Complications of pelvic reconstructive surgery

Evaluating comorbidities and perioperative risk

Before a patient undergoes pelvic reconstructive surgery, the risk of potential complications should be carefully assessed and addressed with the patient. Complications may occur in the perioperative period, and it is necessary to recognize high-risk patients and minimize risk from surgery before their arrival to the operating room. The lifetime risk of a woman undergoing prolapse or incontinence surgery by the age of 80 years is 19% to 25% ( ; ; ). The prevalence of perioperative complications among women undergoing reconstructive pelvic surgery has been reported to be as high as 33% ( ). A large cross-sectional study including 366 women who had undergone prolapse surgery found an overall complication rate of 11.3% ( ). Risk factors for complications in the perioperative period are listed in Box 26.1 .

Age is an important factor to consider when assessing perioperative risk. The median age of patients who undergo pelvic reconstructive surgery is 61.5 years ( ). Increasing age corresponds with increasing medical comorbidities, including chronic illness, hypertension, coronary heart disease, diabetes, pulmonary disease, and central nervous system disease ( ). A retrospective cohort study of 264,340 women undergoing pelvic surgery found that increasing age is associated with higher mortality risks and higher complication risks. Specifically, elderly women (>80 years of age) were found to have increased risk of perioperative complications compared with younger women ( ). In this same study, elderly women who underwent obliterative procedures (e.g., colpocleisis) had a lower risk of complications compared with patients who underwent reconstructive procedures for prolapse. Furthermore, in a decision analysis by , it was found that Le Fort colpocleisis is the preferred obliterative procedure, and that, as patients age, the difference between Le Fort alone and hysterectomy with colpocleisis widens, favoring Le Fort. In a retrospective review of patients 75 years and older, 25.8% of patients had significant perioperative complications including significant blood loss, pulmonary edema, and congestive heart failure. Independent risk factors that were predictive of perioperative complications in this patient population included length of surgery, coronary artery disease, and peripheral vascular disease ( ). In a retrospective cohort study including 508 women undergoing urogynecologic surgery, women who were older than age 65 years had an increased risk of postoperative complications on the Dindo–Clavien scale compared to women who were younger than age 65 years ( ). When surgeons are determining the best procedure for the patient, age should play a role in that decision.

Cardiac risk factors also impact postoperative morbidity in pelvic surgery. In a retrospective cohort study by , perioperative complications were increased in patients with a history of myocardial infarction or congestive heart failure, perioperative hemoglobin decrease greater than 3.1 g/dL, preoperative hemoglobin less than 12.0 g/dL, or history of prior thrombosis. In a retrospective cohort study of 4315 patients undergoing elective major noncardiac surgery, predictors of major cardiac complications included high-risk types of surgeries, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and a serum creatinine of 2.0 mg/dL or greater ( ). To decrease cardiac morbidity in patients undergoing surgery, it has been shown that continuing β blockers in the perioperative period in patients with chronic β blockade will decrease cardiovascular mortality ( ). In a very large retrospective cohort study by , the rate of myocardial infarction or cardiac arrest was 0.11% among 46,367 women who underwent pelvic reconstructive surgery. In a retrospective chart review by , 983 women who underwent transvaginal colpopexy were found to have a 0.8% rate of cardiac complications. These numbers are reassuring when considering pelvic floor surgery for many patients, even those who are elderly or with comorbidities. Consultation with the patient’s primary care physician or cardiologist before surgery is often warranted in patients with cardiac disease.

Obesity is a significant risk factor for perioperative complications. With obesity, there is an increase in comorbid conditions, including cardiac disease, type 2 diabetes, hypertension, stroke, sleep apnea, and some cancers ( ). One study of obese and overweight women undergoing retropubic surgery for stress urinary incontinence found that obese women had significantly increased estimated blood loss and operative time ( ). In a retrospective cohort study, obese patients who underwent vaginal surgery were matched to patients who were of normal weight, and perioperative comorbidities and complications were analyzed. This study found that there was no difference in perioperative complications between obese and nonobese patients; however, there was a higher rate of surgical site infection in the obese population ( ). In a large retrospective cohort study of 16,639 women who underwent pelvic floor reconstructive surgery, 10% of the patients were obese, and the overall perioperative complication rate during the surgical admission was 25%. On multivariable analysis, obesity increased the odds of perioperative complications by approximately 40% after adjusting for age, race, income, concomitant hysterectomy, and medical comorbidities ( ).

