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

3. Complications of Anterior Compartment Repair

Alana Murphy1 and Courtenay K. Moore 

(1)

Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA

Courtenay K. Moore

Email: moorec6@ccf.org

Abstract

Transvaginal repair of anterior compartment prolapse was popularized by Kelly in the early twentieth century [1]. While this plication technique has generally fallen out of favor for the treatment of stress urinary incontinence (SUI), the same principles are utilized in contemporary anterior compartment repairs. In addition to a traditional colporrhaphy, the role of mesh in anterior compartment repair continues to evolve, with current evidence supporting superior anatomic results with mesh repairs but at the cost of higher complications rates. This chapter will focus on complications associated with anterior repairs. The specific complications associated with the use of mesh in vaginal surgery will be discussed in detail in another chapter.

Introduction

Transvaginal repair of anterior compartment ­prolapse was popularized by Kelly in the early twentieth century [1]. While this plication technique has generally fallen out of favor for the treatment of stress urinary incontinence (SUI), the same principles are utilized in contemporary anterior compartment repairs. In addition to a ­traditional colporrhaphy, the role of mesh in anterior compartment repair continues to evolve, with current evidence supporting superior anatomic results with mesh repairs but at the cost of higher complications rates. This chapter will focus on ­complications associated with anterior repairs. The specific complications associated with the use of mesh in vaginal surgery will be discussed in detail in another chapter.

Intra-operative and immediate postoperative complications associated with anterior compartment repairs are uncommon. However, potential anterior compartment repair complications include intra-operative hemorrhage and blood transfusion, genitourinary tract injury, onset of de novo SUI, and recurrent prolapse. Given the infrequent nature of these complications, there is a paucity of literature focusing on intra-operative and immediate postoperative complications. In this regard, data on the immediate and shorter-term complications must be extracted from studies that focus primarily on long-term anatomical and functional outcomes. Utilization of this data is further complicated by the inclusion of concomitant procedures. Women with high-grade anterior compartment prolapse may require a simultaneous vault procedure to adequately address all aspects of pelvic floor support. While these additional procedures often have complication profiles similar to anterior repairs, the complication rates are often higher. This chapter will focus on the complications and complication rates only for anterior repairs.

Injury to the Lower Urinary Tract

The incidence of lower urinary tract injuries varies based on the type of vaginal surgery, ranging from 0 to 19.5/1,000 surgeries performed, with injuries occurring more commonly after surgery for reconstructive pelvic and incontinence surgery than other gynecological surgeries [24]. While injuries are uncommon, the consequences of unrecognized injuries can significantly increase patient morbidity.

Bladder Injuries

Bladder injury at the time of anterior colporrhaphy is very rare. Gilmour et al. conducted a systematic review of the literature from 1966 to 2004 and found the rate of bladder injuries during urogynecologic surgery excluding hysterectomies varied from 12.1/1,000 surgeries to 16.3/1,000 surgeries when intra-operative cystoscopy was performed [2]. Of those studies that performed intra-operative cystoscopy, 95% of bladder injuries were diagnosed and corrected intra-operatively compared to a 43% detection rate when cystoscopy was not performed, underscoring the importance of intra-operative cystoscopy.

While the majority of the studies on bladder injuries during urogynecological surgery include multiple concomitant procedures, several do report on the rate of bladder injury after anterior colporrhaphy alone. In a study by Kwon et al., of the 346 women who underwent traditional anterior colporrhaphy, there were no reported bladder injuries [5].

When comparing the rate of bladder injury among traditional anterior colporrhaphy and transvaginal mesh kits, two randomized controlled studies found there to be no difference in the rate of cystotomy with Weber et al. reporting no injuries and Hiltunen reporting one in the mesh group [67]. A more recent randomized controlled study by Altman et al. found there to be a higher rate of cystotomy in the transvaginal mesh group vs. traditional anterior colporrhaphy, 3.5% vs. 0.5%; however, this did not reach statistical significance (p  =  0.07) [8].

