CASE REPORT
Minimally Invasive Management of Retropubic Bleeding and Hematoma Evacuation After a TVT Secur or Mini-Sling Procedure Amy L. O’Boyle, MD,* Angela DiCarlo-Meacham, MD,Þ and Sandra Hernandez, MD*
Background: Retropubic hematomas may complicate up to 4.1% of tension-free vaginal tape (TVT) procedures in the surgical treatment of stress urinary incontinence. Symptomatic or expanding hematomas often require intervention, usually accomplished through an abdominal incision. Case: A 43-year-old woman underwent transvaginal management of venous bleeding and evacuation of a 1500-mL retropubic hematoma after a TVT Secur or ‘‘mini-sling’’ procedure. Conclusions: Significant bleeding can complicate even the least invasive surgical approach to treat stress urinary incontinence. Transvaginal evacuation of a symptomatic retropubic hematoma with instillation of a hemostatic agent may be a safe alternative to laparotomy in a hemodynamically stable patient. Key Words: TVT Secur, mini-sling, retropubic hematoma, bleeding complications (Female Pelvic Med Reconstr Surg 2014;20: 119Y120)
T
he minimally invasive retropubic midurethral sling, first popularized by the tension-free vaginal tape (TVT) procedure, quickly became the treatment of choice of many surgeons who treat stress urinary incontinence.1 Despite the widespread popularity of these procedures, rare but potentially lifethreatening hemorrhage may occur. Arterial injury to the obturator, external iliac, femoral, and inferior epigastric vessels have all occurred secondary to the TVT trochar.2 Venous bleeding in the retropubic space, possibly from the inferior vesical veins, may result in retropubic hematoma formation in up to 4.1% of cases.3Y5 Hematoma formation may be immediate or delayed and are self-limited in most cases. Even large hematomas, up to 10 cm, have been managed expectantly resolving within 6 months.2 Reoperation becomes necessary when the patient develops severe pain or hemodynamic instability and is most commonly managed through an abdominal incision.4,5 In most cases, a distinct bleeding vessel may not be identified upon abdominal exploration for retropubic hematomas.2 Other reported complications secondary to the TVT trochar include bladder, urethra, and bowel injuries. In an effort to reduce these complications, the single-incision ‘‘mini-slings,’’ such as the
From the *Walter Reed National Military Medical Center, Bethesda, MD; and †Naval Hospital Okinawa, Okinawa, Japan. Reprints: Amy L. O’Boyle, MD, Division of Urogynecology, Department of Women’s Health, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889-5600. E-mail: [email protected]; amy.l.o’[email protected]. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. The authors have declared they have no conflicts of interest. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/SPV.0000000000000059
Female Pelvic Medicine & Reconstructive Surgery
&
TVT Secur (TVT-S; Ethicon), were developed. However, serious bleeding as a result of injury to the corona mortis vessel and internal obturator muscle has been reported with the Secur.6,7 We describe a minimally invasive treatment approach for a massive retropubic hematoma after the placement of a TVT-S.
CASE A 42-year-old woman underwent a TVT-S placement and cystourethroscopy for stress urinary incontinence. Her medical history was unremarkable, and the procedure is uncomplicated, with an estimated blood loss of 75 mL. The Foley catheter was removed 2 hours postoperatively, at which time the patient reported no pain. Over the next 2.5 hours, the patient had an approximately 20 beats per minute increase in her pulse rate, developed mild nausea, lower abdominal pain, and an associated strong urge to void. The concern was that the patient had either developed bladder overdistention or had a retropubic hematoma. A Foley catheter was therefore replaced, and a complete blood cell count was obtained. The catheter only returned 200 mL of clear yellow urine, but a 4% drop in the hematocrit level from the preoperative level was discovered. The decision was then made to admit the patient for observation. The patient subsequently developed worsening lower abdominal pain, a sensation of abdominal distention, tachycardia, and an additional 4% drop in hematocrit level. Twelve hours after the surgery, the patient was returned to the operating department with an ultrasound confirming retropubic hematoma extending to the level of the umbilicus. A blood transfusion was also started. In the operating department, the patient was positioned in a high lithotomy position, and the vaginal incision was opened. The retropubic space was gently entered lateral to the sling so as not to disturb its placement. No active or profuse bleeding was encountered, but 1500 mL of blood and clot was evacuated with the assistance of ultrasound and a combination of suction and copious irrigation. After the evacuation, FloSeal Hemostatic Matrix was instilled with syringe into the retropubic space through the vaginal incision. A cystoscopy was then performed, which confirmed bladder integrity and ureteral patency. A Foley catheter was replaced but clamped to allow approximately 300 mL of cystoscopy fluid to remain in the bladder, providing tamponade of the surrounding tissue. The vaginal incision was reapproximated with a 2-0 absorbable suture, and a vaginal packing was placed. In the recovery room, the bladder volume was periodically measured with ultrasound, and the Foley was intermittently unclamped to monitor adequate urine production while maintaining comfortable bladder distention for continued tamponade during the completion of the blood transfusion. The patient ultimately received a total of 4 units of packed red blood cells and 1 unit of fresh frozen plasma. Once it was believed that no ongoing bleeding was occurring, the Foley was unclamped, and the patient was transferred to the ward. Before discharge on the third postoperative day, the patient successfully passed a voiding trial. Nearly 4 years after
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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
O’Boyle et al
the surgery, a thorough review of our outpatient electronic medical record confirmed that the patient has denied urinary complaints at all subsequent postoperative and routine health care appointments since the procedure.