In obese women undergoing hysterectomy, the abdominal approach results in significantly higher rates of wound infection than vaginal hysterectomy ( ). In a systematic review, compared with vaginal and laparoscopic hysterectomy, patients with body mass index (BMI) over 35 kg/m ² who underwent abdominal hysterectomy had more postoperative complications and longer hospitalizations ( ). Overall, vaginal surgery appears to be the safest approach for obese women. Despite this, in a large retrospective study of over 18,800 women undergoing hysterectomy for benign conditions, rates of abdominal hysterectomy increased from 46% in patients with ideal body weight to 62% in morbidly obese patients ( ).

It is important to assess BMI when planning route of surgery and to consider the increased risks with obesity. In a large Swedish retrospective cohort study, women with a BMI of 25 kg/m ² or greater were more likely to have increased blood loss and longer duration of surgery, and women with a BMI of 35 kg/m ² or greater were more likely to have postoperative infections ( ). Furthermore, in a large retrospective study of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 55,409 women who underwent hysterectomy for benign conditions were studied, and patients with a BMI of 40 kg/m ² or greater had five times the odds of wound dehiscence, five times the odds of wound infection, and 89% higher odds of sepsis compared to women with normal BMI ( ).

In conclusion, when considering pelvic reconstructive surgery it is important to examine and evaluate the whole patient, including her medical comorbidities to appropriately assess her perioperative risk. Because of age and comorbidities, many patients should be evaluated by their primary care doctor or cardiologist before undergoing surgery. In high-risk patients, the vaginal route is often the lowest risk approach. In elderly patients no longer interested in sexual activity, obliterative procedures should be considered because of their shorter surgical times and low risk of complications relative to reconstructive procedures. Furthermore, when considering obliterative procedures, a LeFort colpocleisis tends to be the safest obliterative procedure to perform if feasible.

Enhanced recovery

Before bringing the patient to the operating room, careful planning and preoperative protocols may contribute to reduced complications and hospital stays through the use of Enhanced Recovery After Surgery (ERAS) pathways. Although not standardized specifically for pelvic floor surgeries, ERAS pathways were developed to decrease postoperative pain and recovery times, and, in many cases, promote shorter hospital stays. In general, ERAS consists of preoperative counseling about expectations after surgery; preoperative nutritional strategies; use of analgesic, neuropathic, and antiemetic medications in the preoperative environment; a perioperative focus on multimodal analgesia, fluid balance, and maintenance of normothermia; and promoting early mobilization after surgery.

In a prospective observational study of women undergoing minimally invasive hysterectomy via laparoscopy or robotic approaches in an ERAS pathway, rates of same-day discharge increased, with no increase in emergency room visits or readmissions compared with a non-ERAS historical control group. Factors that were more common in those admitted after surgery included a higher (worse) American Society of Anesthesiologists physical status score, Black race, urinary retention, and postoperative pain ( ). In a retrospective study, women who underwent surgery for prolapse or incontinence before and after implementation of an ERAS pathway were compared ( ). The ERAS (vs. non-ERAS) group had a higher proportion of same-day discharge (91.7% vs. 25.9%, P < .001) and a 13.8-hour shorter duration of stay. Patients in the ERAS group were more likely to be discharged using a urethral catheter. There were no differences in total 30-day postoperative complications, but the ERAS group had a slightly increased rate of 30-day readmission (6.7% vs. 1.5%, P = .048). The ERAS group had high patient satisfaction scores. Their urogynecology tailored ERAS protocol is shown in Table 26.1 .

The American College of Obstetricians and Gynecologists (ACOG) recommends using ERAS pathways “to promote more rapid surgical recovery, shorter length of stay, greater patient satisfaction, and decreased costs when compared with traditional approaches” ( ).

