 1.8% [89]. Brachial plexus injury has a reported incidence of 0.16% [90]. Risk factors for developing nerve injuries during surgery include increased operating room time, patient positioning, and history of smoking [91]. Stretching or direct compression of the nerve results in ischemia, and when prolonged, necrosis can develop [92]. With muscle relaxants given during anesthesia, patients are unable to reposition themselves from nonphysiologic positions, and risk of nerve damage increases. With nerve compression, blood flow to the nerve is decreased, therefore operating room time is a critical factor for nerve injury. The longer a patient is incorrectly positioned, the worse the nerve injury. With the development of robotic surgery, it has been theorized that brachial plexus injuries may become more common [93]. Most robotic procedures require steep Trendelenberg positioning, and depending on the operator, may require longer operating room times. Other risk factors include history of diabetes, alcoholism, and history of herpes zoster [94].

Nerve injuries to the upper extremity mostly occur from overstretching or compression of the brachial plexus or the ulnar nerve. Brachial plexus injury may result in both sensory and/or motor injury. Risk factors for brachial plexus injury includes Trendelenberg positioning, longer operating room time, use of shoulder braces, abduction of the arm ≥90°, and unequal shoulder support [89]. Patients with brachial plexus injury may present with numbness of the first, second, and third digits and the radial side of the fourth digit. Patients may experience motor deficits that involve the shoulder, wrist, arm, and hand. In severe cases, patients may experience Erb’s palsy or Klumpke’s paralysis [92]. Patients with ulnar nerve injury may present with the sensory loss of the lateral hand, with loss of sensation in the fourth and fifth digits.

Management of brachial plexus injury includes physical therapy, analgesics, nonsteroidal anti-inflammatory medications, physical therapy, and neuroleptic medications. Prevention of brachial plexus injury includes utilizing the minimum amount of Trendelenberg positioning, decreasing operating room times as much as possible, avoiding abduction or extension of the upper extremities, and avoiding shoulder braces [92]. For robotic and laparoscopic surgeries, we recommend padding and tucking the patient’s arms to her sides, using a “thumbs up” hand position with the patient’s palms facing her thighs to avoid overabduction. To avoid sliding down the operating room table while in Trendelenberg, placing the patient on an egg crate mattress that is taped to the operating room table and then padding the patient’s chest with additional foam and tape the foam down to the operating room table can be helpful (Fig. 2.1).

A213469_1_En_2_Fig1_HTML.jpg

Fig. 2.1

Appropriate positioning of patients for laparoscopic or robotic pelvic reconstructive procedures with padding and taping to prevent neurologic injury

Common lower extremity nerve injuries associated with female pelvic reconstructive medicine include femoral, lateral femoral cutaneous, obturator, sciatic, and common peroneal nerve injuries. Risk factors for lower extremity nerve injuries include ill positioning of the lower extremities using stirrups, lithotomy position, slender patients, smokers, Trendelenberg position, and operating room time greater than 4 h [95]. In laparoscopic and vaginal surgeries, the femoral nerve may be injured due to stretch encountered from the lithotomy position. The lateral cutaneous femoral nerve is one of the most common nerves injured from lithotomy position and injury is caused from compression and stretching under the inguinal ligament, most likely from prolonged flexion of the lower extremities. The obturator nerve may be injured from prolonged flexion of the legs in the lithotomy position. Sciatic nerve injury is less common in the dorsal lithotomy position; however, it may be caused by overflexion of the hip with abduction and external rotation. The common peroneal nerve can be injured via direct pressure on the nerve when legs are touching the pole of the candy cane stirrups—boot stirrups may aid in decreasing risk of injury to this nerve [94].

To prevent lower extremity neuropathies caused by female pelvic reconstructive surgery, it is necessary to utilize correct positioning of the lower extremities. Whenever possible, avoid candy can stirrups as they offer little support and may cause undue hip abduction and external rotation. When positioning the lower extremities in boot stirrups, make sure the heel of the patient’s foot fits directly into the boot. Padding the lateral aspect of the knee avoids injury to the peroneal nerve. When placing patient in high lithotomy, the knee should be flexed 90–120°, hip flexion should be less than 60°, and abduction of the thighs should be no greater than 90° (Figs. 2.2 and 2.3). Nerve injuries from reconstructive pelvic surgery are minimized when the patient’s extremities are positioned correctly.

A213469_1_En_2_Fig2_HTML.jpg

Fig. 2.2

Appropriate positioning of the lower extremities for dorsal lithotomy position using candy cane stirrups

A213469_1_En_2_Fig3_HTML.jpg

Fig. 2.3

Appropriate positioning of the lower extremities for dorsal lithotomy position using Boot stirrups

Diagnosis of postoperative neuropathy should include a thorough musculoskeletal and neurological exam (Table 2.5). Patient may also experience pain, numbness, and tingling in dermatomes of the nerve routes. EMG and MRI are procedures that may further aid in diagnosis. Treatment includes oral analgesics, nonsteroidal anti-inflammatory medications, low-dose anti-­depressants, neurologic medications including gabapentin and pregabalin, and physical therapy, especially for prolonged neuropathies. Surgery and steroid injections may be used for severe cases [94].

Table 2.5

Motor and sensory defects associated with lower extremity neuropathy

Nerve

Motor function

Sensation

Femoral

Hip flexion and knee extension

Anterior and medial thigh, medial calf

Lateral femoral cutaneous

N/A

Anterior, and lateral thigh

Sciatic

Foot dorsiflexion and eversion

Foot, toes

Obturator

Thigh adduction and internal rotation

Medial aspect of the thigh

Common peroneal

Foot dorsiflexion and eversion

N/A

N/A not applicable

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