Immediate recognition of bladder injury during anterior compartment repairs is essential in reducing postoperative morbidity and potential fistula formation. As sited earlier, intra-operative cystoscopy increases the rate of intra-operative diagnosis and repair. If an intra-operative cystotomy is detected, then the injury should be closed in two layers with absorbable sutures. If the planned anterior repair involved the use of mesh, it is our practice to abort the mesh procedure and perform a traditional anterior colporrhaphy.

Should the injury be missed, depending on the duration of postoperative catheter drainage and the extent of the injury, the patient is at risk for developing a vesico-vaginal fistula requiring either prolonged catheter drainage or a transvaginal vesico-vaginal fistula repair.

Ureteral Injuries

Ureteral injuries occur infrequently after routine gynecological procedures, with patients undergoing complex reconstructive procedures for pelvic organ prolapse at an increased risk of ureteral injury [9]. Like bladder injuries, the incidence of ureteral injuries varies depending on the type of urogynecologic surgery, ranging from 2 to 11% [310]. Women with pelvic organ prolapse are also at an increased risk of ureteric injury given the anatomic distortion caused by the prolapse itself, with 12–20% of women with symptomatic pelvic organ prolapse having moderate-to-severe hydronephrosis secondary to chronic obstruction from ureteral kinking [10].

The majority of the studies on ureteral injuries during gynecologic surgery do not separate the rate of injury by procedure. However, a study by Kwon et al. looked at the incidence of ureteral injury after anterior colporrhaphy alone [5]. Of the 346 procedures performed, there were 7 reported ureteral injuries (2.0%). There was no comment on the POP-Q staging of the women with ureteral injuries. All injuries were recognized at the time of surgery.

Diagnosis of Ureteral Injuries

Intra-operative Diagnosis

If a ureteral injury does occur, the ability to identify the injury at the time of the initial operation is paramount to avoid the permanent damage associated with unrecognized injuries. The single most controllable factor adversely affecting the outcome of ureteral injuries is delayed diagnosis. Studies have shown that intra-operative recognition and repair of ureteral injuries decreases postoperative morbidity and minimizes loss of renal function and need for nephrectomy. Early recognition also decreases the incidence of ureterovaginal fistulas as compared to postoperative diagnosis with delayed repair [11].

If a ureteral injury is suspected during abdominal surgery, direct inspection of the ureter is recommended. However, during vaginal surgery, direct visualization of the ureter is usually not feasible. Therefore, intra-operative cystoscopy has been recommended as a means to identify ureteral injuries during vaginal surgery while obviating the need for an abdominal incision. Five to 10 mL of intravenous indigo carmine dye is given intravenously prior to cystoscopy. Efflux of blue urine from both ureteral ostia assesses ureteral patency. By patiently observing and comparing to the opposite ureter, one may detect subtle sluggish flow which may suggest obstruction.

If fluoroscopy is available, another method of assessing ureteral patency is retrograde ureterography. If fluoroscopy is not available, a one-shot excretory urogram can be obtained 10 min after the administration of intravenous contrast material (1 mL/lb of body weight). Fluoroscopically, ureteral injuries present as urinary extravasation or obstruction.

Delayed Diagnosis

Most ureteral injuries are unsuspected and diagnosed postoperatively [12]. In a study by Meirow et al., the mean delay to diagnosis of patients sustaining ureteral injuries after gynecologic surgery was 5.6 days [13]. Undiagnosed ureteral injuries are associated with significant morbidity, the formation of ureterovaginal fistulas and potential loss of renal function [14]. The majority of patients present with fever, flank pain, continuous incontinence, pyelonephritis, ileus, peritonitis, or anuria. However, 5% of patients remain asymptomatic and are diagnosed at a later date secondary to a nonfunctioning or hydronephrotic kidney [12]. Delayed diagnosis is most often (66–76%) made by CT pyelography, excretory urography, or retrograde ureterography [15].