Pulmonary complications

Postoperative pulmonary complications are a frequent cause of morbidity and mortality in the urogynecology patient. Postoperative pneumonia, atelectasis, pneumothorax, and respiratory failure are postoperative complications that increase length of stay and are more common than postoperative cardiac complications ( ). The incidence of postoperative pulmonary complications in gynecologic patients has been reported to be between 1.22% and 2.3% ( ; ). Multiple risk factors may increase pulmonary complications in the postoperative surgical patient. In a randomized trial of patients who underwent nonthoracic surgery, multivariate analysis identified four risk factors for postoperative pulmonary complications, including age greater than 65 years, positive “cough test,” perioperative nasogastric tube, and duration of anesthesia (procedures lasting >2.5 hours) ( ). A retrospective review of patients undergoing gynecologic laparoscopy found that operative time greater than 200 minutes and age greater than 65 years contributed to hypercarbia. Predictors of the development of pneumothorax included pneumoperitoneum pressure greater than 50 mm Hg and operative time greater than 200 minutes ( ). In a retrospective review of 3226 patients who underwent hysterectomy for benign conditions, the incidence of pulmonary complications was extremely low, at 0.3% ( ).

Surgical approach may also be a contributing factor to postoperative pulmonary complications. A study of patients undergoing abdominal surgery found that age greater than 60 years, smoking history within the past 8 weeks, BMI 27 kg/m ² or more, history of cancer, and incision site in the upper abdomen were independent risk factors for postoperative pulmonary complications ( ). In a clinical trial involving 994 patients performed by , patients were divided into three groups: (1) elective superficial plastic surgery, (2) upper abdominal surgery, and (3) thoracoabdominal (TA) surgery. It was found that the incidence of hypoxemia in the postoperative period was closely related to the operative site, with the upper abdominal and TA sites associated with the greatest risk. When evaluating this study, patients undergoing pelvic reconstructive surgery would most likely fall into the low-risk category, similar to elective superficial plastic surgery, with a low risk of hypoxemia in the postoperative period.

Smoking is another risk factor associated with postoperative pulmonary complications. In a prospective cohort study of patients referred for nonthoracic surgery, the risk for postoperative pulmonary complications was increased with age greater than 65 years and smoking history of 40 pack-years or more ( ). In a large retrospective review of 635,265 patients from the NSQIP database, current smokers had increased odds of postoperative pneumonia and unplanned intubation ( ). Pulmonary complications significantly decrease after 8 weeks of smoking cessation ( ).

Patients with chronic obstructive pulmonary disease are also at increased risk of having postoperative pulmonary complications, and preoperative pulmonary function tests may help to identify patients with increased pulmonary risk ( ). Patients with chronic obstructive pulmonary disease were 300 to 700 times more likely to have a postoperative pulmonary complication in a prospective cohort study ( ). Of note, nasogastric intubation instead of orogastric intubation increases the risk of pneumonia in this patient population as well ( ).

Sleep apnea is an additional risk factor for postoperative pulmonary complications. Obstructive sleep apnea is defined as partial or complete obstruction of the upper airway during sleep. The prevalence of sleep apnea ranges from 1% to 24% ( ). For gynecologic patients, diagnosing and treating sleep apnea is very helpful for the postoperative course. Regional anesthesia should be used on these patients when possible and reducing the length of surgery is imperative for safety. In a retrospective cohort study of orthopedic and general surgery patients by , 51,509 patients with sleep apnea who underwent general surgery procedures were assessed for postoperative pulmonary complications. Patients with sleep apnea developed pulmonary complications more frequently than their matched controls. Because of relaxation of the pharyngeal muscles from anesthetic agents, sedatives, and opioids, patients with obstructive sleep apnea may have increased airway collapse in the postoperative period ( ). Anesthesia may also blunt the hypercapnic and hypoxic respiratory drive, as well as the arousal response. In a study performed by , the frequency of postoperative hypoxemia was measured in sleep apnea patients in the postoperative period, and 16% of the patients studied had postoperative sleep-related episodes of oxygen desaturation.

To avoid hypoxemia in obstructive sleep apnea patients, it is necessary to encourage patients to bring in their home continuous positive airway pressure (CPAP) machines or to order home CPAP settings for hospital machines. Careful evaluation of the patient is essential to prevent postoperative complications. If a patient is suspected to have sleep apnea but has not been diagnosed, it is useful to place the patient under continuous pulse oxygen saturation monitoring for the first 24 hours after surgery ( ).

