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.)
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.
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.
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.
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.
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. 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. 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.
1. Delorme E. Transobturator urethral suspension: mini invasive procedure in the treatment of stress urinary continence in women. Prog Urol 2001;11:1306.
2. Sung VW, Schleinitz MD, Rardin CR, Ward RN, Myers DL. Comaparison of retropubic verses transobturator approach to 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 2002;122:163-4.
4. Darmanis S, Lewis A, Mansoor A, Bircher M. Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum. Clin Anat 2007;20:433-439.
5. Berberoğlu M1, Uz A, Ozmen MM, Bozkurt MC, Erkuran C, Taner S, Tekin A, Tekdemir I. Corona mortis: an anatomic study in seven cadavers and an endoscopic study in 28 patients. Surg Endosc 2001;15:72-5.