General Principles of Management

Immediate Intra-operative Management

The management of ureteral injuries depends on the time of diagnosis, location, nature, and extent of the injury. Injuries recognized intra-operatively must be treated immediately. Inadvertent ligation or kinking of the ureter should be treated by suture removal and repeat cystoscopy to ensure ureteral efflux. Typically, if recognized immediately, ureteric damage is minimal as these ­injuries include other tissue in the ligature [11]. If the extent of the ureteral injury is in question, at a minimum, ureteral stent placement is warranted [11]. For more severe injuries, when ureteral viability is unlikely, exploration and direct visualization of the ureter is recommended [16]. The involved ureter should be resected, debrided, and reanastomosed over a stent. If the diagnosis of an intra-operative ureteral injury is made during retrograde ureterography, attempts at retrograde stent placement should be made.

Delayed Management

The type of repair and the timing of delayed recognition injury repair are controversial. Postoperatively noted suture entrapment can be managed conservatively with immediate attempt at placement of a double-J ureteral stent or nephrostomy tube drainage if the suture is absorbable [17]. However, placement is only possible in 20–50% of patients [15]. In a study by Ghali, only 2 of 21 (19%) iatrogenic ureteral injuries identified postoperatively were able to be stented [15]. When stent placement is possible, as many as 73% of patients will not require open surgery.

While some have suggested stent placement or percutaneous nephrostomy as the first line of therapy, others recommend open repair. The traditional recommendation is that repair of ­iatrogenic ureteral injuries after urogynecologic surgery should not be undertaken for 3–6 months [18]. Yet, more recent studies suggest similar outcomes after immediate and delayed repairs [18].

Given that most injuries after vaginal surgery occur to the distal one-third of the ureter, open intervention often involves ureteral reimplantation or ureteroneocystostomy. Ureteroneocystostomy is used to repair distal ureteral injuries close to the bladder or in the intramural tunnel.

Hemorrhage

Hemorrhage is a rare complication of anterior compartment repair. During a traditional suture plication repair, proper dissection between the vaginal epithelium and the underlying vaginal muscularis (or the controversially named pubocervical fascia) will minimize blood loss and reduce the risk of postoperative hemorrhage. Judicious use of electrocautery during the anterior vaginal wall dissection can also be used to maintain hemostasis. A recent randomized controlled trial by Altman et al. included 389 women who underwent isolated anterior compartment repair [8]. Women with stage ≥2 prolapse were randomized to a repair using trocar-guided transvaginal mesh (n  =  200) or a traditional colporrhaphy (n  =  189). The two treatment groups did not differ significantly in terms of POP-Q stage or previous anterior compartment repairs. The traditional colporrhaphy group had a significantly lower mean estimated blood loss (EBL) (35.4  ±  35.4 mL) compared to the trocar-guided transvaginal mesh group (84.7  ±  163.5 mL, p  <  0.001). The study reported five cases (1.3%) of clinically significant intra-operative blood loss with all 5 patients having undergone trocar-guided transvaginal mesh placement: 4 patients (1.0%) had an EBL greater than 500 mL and 1 patient (0.3%) had an EBL greater than 1,000 mL and a subsequent retropubic hematoma. The authors did not provide data on transfusion rates. Due to its focus on anterior compartment repairs without concomitant pelvic floor procedures, the Altman study is a valuable addition to the limited body of literature that addresses the complications of isolated anterior compartment repairs.

Studies that included concomitant pelvic floor procedures also provide data regarding the low incidence of hemorrhage associated with anterior compartment repair [71921]. Weber et al. who performed the very first randomized study of anterior compartment repairs, comparing standard plication, plication with absorbable mesh, and ultra-lateral anterior colporrhaphy [6]. Subjects were excluded if they underwent any anti-incontinence procedure other than a suburethral plication. Subjects undergoing additional procedures for prolapse were included. Of the 109 women undergoing anterior compartment repair with concomitant pelvic floor procedures, 1 patient (0.9%) in the standard anterior colporrhaphy group required transfusion rate.