DISCUSSION Retropubic hematoma formation after the TVT procedure occurs in up to 4.1% of TVT procedures.2,3 In a series by Flock et al,4 10% of retropubic hematomas that occurred after the TVT required surgical intervention for moderate or severe symptoms associated with hematomas measuring 250 mL or greater (range, 250Y1000 mL). These authors also reported on their experience in performing endoscopic management or ‘‘retziusscopy’’ to gain entry into the space of Retzius for hematoma management.8 McNanley and Duecy9 reported the successful management of 2 cases in which profuse retropubic bleeding occurred with the placement of a TVT that were managed intraoperatively with the use of FloSeal Hemostatic Matrix Sealant (Baxter) into the retropubic space, as we performed after evacuating the hematoma. Other methods that have been reported for the management of retropubic bleeding and hematoma include arterial embolization and computed tomographyYguided drainage.3,5,10Y12 In our case, it is believed that the bleeding was venous and likely began during or shortly after the original procedure. Hemostasis was achieved through a combination of a retropubically administered hemostatic agent, FloSeal, and tamponade of the surrounding vessels and with bladder distension and vaginal packing. Although preparations were made to rapidly convert to an abdominal incision at the onset of the reoperation, by first approaching the hematoma vaginally, we were able to quickly gain access to the retropubic space and assess the severity of the ongoing bleeding through the original incision. This was technically simple to perform and allowed for complete evacuation of the hematoma, reducing the morbidity of an abdominal incision, increased postoperative pain, prolonged recovery, and disappointment associated with this complication. A limitation of this approach, however, was that a discrete source of bleeding or direct visualization of the space of Retzius was not possible. Most retropubic hematomas occur as a result of venous bleeding; therefore, abdominal exploration usually fails to identify a distinct bleeding vessel. It is unlikely that an abdominal incision would have afforded an advantage in this case.2 We feel that the vaginal approach was a safe initial management option. Fortunately for our patient, we were able to preserve the minimally invasive nature of her treatment while successfully managing a rare but potentially life-threatening complication of a midurethral sling procedure. Intentional bladder distention is an excellent tool that can be used to apply tamponade to the retropubic venous plexus. In this case, the bladder was not drained after the cystoscopy to provide compression of the surrounding tissue. These, in combination with a vaginal packing, were the additional measures that we used to help achieve hemostatis. These techniques also maintained the integrity of the sling, giving the patient the best chance to achieve continence through a minimally invasive approach and the desired treatment outcome. In the event that such techniques are not successful in securing bleeding, surgeons can always proceed with more invasive techniques. The mini-sling is a newer version of the midurethral sling for the treatment of stress urinary incontinence in women. A
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Volume 20, Number 2, March/April 2014
single vaginal incision and a theoretically lower risk for major vascular or bowel injury had made this an attractive alternative to the blind passage of a trochar into the space of Retzius. Most arterial bleeding is recognized during the initial surgery or in the immediate postoperative period because of rapid hematoma expansion and the development of hemodynamic instability. In such cases, when arterial bleeding or injury to the small bowel is suspected, laparotomy still remains the most prudent initial management approach to achieve optimal exposure to the injury.