Atelectasis and hypoxemia are common after surgery, especially surgeries that involve the abdomen or thorax. Early on, atelectasis may result from soft tissue edema from the upper pharynx because of intubation and tongue manipulation. Later, especially in patients who have undergone abdominal surgery, there is decreased ability to take deep breaths or cough because of postoperative pain. Postoperative patients have decreased functional residual capacity ( ). These factors lead to hypoventilation. Diagnosis of atelectasis may be made clinically and/or via imaging tests. Atelectasis may present as postoperative fever or decreased breath sounds at the lung bases and can be found on chest x-ray or computed tomography (CT).

Pre- and postoperative incentive spirometry is the most common prevention and treatment intervention for atelectasis. Incentive spirometry used in the perioperative period enhances postoperative functional residual capacity and reminds patients to continue to take in large breaths. If a patient becomes hypoxic from atelectasis, bronchoscopy may be performed to remove secretions from the airway ( ). CPAP can be used in the postoperative period, and has also been shown to decrease the need for intubation in patients at high risk of hypoxemia from atelectasis after abdominal surgery ( ).

Postoperative pneumonia is a common postoperative pulmonary complication. Hospital-acquired pneumonia refers to pneumonia that develops after 48 hours in the hospital. Diagnosing postoperative pneumonia can be difficult, as infiltrates from atelectasis, pulmonary edema, and acute lung injury can all look identical to pneumonia on chest x-ray. Diagnosis should be suspected if patient has new-onset fever, purulent sputum, leukocytosis, hypoxemia, and an infiltrate on chest x-ray. In a prospective case series of patients presenting with postoperative pneumonia within 14 days of surgery, 61% of patients developed pneumonia within the first 5 days postoperatively. The most common etiologic agents were Staphylococcus aureus , Streptococci , and Enterobacter ( ).

Treatment of postoperative pneumonia should begin with broad-spectrum antibiotics, given the polymicrobial nature of hospital-acquired pneumonia. Recommendations by the American Thoracic Society and the Infectious Disease Society of America ( ) include coverage for aerobic bacteria, as well as anaerobic bacteria. Most hospitals have guidelines for treating hospital-acquired pneumonia based on regional microbial patterns and antibiotic sensitivities.

Venous thromboembolism

Deep venous thrombosis (DVT) and pulmonary embolism (PE), jointly referred to as venous thromboembolism (VTE), are among the leading causes of preventable perioperative morbidity and mortality. In the perioperative period, the risk of death after VTE is approximately 3% to 4% ( ). The combination of epithelial damage, venous stasis, and hypercoagulability, collectively referred to as Virchow’s triad, increases the risk of VTE for any patient undergoing surgery. Many pelvic reconstructive surgeries require the dorsal lithotomy and steep Trendelenburg positions; both exacerbate the risk of venous stasis. The postoperative risk of VTE may be elevated up to 1 year after the initial procedure has been performed but is highest in the immediate perioperative period ( ).

The risk of VTE has been well studied in the general surgery, urology, and gynecologic oncology population. Recently there have been large studies that have addressed this issue in the population of patients who undergo pelvic reconstructive surgery. In a large cohort study by , the risk of VTE in this patient population that used intermittent pneumatic compression devices as the main form of postoperative thromboprophylaxis was 0.25%. Similarly, in an NSQIP registry study, the incidence of VTE was 0.3% among 20,687 women who underwent reconstructive pelvic surgery ( ). Overall, it seems that the risk is below 0.5% in the population undergoing these procedures.

A number of risk factors for VTE have been suggested for women in general and for those undergoing pelvic surgery. In a retrospective review of 1232 patients who underwent surgery for gynecologic conditions in Japan, it was found that malignancy, history of VTE, age greater than 50 years, and allergic-immunologic disease were all risk factors for VTE ( ). However, this study only found three episodes of VTE in patients with benign disease, making it underpowered for this patient group. In a large prospective study by that included 40,000 women, moderate drinkers of alcohol, women who engaged in strenuous exercise most days, and nonsmokers had the lowest risk of VTE.

