Key words
retropubic haematoma - vaginal revision - retropubic tape placement
Schlüsselwörter
retropubisches Hämatom - vaginale Revision - retropubische Bandeinlage
Introduction
The retropubic placement of tension-free suburethral tapes belongs to the standard
surgical therapy for stress incontinence [1], [2]. Among the possible complications, besides the danger of intraoperative perforation
of the urinary bladder, is the postoperative formation of a retropubic haematoma [3]. During movement of the special needle for inserting the tape along the rear edge
of the symphysis through the lesser pelvis in a suprasymphysary direction, injuries
to vessels in the retropubic space (cavum retzii) are possible and these can then
lead to the formation of a retropubic haematoma. Haemorrhagic complications and haematoma
formation are rare occurrences with an incidence of 2–3 % but have been described
[3], [4]. In most cases a conservative wait and see procedure is possible. Kuuva et al. reported
on two revision operations in 27 cases of retropubic haematoma formation in Finland
[3]. The rate of revisions in the Austrian registry of Kölle et al. amounts to 0.8 %
[4]. In the case of a revision operation to remove a symptomatic haematoma after retropubic
tape placement, the laparotomy subperitoneal approach under general anaesthesia is
the standard procedure, however, under certain circumstances the less traumatic vaginal
approach under analgosedative local anaesthesia is also possible. We now report on
two cases in which retropubic haematomas could successfully be removed by the vaginal
approach. In one case the procedure was performed under analgosedative local anaesthesia;
the vaginal approach thus represents a more gentle alternative under certain circumstances.
Case Reports
We report on two cases of vaginal revision of haematomas after retropubic placement
of tapes, in the first case on the second postoperative day under analgosedative local
anaesthesia and after 14 days under general anaesthesia in the second case.
Case 1
In the case of an 80-year-old patient without prior urogynaecological operations,
a retropubic tape was inserted for clinically and urodynamically confirmed stress
incontinence. After comprehensive information and consent by the patient the operation
was performed successfully. During a routine follow-up examination (vaginal palpation
and transvaginal ultrasound) on the 2nd postoperative day an 8-cm diameter retropubic
haematoma was detected by ultrasonography together with correct tape placement ([Fig. 1]). The revision operation for removal of the haematoma was performed on the following
day since the patient was haemodynamically stable and more or less free of pain. Because
of a report of postoperative bleeding in the case history, we decided in favour of
a vaginal revision under local anaesthesia, in order to minimise the renewed risk
of bleeding due to an additional surgical approach and to avoid a second general anaesthesia.
After performance of the revision operation without any complications, we decided
to administer two erythrocyte concentrates in view of the patientʼs reduced general
condition and initial postoperative anaemia (haemoglobin 5.10 mmol/l). In the follow-up
examination after haematoma removal we found a residual haematoma of ca. 4 cm. Following
mobilisation, an adequate increase of haemoglobin (8.07 mmol/l) and continuing antibiotic
therapy the patientʼs general condition improved rapidly such that she could be released
home in good general condition 3 days after the revision operation. In the course
of the regular follow-up examination 2 months postoperatively, the patient presented
in good health with a good bladder function.
Fig. 1 Postoperative transvaginal ultrasonographic control after primary intervention in
the 1st case with demonstration of a retropubic haematoma (ca. 8 cm). * = symphysis.
Case 2
In the second case of a 75-year-old, obese (BMI 33.4 kg/m2) patient with prior urogynaecological operations and mixed urinary incontinence with
a urodynamically confirmed hypotonic urethra we also decided in favour of placement
of a retropubic tape. Due to her condition after several operations for descensus
and the preoperative sonographic suspicion of the suburethral presence of an inserted
mesh (after cystocele correction with anterior mesh insertion), it was decided initially
to remove part of this mesh in the course of the planned retropubic tape placement
in order not only to make the topographically correct positioning of the retropubic
tape possible, but also because we suspected that the false position of this mesh
could be the cause of the urge components reported by the patient. After comprehensive
clarification and the patientʼs informed consent, the operation was performed without
any complications. In the immediate postoperative period the patient exhibited strongly
hypertonic blood pressure values and the complaints of angina pectoris from the known
arterial hypertension. After excluding an acute coronary syndrome, the patient spent
the first postoperative night under observation in the intensive care unit.