A more recent randomized controlled trial by Hiltunen et al., comparing anterior colporrhaphy with and without tailored mesh, included 201 women with pelvic organ prolapse [7]. Subjects were excluded from the study if they had gynecologic malignancies, apical prolapse mandating apical fixation, SUI, or their main symptomatic compartment was the posterior vaginal wall. Women could be included if they underwent concomitant vaginal hysterectomy, resection of an enterocele, culdoplasty, or posterior colporrhaphy without mesh. Women were randomized to traditional anterior compartment repair (n  =  97) or anterior compartment repair reinforced with mesh (n  =  104). A total of 29 patients (14%) underwent an isolated anterior compartment repair with no concomitant procedure. There was no difference in rates of previous vaginal surgery or concomitant hysterectomy between groups. All patients had vaginal packing in place for 20 h postoperatively. Although the mean EBL in the traditional repair group (114  ±  109 mL) was less than the mean EBL in the mesh group (190  ±  23 mL), the difference was not statistically significant (p  =  0.004). There was no statistically significant difference in clinically significant blood loss (EBL  >  400 mL) between the groups (3.1% vs. 9.6%, p  =  0.07). Two patients in total (1.0%) required blood transfusions (not specified which group they were in).

Careful attention should be paid during dissection of anterior vaginal wall and muscularis to minimize blood loss. Hemostasis can typically be attained using electrocautery. If electrocautery is insufficient, a figure-of-eight stitch with a 2-0 Vicryl suture can be used to oversew a small vessel. When closing the anterior vaginal wall incision, great care should be taken to achieve a secure hemostatic closure. A tight closure can provide an additional degree of hemostasis by allowing tamponade within the closed anterior compartment.

The low incidence of clinically significant blood loss affects our routine postoperative care pathway. Given that hemorrhage is a rare complication of anterior compartment repair, our practice is to not obtain routine postoperative lab work. If the patient undergoes a pelvic floor reconstruction that includes a concomitant ­hysterectomy, then we will obtain routine ­postoperative blood work and admit the patient for overnight observation. A vaginal pack is placed at the completion of the anterior compartment repair and removed after 1 h in the recovery room. If the patient is admitted for observation due to a concomitant pelvic floor procedure, then the vaginal packing is removed in the early morning of the first postoperative day. Vaginal packs are commonly used as a means to reduce postoperative hemorrhage, despite the lack of evidence in the literature. A recent abstract from Thiagamoorthy et al. reported the results of a randomized controlled trial assessing the effect of vaginal packing after a vaginal hysterectomy and/or pelvic floor repair [22]. Women were randomized to receive a vaginal pack (n  =  86) or no vaginal pack (n  =  87). A total of five patients were withdrawn from the no packing group due to intra-operative bleeding. The study demonstrated no significant difference in mean postoperative hemoglobin on the first postoperative day (11.75 g/dL vs. 11.94 g/dL, p  =  0.061) and 6 weeks postoperatively (12.55 g/dL vs. 12.49 g/dL, p  =  0.884) between the packing and the no packing group. Although the packing group had fewer postoperative hematomas (n  =  4) compared to the no packing group (n  =  9), the difference was not significant (p  =  0.098). Despite the lack of statistical significance, all three clinically significant complications related to bleeding were in the no packing group. One patient returned to the operating room for hemorrhage and two patients required repeat admission for intravenous antibiotics to treat an infected pelvic hematoma. The data presented in the abstract supports our continued use of vaginal packing until additional data is available to influence our care pathway.