In a retrospective review of 1862 gynecologic surgery patients given VTE prophylaxis with intermittent compression devices alone, the incidence of VTE was 1.3%. The risk factors associated with VTE in this study were diagnosis of cancer, age over 60 years, and anesthesia time over 3 hours. Patients with two or three of these variables had a 3.2% incidence of developing VTE, versus 0.6% in patients with zero or one risk factor ( ). A large systematic review by concluded that intermittent pneumatic compression devices provide sufficient prophylaxis for most patients undergoing pelvic reconstructive surgery. The authors determined that additional chemoprophylaxis should be added to the use of intermittent compression devices in patients with at least two out of three risk factors assessed: age over 60 years, history of cancer, or history of past VTE.

The question of which thromboprophylactic modality is best in the perioperative period for women undergoing pelvic reconstructive surgery is still uncertain. As mentioned previously, in the study by the rate of VTE among patients who underwent pelvic reconstructive surgery was 0.25% where the only thromboprophylaxis used was sequential compression devices placed during the perioperative period. ACOG follows the recommendations provided by the American College of Chest Physicians from the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy, published in 2004. The American College of Chest Physicians has since updated its recommendations for prophylaxis in all surgical patients ( Table 26.2 ). Furthermore, they recommend chemothromboprophylaxis in patients who are at moderate and high risk. Most female pelvic reconstructive surgery patients fall into the “high” risk category, suggesting they should receive chemothromboprophylaxis ( ). However, as the rate of VTE appears to be below 0.5% in the urogynecologic population, it could be argued that our patients fall into the very low risk category, where no specific recommendations for prophylaxis are made.

It is essential to be able to recognize the symptoms of VTE in the postoperative patient. Although many patients who have VTE may be asymptomatic, the symptoms of dyspnea, orthopnea, hemoptysis, calf pain, calf swelling, chest pain, and tachypnea may signify a thrombotic event ( ). The physical signs that suggest VTE include hypotension, tachycardia, crackles, decreased breath sounds, lower extremity edema, tenderness in lower extremities, and hypoxia ( ). Although the signs and symptoms of VTE are well known, it is difficult to rule out VTE by clinical diagnosis alone. A systematic review evaluating the d -dimer test used in combination with clinical probability to rule out VTE found that the d -dimer test is a safe and relatively reliable first-line test to use. After a 3-month follow-up, only 0.46% of patients were later diagnosed with PE ( ). However, the d -dimer test is not useful in pregnant patients, elderly patients, and hospitalized patients owing to decreased specificity ( ).

Compression ultrasonography is a noninvasive, easy, and cost-effective procedure for the diagnosis of DVT in the lower extremities. The sensitivity and specificity for detecting DVT using compression ultrasonography in symptomatic patients is 89% to 96%, although the sensitivity is decreased in patients with calf DVT or in asymptomatic patients ( ). Compression ultrasonography may also be used in conjunction with other diagnostic tests if PE is suspected ( ). If compression ultrasound is negative but the patient remains symptomatic, venography may be used to further rule out DVT.

Indicated imaging for patients presenting with signs and symptoms of PE include ventilation perfusion (V/Q) scanning, CT, pulmonary angiography, and spiral CT of the chest. The V/Q scan was the imaging modality of choice for decades; however, owing to lack of ease of use and potential for indeterminate testing, CT has become the modality of choice ( ). CT angiography has a specificity of 96%, as well as 83% sensitivity, and has become the gold standard for PE diagnosis ( ).

It is important to start anticoagulation immediately once VTE has been diagnosed; furthermore, if there is high suspicion for PE, anticoagulation may be started even before the diagnosis is confirmed. Acute PE should be treated initially with a rapid-onset anticoagulant, which may be followed by treatment with an oral anticoagulant for at least 3 months ( ). For rapid-onset anticoagulation, patients may be started on intravenous unfractionated heparin, subcutaneous unfractionated heparin, subcutaneous low-molecular-weight heparin, and subcutaneous fondaparinux. The American College of Chest Physicians recommends using subcutaneous low molecular weight heparin for the initial treatment of acute, nonmassive PE. If the patient has decreased kidney function, is morbidly obese, or is pregnant, intravenous unfractionated heparin may be used, because of its shorter duration and titratability ( ). Once anticoagulation therapy has been established, the patient may continue on subcutaneous therapy or can be bridged to warfarin or other oral anticoagulant for at least 3 months. If the patient has contraindications to anticoagulation therapy, an inferior vena cava filter can be considered.