CONCLUSIONS Although bleeding remains a known and potentially lifethreatening complication of the midurethral sling procedure, when venous bleeding is suspected, it may still be feasible to preserve the minimally invasive treatment goal. Transvaginal management of a symptomatic or expanding retropubic hematoma, as in this case, may be a reasonable alternative to an abdominal incision in a hemodynamically stable patient. REFERENCES 1. Ulmsten U, Henriksson L, Johnson P, et al. An ambulatory surgical procedure under local anesthesia for the treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:81Y86. 2. Walters MD, Tulikangas PK, LaSala C, et al. Vascular injury during tension-free vaginal tape procedures for stress urinary incontinence. Obstet Gynecol 2001;98:957Y959. 3. Daneshgari F, Kong W, Swartz M. Complications of mid urethral slings: important outcomes for future clinical trials. J Urol 2008;180:1890Y1897. 4. Flock F, Reich A, Much R, et al. Hemorrhagic complications associated with tension-free vaginal tape procedure. Obstet Gynecol 2004;104:989Y994. 5. Kolle D, Tamussino K, Engelbert H, et al. Bleeding complications with the tension-free vaginal tape operation. Am J Obstet Gynecol 2005;193:2045Y2049. 6. Masata J, Martan A, Svabı´k K. Severe bleeding from internal obturator muscle following tension-free vaginal tape Secur hammock approach procedure. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1581Y1583. 7. Larsson PG, Teleman P, Persson J. A serious bleeding complication with injury of the corona mortis with the TVT-Secur procedure. Int Urogynecol J 2010;21:1175Y1177. 8. Flock F, Kohorst F, Kreienberg R, et al. Retziusscopy: a minimal invasive technique for the treatment of retropubic hematomas after TVT procedure. Eur J Obstet Gynecol Reprod Biol 2011;1:101Y103. 9. McNanley AR, Duecy EE. FloSeal for treatment of retropubic bleeding during placement of tension-free vaginal tape. J Pelvic Med Surg 2009;15:25Y27. 10. Zorn KC, Daigle S, Belzile F, et al. Embolization of a massive retropubic hemorrhage following a tension-free vaginal tape (TVT) procedure: case report and literature review. Can J Urol 2005;12:2560Y2563. 11. Gallup DG, Cook AH. Tips on controlling pelvic hemorrhage. J Pelvic Surg 2001;7:294Y296. 12. Vierhout ME. Severe hemorrhage complicating tension-free vaginal tape (TVT): a case report. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:139Y140.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Minimally Invasive Management of Retropubic Bleeding and Hematoma Evacuation After a TVT Secur or Mini-Sling Procedure Amy L. O’Boyle, MD,* Angela DiCarlo-Meacham, MD,Þ and Sandra Hernandez, MD*
Background: Retropubic hematomas may complicate up to 4.1% of tension-free vaginal tape (TVT) procedures in the surgical treatment of stress urinary incontinence. Symptomatic or expanding hematomas often require intervention, usually accomplished through an abdominal incision. Case: A 43-year-old woman underwent transvaginal management of venous bleeding and evacuation of a 1500-mL retropubic hematoma after a TVT Secur or ‘‘mini-sling’’ procedure. Conclusions: Significant bleeding can complicate even the least invasive surgical approach to treat stress urinary incontinence. Transvaginal evacuation of a symptomatic retropubic hematoma with instillation of a hemostatic agent may be a safe alternative to laparotomy in a hemodynamically stable patient. Key Words: TVT Secur, mini-sling, retropubic hematoma, bleeding complications (Female Pelvic Med Reconstr Surg 2014;20: 119Y120)
T
he minimally invasive retropubic midurethral sling, first popularized by the tension-free vaginal tape (TVT) procedure, quickly became the treatment of choice of many surgeons who treat stress urinary incontinence.1 Despite the widespread popularity of these procedures, rare but potentially lifethreatening hemorrhage may occur. Arterial injury to the obturator, external iliac, femoral, and inferior epigastric vessels have all occurred secondary to the TVT trochar.2 Venous bleeding in the retropubic space, possibly from the inferior vesical veins, may result in retropubic hematoma formation in up to 4.1% of cases.3Y5 Hematoma formation may be immediate or delayed and are self-limited in most cases. Even large hematomas, up to 10 cm, have been managed expectantly resolving within 6 months.2 Reoperation becomes necessary when the patient develops severe pain or hemodynamic instability and is most commonly managed through an abdominal incision.4,5 In most cases, a distinct bleeding vessel may not be identified upon abdominal exploration for retropubic hematomas.2 Other reported complications secondary to the TVT trochar include bladder, urethra, and bowel injuries. In an effort to reduce these complications, the single-incision ‘‘mini-slings,’’ such as the
From the *Walter Reed National Military Medical Center, Bethesda, MD; and †Naval Hospital Okinawa, Okinawa, Japan. Reprints: Amy L. O’Boyle, MD, Division of Urogynecology, Department of Women’s Health, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889-5600. E-mail: [email protected]; amy.l.o’[email protected]. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. The authors have declared they have no conflicts of interest. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/SPV.0000000000000059
Female Pelvic Medicine & Reconstructive Surgery
&
TVT Secur (TVT-S; Ethicon), were developed. However, serious bleeding as a result of injury to the corona mortis vessel and internal obturator muscle has been reported with the Secur.6,7 We describe a minimally invasive treatment approach for a massive retropubic hematoma after the placement of a TVT-S.