Hemorrhage recognized in the postoperative setting is rare after an anterior compartment repair. If a patient demonstrates a clinical sign of hemorrhage, such as significant transvaginal bleeding or tachycardia, a vaginal packing should be placed, vital signs closely monitored, and serial hematologic profiles checked until stable values are achieved. As demonstrated in the previously discussed studies, up to 1% of patients will require a transfusion after an anterior ­compartment repair. In cases of severe hemorrhage that are not responsive to transfusion or are associated with significant hemodynamic instability, angiography with selective embolization may be utilized to control the hemorrhage.

De Novo Stress Urinary Incontinence

De novo SUI should be included in the preoperative discussion of potential postoperative complications with greater emphasis in patients with high-grade anterior compartment prolapse. Women with severe anterior compartment prolapse may not experience SUI due to urethral kinking and SUI may not be detected by the patient or the physician until the prolapse is reduced or surgically repaired [23]. According to the International Continence Society (ICS), occult SUI is defined as SUI observed only after the reduction of coexistent prolapse [24]. Once any degree of urethral kinking is relieved with reduction of the anterior compartment prolapse, the mechanism of de novo SUI is likely multifactorial and may include urethral hypersuspension or intra-operative damage to the sphincter [25]. In addition to intra-operative factors, reduction of anterior compartment prolapse may unmask compromised periurethral support or frank intrinsic sphincter deficiency [26]. In order to minimize the risk of developing de novo SUI, each patient without subjective and/or objective evidence of SUI should be assessed for occult SUI before undergoing anterior compartment repair for high stage prolapse.

Proper assessment of occult SUI requires adequate reduction of the patient’s anterior compartment prolapse. In the office setting, our practice is to perform a stress test after the anterior prolapse is reduced with half of a speculum. If SUI is not demonstrated in the office, the patient may then be referred for urodynamic evaluation with prolapse reduction. The most common techniques for prolapse reduction include a vaginal pack, pessaries, and a speculum. No general consensus exists regarding the best method for prolapse reduction. A study conducted by Mattox and Bhatia demonstrated no difference in maximal urethral closure pressure whether a Smith-Hodge pessary, a ring pessary, or half of a Graves speculum was used for prolapse reduction [27]. Visco et al. found that rates of occult SUI differed based on method of prolapse reduction, which included a pessary, manual reduction, a forceps, a swab, and a speculum [28]. When interpreting urodynamic results, it is important to remember that each method of prolapse reduction may partially obstruct the urethra and lead to a false-negative occult SUI assessment.

Controversy continues to surround the management of women with either isolated occult SUI or no evidence of subjective or objective SUI with prolapse reduction. Should these women undergo a concomitant anti-incontinence procedure at the time of anterior compartment repair?

A study done by Chaikin et al. on 24 stress-continent women with stage III or IV pelvic organ prolapse (POP) found 14 patients (58.3%) to have occult SUI on preoperative urodynamics who subsequently underwent pubovaginal sling placement with concomitant anterior compartment repair [29]. The remaining ten patients (41.7%) had no occult SUI and underwent isolated anterior compartment repair. Two of the patients (14%) in the pubovaginal sling group had persistent postoperative SUI, while no patient in the group without occult SUI developed de novo SUI at a mean follow-up of 44 months.

Liang and colleagues reported on 79 stress-continent women with stage III or IV POP [30]. The patients were divided into three treatment groups based on the presence or absence of occult SUI on preoperative urodynamics. In group I, 32 patients with occult SUI underwent total vaginal hysterectomy (TVH), anterior/posterior (AP) repair, and a midurethral sling (MUS). In group IIa, 17 patients with occult SUI underwent TVH and AP repair with no anti-incontinence procedure. In group IIb, 30 patients without occult SUI underwent TVH and AP repair with no anti-incontinence procedure. Postoperatively, group I had three patients (9.4%) with subjective SUI and zero patients with objective SUI. Group IIa had 11 patients (64.7%) with subjective SUI and 9 patients (52.9%) with objective SUI on repeat urodynamics. Group IIb had 3 patients (10.0%) with subjective SUI and zero patients with objective SUI. The data presented by both Chaikin and colleagues and Liang and colleagues suggests that the rate of de novo SUI is low in women with no subjective or occult SUI, while women with occult SUI appear to benefit from a concomitant anti-incontinence procedure.