Already on the 1st postoperative day, the patientʼs general condition was so good
that she could be transferred to the normal ward. The further postoperative course
was unremarkable. During a routine follow-up examination on the 2nd postoperative
day, a 6 cm diameter retropubic haematoma and correct tape position were demonstrated
by sonography. In consultation with the patient and in view of the almost complete
freedom from pain, cardiovascular stability, residual urine-free spontaneous micturition
and under consideration of the immediately postoperative hypertonic crisis, we decided
in favour of conservative therapy. The patient was released home in good general condition
on the 3rd postoperative day.
Fourteen days later the patient presented again in our urogynaecological office with
a reduced general condition. Although she was still more or less free of pain the
vaginal ultrasonographic examination revealed the already detected 6 cm diameter haematoma
in a left paravesical position with correct tape position, however, on account of
the obesity, the haematoma could be only poorly evaluated in the cranial direction.
In view of the pathological laboratory values and highly elevated inflammatory parameters
(haemoglobin 6.33 mmol/l, thrombocytes 392 gpt/l, leukocytes 10.7 gpt/l, C-reactive
protein 237.3 mg/l; temperature 38.3 °C) the patient was admitted to our hospital
and an intravenous antibiotic therapy with cefuroxim 3 × 1.5 g and metronidazole 2 × 500 mg
was initiated. Since the findings could not be completely evaluated by sonography,
further imaging diagnostics were undertaken. After computed tomographic demonstration
of a 600–700 ml haemorrhagic superinfected haematoma in the lesser pelvis we decided
to remove the haematoma on the same day ([Fig. 2 a] and [b]). Since, in view of the time point of the revision operation, a well advanced vaginal
wound healing could be assumed, we also discussed an abdominal approach with the patient.
The hypertensive accompanying disease known from the case history, the need for rapid
action and the fact that an abdominal revision could also be necessary, required that
the operation be carried out under general anaesthesia. Intraoperatively, a wound
secretion was seen in the vaginal setting in the vicinity of the suburethral colpotomy.
Since this could be opened bluntly we decided upon a vaginal procedure. After performance
of the revision operation without any complications, an initial postoperative anaemia
(haemoglobin 5.23 mmol/l) and reduced general condition necessitated administration
of two erythrocyte concentrates to the patient. Under mobilisation, adequate increase
of haemoglobin (6.83 mmol/l) and continuation of the antibiotic therapy as well as
a marked reduction of the inflammatory parameters, the patient recovered rapidly.
In a control CT scan on the 2nd postoperative day a small residual haematoma of 25 mm
diameter was seen. Also the routine follow-up examination on the 2nd postoperative
day did not show any remarkable findings apart from the remaining residual haematoma.
The further postoperative course remained free of complications and the patient could
be released home in good general condition and well-being on the 7th postoperative
day. The first follow-up examination one week after release confirmed the unremarkable
recovery process.
Fig. 2 a and b Preoperative abdominal CT in the 2nd case with demonstration of a chambered, haemorrhagic
and superinfected haematoma (ca. 600–700 ml) in the lesser pelvis without any evidence
for a fistular connection to the bladder and intestine.
Operative Procedure
The vaginal haematoma removal was realised in both cases by opening the colpotomy
and blunt preparation along the previously placed tape through to the retropubic space
after the urogenital diaphragm had been punctured and opened sufficiently so that
aspiration was possible. The aspiration is achieved under careful introduction of
the aspirator along the previously inserted tape with the aspirator tip pointing medially
in order to avoid injury to the obturator vessels as well as a reactivation of the
old bleeding source. After several lavages, a suction drain is inserted and, in the
first case, the colpotomy is closed. A vaginal tamponade and an indwelling catheter
are left in place for 24 h. The suction drainage is removed on the 2nd postoperative
day.
In the second case ingrowth of the previously placed retropubic tape did not occur
due to an inflammatory process so that it could be removed in toto by tension during
the revision operation. Except for an adapting suture, the colpotomy is not closed
in order to enable drainage of the wound secretions via two paravesically positioned
drains. An indwelling catheter is left in place for 24 h. The drainage is removed
on the 3rd postoperative day.
