Author Information
Asmita Patil*, Samant PY**, Parulekar SV***, Kothari K****
(*Senior
Resident, ** Additional Professor, *** Professor and Head
of Department. Department of Obstetrics and Gynecology, **** Associate Professor, Department of Pathology, Seth GS Medical College and KEM Hospital,
Mumbai, India.)
Abstract
Transobturator
sling surgery is the most common minimally invasive surgery done nowadays for
stress urinary incontinence. This surgery is known to have fewer complications
as compared to surgeries done with retropubic approach. We present a case of a
large retropubic hematoma in a patient with a “corona mortis” artery following
a transobturator sling procedure. The patient was managed surgically and the
patient remained continent after surgery.
Introduction
Transobturator
surgery may be associated with complications like urinary tract infection,
urinary retention, erosion of tape, injury to urethra, groin pain, intra and
postoperative bleeding in a few cases. Amongst all postoperative bleeding is
the rarest. Intraoperative bleeding can be controlled with pressure.
But postoperative bleeding or hematoma formation may need surgical
intervention.
Case Report
A 45 year
old perimenopausal woman presented to our outpatient department with stress
urinary incontinence (SUI) and pelvic organ prolapse associated with backache for
2 years. On clinical examination she had lax perineum and second degree
uterovaginal prolapse with cystocele having 3 cm of central transeverse defect.
Bonney's test for SUI was positive. A vaginal hysterectomy with transobturator
sling surgery, anterior colporrhaphy and posterior colpoperineorrhaphy was
done. Her immediate postoperative period was uneventful and she was discharged
from hospital on day 5 of surgery. On day 21 of surgery she presented with pain in right iliac fossa, inability to flex
the right hip joint, constipation and urinary symptom suggestive of urge incontinence.
She did not have fever, dysuria. On examination her vital parameters were
stable. Mild pallor was present. Per abdomen 12 weeks size mass was palpable
suprapubically extending to the right iliac fossa, which was firm, immobile and
tender. On per vaginal examination 8×10×10 centimeter size firm, irregular mass
was palpable right and anterior to vault with moderate tenderness. Her
hemoglobin was 8.1 g/dL and coagulation profile was within normal limit. She
was given intravenous antibiotics and 2 units of blood. An ultrasonographic
examination showed an ecoluscent mass with few septae in the retropubic area. With
suspicion of vaginal vault hematoma, and in view of her severe symptoms, an
exploratory laparotomy was performed. A preperitoneal organized haematoma of approximately 8x8x8 centimeters was found extending
retropubically. The pseudocapsule of hematoma was opened and chocolate brown
material with old clots weighing approximately 400 g was removed. The top of
the pseudocapsule was excised. Saline wash was given. There was no evidence of
any active bleeder. The inner wall of the hematoma wall was smooth. The peritoneum
was opened and inspected, there was no evidence of any bleeding in the
peritoneum. Extraperitoneal drain was kept and the abdomen was closed.
Immediate postoperative period was uneventful. Her urinary complaints resolved
slowly. The histopathological report showed the wall to be composed of
fibrocollaginous tissue, hemosiderin laden macrophages and scattered
inflammatory cells. There was no lining epithelium, no endometrial glands or
stroma. There were blood clots and fibrin lining the inner surface of the wall.
Figure 1 :This is the
transvaginal ultrasonographical picture
of the retropubic space hematoma. Red arrow shows hematoma and the green arrow
shows bladder.
Figure 2
This is intraoperative picture of the cavity left after draining the hematoma,
which had a pseudocapsule.
Figure 3. Histopathological image showing the wall of the hematoma with fibrin material without the lining epithelium and inner wall shows evidence of fresh hemorrhage.
Figure 4.
Hemosiderin laden macrophages are seen which are characteristics of old
hemorrhage.
Discussion
The
transobturator sling surgeries were introduced first in 2001 in order to
minimize the complications rate of retropubic insertion, mainly the vascular
injuries in that space.[1]
This
technique involves passage of needles through the medial portion of the
obturator foramen. The retropubic space is not entered during this procedure,
and hence theoretically chances of vascular injury or any structure in the
proximity of this space are remote. However, vascular complications, although
infrequent, can occur. Sung et al during their metanalysis found that the rate of significant hematoma
was 0.08% for the transobturator approach.[2] Usually these bleeding
complications occur intraoperatively or during immediate postoperative period .
The retropubic
hematoma in our case was most likely related to direct injury to obturator vessels
secondary to injury to the obturator muscle. As our case has presented after
nearly three weeks, we believe that it was a venous injury which bled slowly
and formed a hematoma which eventually got organized to form a mass. Another
possibility might be an injury to the “corona mortis” which is a connection
between the obturator artery and the inferior epigastric artery. It is found
behind the superior pubic ramus at a distance of about 3 to 7 cm from the
symphysis pubis. Several investigators have estimated incidence of arterial
anastomoses as 10-43%. [3,4] Berberoğlu on their study on 28
cadaveric dissection has found 96% of venous anastomosis on the superior pubic
ramus and accessory branches of the obturator artery were
observed in only 8% of the dissections.[5] Since it lies behind the
superior pubic ramus, it is unlikely to be injured during the passage of the
needle for transobturator tape insertion. This case demonstrates the importance
of precise knowledge about the surgical anatomy helps prevent surgical
accidents.
References
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Sung VW, Schleinitz MD, Rardin CR, Ward RN,
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midurethral sling: a systematic review and meta analysis. Am J Obstet
Gynecol.2007;197:3-11.
3.
Karakurt L, Karaca I, Yilmaz E, Burma O, Serin
E. Corona mortis: incidence and location. Arch Orthop Trauma Surg
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seven cadavers and an endoscopic study in 28 patients. Surg Endosc
2001;15:72-5.
Citation