CASE A 42-year-old woman underwent a TVT-S placement and cystourethroscopy for stress urinary incontinence. Her medical history was unremarkable, and the procedure is uncomplicated, with an estimated blood loss of 75 mL. The Foley catheter was removed 2 hours postoperatively, at which time the patient reported no pain. Over the next 2.5 hours, the patient had an approximately 20 beats per minute increase in her pulse rate, developed mild nausea, lower abdominal pain, and an associated strong urge to void. The concern was that the patient had either developed bladder overdistention or had a retropubic hematoma. A Foley catheter was therefore replaced, and a complete blood cell count was obtained. The catheter only returned 200 mL of clear yellow urine, but a 4% drop in the hematocrit level from the preoperative level was discovered. The decision was then made to admit the patient for observation. The patient subsequently developed worsening lower abdominal pain, a sensation of abdominal distention, tachycardia, and an additional 4% drop in hematocrit level. Twelve hours after the surgery, the patient was returned to the operating department with an ultrasound confirming retropubic hematoma extending to the level of the umbilicus. A blood transfusion was also started. In the operating department, the patient was positioned in a high lithotomy position, and the vaginal incision was opened. The retropubic space was gently entered lateral to the sling so as not to disturb its placement. No active or profuse bleeding was encountered, but 1500 mL of blood and clot was evacuated with the assistance of ultrasound and a combination of suction and copious irrigation. After the evacuation, FloSeal Hemostatic Matrix was instilled with syringe into the retropubic space through the vaginal incision. A cystoscopy was then performed, which confirmed bladder integrity and ureteral patency. A Foley catheter was replaced but clamped to allow approximately 300 mL of cystoscopy fluid to remain in the bladder, providing tamponade of the surrounding tissue. The vaginal incision was reapproximated with a 2-0 absorbable suture, and a vaginal packing was placed. In the recovery room, the bladder volume was periodically measured with ultrasound, and the Foley was intermittently unclamped to monitor adequate urine production while maintaining comfortable bladder distention for continued tamponade during the completion of the blood transfusion. The patient ultimately received a total of 4 units of packed red blood cells and 1 unit of fresh frozen plasma. Once it was believed that no ongoing bleeding was occurring, the Foley was unclamped, and the patient was transferred to the ward. Before discharge on the third postoperative day, the patient successfully passed a voiding trial. Nearly 4 years after
Volume 20, Number 2, March/April 2014
www.fpmrs.net
119
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Female Pelvic Medicine & Reconstructive Surgery
O’Boyle et al
the surgery, a thorough review of our outpatient electronic medical record confirmed that the patient has denied urinary complaints at all subsequent postoperative and routine health care appointments since the procedure.