Delirium

Delirium is an acute confusional state characterized by an alteration of consciousness with reduced ability to focus, sustain, or shift attention. Postoperative delirium is a common complication in elderly patients and can be life-threatening. Five percent of low-risk older adults having minor surgical procedures, and up to 50% of high-risk older adults having high-risk operations develop postoperative delirium. The sequelae include cognitive impairment, lack of functionality, and prolonged hospitalization with other associated morbidity. Symptoms of delirium can include hyperactive (e.g., agitation, heightened arousal, aggression) or hypoactive (e.g., withdrawn, decreased motor activity) behavior.

Delirium has been shown to be preventable in up to 40% of cases. Thus, prevention is the main management intervention, and commences by identifying high-risk patients who are aged 65 years or older, with past or present cognitive impairment, with current hip fracture, and with severe illness. Other risk factors include depression, alcohol or substance abuse, sleep deprivation, hypoxia, anemia, poor functional status, and polypharmacy, but preexisting cognitive impairment and dementia are the strongest predisposing factors. For any patient without known cognitive impairment, obtaining a detailed history and performing a cognitive assessment, such as the Mini-Cog, is strongly recommended. found the following rates of cognitive impairment using the Mini-Cog in elderly urogynecology patients: 65 to 74 years, 5.3%; 75 to 85 years, 13.7%; and 85 years and older, 30%. Interviewing family members or other close contacts about the evolution of any cognitive or functional decline can be very helpful. Nonpharmacologic interventions to prevent postoperative delirium may include the following elements: cognitive reorientation, sleep enhancement (i.e., nonpharmacologic sleep protocol and sleep hygiene), early mobility and/or physical rehabilitation, adaptations for visual and hearing impairment, nutrition and fluid repletion, pain management, appropriate medication usage, adequate oxygenation, and prevention of constipation. Postoperative pain control should be optimized, preferably with nonopioid medications. Medications known to be associated with delirium, such as anticholinergic medications (particularly oxybutynin), benzodiazepines, diphenhydramine, sedative-hypnotics, and meperidine, should be avoided in at-risk patients.

Treatment of delirium should consist primarily of multidisciplinary nonpharmacologic interventions as described above for prevention. Supportive and restorative care to prevent further physical and cognitive decline should be implemented. Additionally, any underlying acute illness that may be contributing should be identified and treated. A focused history and physical should be performed, and medications reviewed. Basic laboratory studies that should be considered include blood count, metabolic panel, serum glucose, and urinalysis, as well as pulse oximetry and electrocardiogram. Focal neurologic findings should prompt a CT of the brain, and findings suggesting infection should prompt relevant intraabdominal or pelvic imaging. Alcohol or drug withdrawal should also be considered. Supportive care can include reorientation, mobilization, avoidance of restraints, reassurance, noise reduction, hydration, pain control, and bedside sitters. Where appropriate, low-dose, short-acting pharmacologic agents can be used to control dangerous and severely disruptive behaviors. Antipsychotic medications, such as low-dose haloperidol 0.5 to 1 mg as needed (maximum dose of 5 mg per day), can be used to treat moderate to severe hyperactive delirium that does not respond to behavioral and nonpharmacologic interventions. Benzodiazepines should not be used as first-line treatment for agitation associated with delirium. Importantly, antipsychotics and benzodiazepines should be avoided in the treatment of hypoactive delirium.

Fever and perioperative infections

The most common postoperative complication of pelvic surgery is febrile morbidity, which occurs in 10% to 20% of women. Fevers after pelvic surgery can occur for the following reasons: (1) an operative site infection such as vaginal cuff cellulitis, pelvic abscess, or abdominal wound infection; (2) an infection remote from the operative site such as pneumonia or pyelonephritis; or (3) unexplained fever that resolves without consequence (up to 50% of cases). Recent evidence suggests that most unexplained postoperative fevers are not because of pulmonary atelectasis, but are the result of an increase in interleukins and cytokines. Regardless of the cause, a postoperative fever after pelvic surgery increases the hospital stay an average of 1 to 2 days. Fevers that persist and are associated with clinical signs, symptoms, and laboratory findings suggestive of a surgical site or other infection require appropriate treatment with antibiotics.