Discussion
The formation of a haematoma after insertion of retropubic tapes is a typical complication
for which in the relevant literature both conservative and widely different surgical
treatment options have been described. In the two cases reported here the retropubic
haematomas could be successfully managed by a vaginal revision operation. The courses
of the two patients differ with regard to the accompanying infection of the haematoma
and the hypertensive accompanying disease in the second case. However, both cases
demonstrated that the vaginal approach represents a gentle revision option for haematoma
removal that, under certain circumstances, can also be performed under analgosedative
local anaesthesia. In particular in the second case, a secondary wound healing would
have been expected due to the obesity and the infected haematoma. The, in this case,
unilaterally performed suburethral mesh removal could be topographically excluded
as a cause for haematoma formation. A bilateral procedure would not have reduced the
risk for formation of a retropubic haematoma.
Under consideration of the pain and circulatory stability of the patient, a haematoma
size of 5–6 cm can be taken as a rough upper limit between a conservative wait-and-see
procedure and a revision operation for haematoma removal, although one can find examples
in the literature in which haematomas of up to 10 cm [5] have been treated conservatively. In the Austrian registry published in 2002 by
Kölle et al. 2002 among 5578 cases of retropubic tape insertion there were 151 cases
of bleeding complications and haematoma formation with a revision rate of 0.8 %. In
34 of 45 cases this was done via a laparotomy access. The revision operations were
carried out in 30 % of the cases within 24 hours, in 40 % after 11–56 days and the
remaining 20 % within 2–11 days after insertion of the retropubic tapes [4]. Data collected by Flock et al. showed 4.1 % haematoma formation after retropubic
tape insertion [6], [7]. Of 28 patients, 10 had to undergo a revision operation, since symptomatic haematomas
with a volume of > 250 ml were involved [7]. The patients suffered from abdominal pain, urge symptoms, dysuria and circulatory
dysregulation. Patients with asymptomatic haematomas < 250 ml can be treated by a
conservative wait-and-see strategy [7]. After the first revision has been performed by a laparotomy, in subsequent procedures
an endoscopic access is used [6], [7]. The fact that, as a rule, no generally valid access route and time point for a
revision operation can be given was considered as a self-limiting factor by Flock
et al. so that these decisions have to be determined individually on a case to case
basis [7].
Theoretically there are three possible scenarios for the surgical revision of a retropubic
haematoma. The patient is hypovolemic and reports on pain in the immediate postoperative
period; if this raises the suspicion of a retropubic haematoma/haemorrhage, it necessitates
immediate action in general in the form of a subperitoneal revision operation by laparotomy
to remove the haematoma. This procedure is especially required when, besides haematoma
removal, the persistent, usually arterial bleeding site must be found and closed.
If, in the course of a postoperative routine examination during the hospital stay,
sonography of the patient reveals a retropubic haematoma, this can, depending on its
size, the patientʼs condition, and her circulatory stability under certain circumstances
be removed under analgosedative local anaesthesia by the vaginal access in order to
spare the patient from a more traumatic laparotomy procedure under a renewed general
anaesthesia. The objective of the revision in such cases is the avoidance of a long
and tedious convalescence with possibly functional bladder disorder, pain and risk
of haematoma infection as well as adhesions in the paravesical space.
Since the vaginal access for removal of a retropubic haematoma represents a more gentle
alternative, the vaginal revision should be preferred after a waiting time in cases
where a retropubic haematoma is diagnosed in the immediate postoperative period, the
patientʼs circulation is stable, and depending on the size of the haematoma in order
to spare the patient from a laparotomy intervention. Clinical experience has shown
that when waiting up to the third postoperative day a renewed bleeding into the haematoma
cavity can be avoided by self-tamponade. If the revision is performed too soon it
can reactivate the bleeding site.
Conclusions
Depending on the urgency of a revision operation, the patientʼs circulatory stability
and her pain perception, the vaginal access for revision of a haematoma after retropubic
tape placement makes for a more atraumatic procedure in comparison to a laparotomy
via a subperitoneal approach and, when the haematoma is well accessible, carries a
lower risk of secondary wound healing. Under certain circumstances the patient can
also be spared from a further general anaesthesia. Finally if sonography does not
provide a sufficient clarification of the findings, further imaging procedures may
be considered.