DISCUSSION Retropubic hematoma formation after the TVT procedure occurs in up to 4.1% of TVT procedures.2,3 In a series by Flock et al,4 10% of retropubic hematomas that occurred after the TVT required surgical intervention for moderate or severe symptoms associated with hematomas measuring 250 mL or greater (range, 250Y1000 mL). These authors also reported on their experience in performing endoscopic management or ‘‘retziusscopy’’ to gain entry into the space of Retzius for hematoma management.8 McNanley and Duecy9 reported the successful management of 2 cases in which profuse retropubic bleeding occurred with the placement of a TVT that were managed intraoperatively with the use of FloSeal Hemostatic Matrix Sealant (Baxter) into the retropubic space, as we performed after evacuating the hematoma. Other methods that have been reported for the management of retropubic bleeding and hematoma include arterial embolization and computed tomographyYguided drainage.3,5,10Y12 In our case, it is believed that the bleeding was venous and likely began during or shortly after the original procedure. Hemostasis was achieved through a combination of a retropubically administered hemostatic agent, FloSeal, and tamponade of the surrounding vessels and with bladder distension and vaginal packing. Although preparations were made to rapidly convert to an abdominal incision at the onset of the reoperation, by first approaching the hematoma vaginally, we were able to quickly gain access to the retropubic space and assess the severity of the ongoing bleeding through the original incision. This was technically simple to perform and allowed for complete evacuation of the hematoma, reducing the morbidity of an abdominal incision, increased postoperative pain, prolonged recovery, and disappointment associated with this complication. A limitation of this approach, however, was that a discrete source of bleeding or direct visualization of the space of Retzius was not possible. Most retropubic hematomas occur as a result of venous bleeding; therefore, abdominal exploration usually fails to identify a distinct bleeding vessel. It is unlikely that an abdominal incision would have afforded an advantage in this case.2 We feel that the vaginal approach was a safe initial management option. Fortunately for our patient, we were able to preserve the minimally invasive nature of her treatment while successfully managing a rare but potentially life-threatening complication of a midurethral sling procedure. Intentional bladder distention is an excellent tool that can be used to apply tamponade to the retropubic venous plexus. In this case, the bladder was not drained after the cystoscopy to provide compression of the surrounding tissue. These, in combination with a vaginal packing, were the additional measures that we used to help achieve hemostatis. These techniques also maintained the integrity of the sling, giving the patient the best chance to achieve continence through a minimally invasive approach and the desired treatment outcome. In the event that such techniques are not successful in securing bleeding, surgeons can always proceed with more invasive techniques. The mini-sling is a newer version of the midurethral sling for the treatment of stress urinary incontinence in women. A
120
www.fpmrs.net
&
Volume 20, Number 2, March/April 2014
single vaginal incision and a theoretically lower risk for major vascular or bowel injury had made this an attractive alternative to the blind passage of a trochar into the space of Retzius. Most arterial bleeding is recognized during the initial surgery or in the immediate postoperative period because of rapid hematoma expansion and the development of hemodynamic instability. In such cases, when arterial bleeding or injury to the small bowel is suspected, laparotomy still remains the most prudent initial management approach to achieve optimal exposure to the injury.
CONCLUSIONS Although bleeding remains a known and potentially lifethreatening complication of the midurethral sling procedure, when venous bleeding is suspected, it may still be feasible to preserve the minimally invasive treatment goal. Transvaginal management of a symptomatic or expanding retropubic hematoma, as in this case, may be a reasonable alternative to an abdominal incision in a hemodynamically stable patient. REFERENCES 1. Ulmsten U, Henriksson L, Johnson P, et al. An ambulatory surgical procedure under local anesthesia for the treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:81Y86. 2. Walters MD, Tulikangas PK, LaSala C, et al. Vascular injury during tension-free vaginal tape procedures for stress urinary incontinence. Obstet Gynecol 2001;98:957Y959. 3. Daneshgari F, Kong W, Swartz M. Complications of mid urethral slings: important outcomes for future clinical trials. J Urol 2008;180:1890Y1897. 4. Flock F, Reich A, Much R, et al. Hemorrhagic complications associated with tension-free vaginal tape procedure. Obstet Gynecol 2004;104:989Y994. 5. Kolle D, Tamussino K, Engelbert H, et al. Bleeding complications with the tension-free vaginal tape operation. Am J Obstet Gynecol 2005;193:2045Y2049. 6. Masata J, Martan A, Svabı´k K. Severe bleeding from internal obturator muscle following tension-free vaginal tape Secur hammock approach procedure. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1581Y1583. 7. Larsson PG, Teleman P, Persson J. A serious bleeding complication with injury of the corona mortis with the TVT-Secur procedure. Int Urogynecol J 2010;21:1175Y1177. 8. Flock F, Kohorst F, Kreienberg R, et al. Retziusscopy: a minimal invasive technique for the treatment of retropubic hematomas after TVT procedure. Eur J Obstet Gynecol Reprod Biol 2011;1:101Y103. 9. McNanley AR, Duecy EE. FloSeal for treatment of retropubic bleeding during placement of tension-free vaginal tape. J Pelvic Med Surg 2009;15:25Y27. 10. Zorn KC, Daigle S, Belzile F, et al. Embolization of a massive retropubic hemorrhage following a tension-free vaginal tape (TVT) procedure: case report and literature review. Can J Urol 2005;12:2560Y2563. 11. Gallup DG, Cook AH. Tips on controlling pelvic hemorrhage. J Pelvic Surg 2001;7:294Y296. 12. Vierhout ME. Severe hemorrhage complicating tension-free vaginal tape (TVT): a case report. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:139Y140.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