The Colpopexy and Urinary Reduction Efforts (CARE) trial is the only randomized controlled trial addressing the role of an anti-incontinence procedure at the time of POP repair [31]. A total of 322 women with stage II or greater POP were randomized to abdominal sacrocolpopexy with Burch colposuspension (n  =  157) or abdominal sacrocolpopexy alone (control group, n  =  165). All women were considered stress continent, if they answered of “rarely” or “never” to six questions regarding SUI on the Medical, Epidemiological, and Social Aspects of Aging (MESA) questionnaire, despite preoperative urodynamics results. Three months postoperatively, one or more criteria for SUI were met by 23.8% of patients in the Burch group and 44.1% of patients in the control group (p  <  0.001). When patients with occult SUI were excluded, de novo SUI was reduced from 38.2 to 20.8% in the ­control group vs. the Burch group (p  =  0.007). A 2-year update of the CARE trial reported that the reduction in de novo SUI was durable with 32.0% of the Burch group and 45.2% of the ­control group meeting one or more criteria for SUI [32]. The CARE study also supports the utility of preoperative urodynamic testing in reportedly stress-continent women as a valuable tool to enhance preoperative counseling and planning. Examination of the preoperative urodynamic results revealed that 3.7% of women demonstrated urodynamic SUI without prolapse reduction and 6–30% of women demonstrated occult SUI when their prolapse was reduced (the range of occult SUI rates reflects the use of various methods for reducing prolapse). Regardless of whether or not they underwent Burch colposuspension, patients who demonstrated occult SUI were more likely to have postoperative SUI compared to women without occult SUI (Burch 32% vs. 21% (p  =  0.19), controls 58% vs. 38% (p  =  0.04)) [28]. Widespread application of the lessons learned in the CARE trial is limited by the use of the Burch procedure as the anti-­incontinence procedure.

The literature also suggests that the rate of de novo SUI may be higher after anterior compartment repairs with mesh compared to traditional repairs. A study by Ek et al. randomized 50 women with stage ≥2 anterior compartment prolapse to a traditional repair (n  =  27) or a transvaginal trocar-guided mesh repair (n  =  23) [33]. All patients underwent preoperative urodynamics without prolapse reduction and postoperative urodynamics. Postoperatively, the rate of de novo SUI in the transvaginal mesh group (32%) was significantly higher compared to the traditional repair group (8%, p  =  0.038). In a similar fashion, a previous multicenter randomized controlled study by Altman reported that patients in the transvaginal mesh repair group were noted to have a statistically higher rate of de novo SUI compared to traditional anterior colporrhaphy (12.3% vs. 6.2%; p  =  0.05).

Transvaginal trocar-guided mesh repairs may result in a greater tendency towards hypersuspension of the anterior vaginal axis compared to a traditional repair with subsequent change in urethral pressure dynamics and increased de novo SUI. The more extensive dissection utilized in trocar-guided mesh repairs may also contribute to some degree to impairment of periurethral support and de novo SUI.

Our preference is to perform a concomitant anti-incontinence procedure in patients who demonstrate SUI preoperatively on physical exam or during UDS. Since anterior compartment repair alters the axis of the anterior vaginal wall and may affect the urethral axis, our practice is to perform an anti-incontinence procedure after the anterior compartment repair. If de novo SUI occurs in previously stress-continent women after anterior compartment repair, we perform an anti-incontinence procedure at a later date.

Summary

While complications during anterior compartment repairs are rare, they do occur. Attention to detail and an in-depth knowledge of pelvic anatomy can reduce the risk of complications and potential patient morbidities.

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