Pelvic Hematoma Research Articles

Predictors of Positive Angiography in Pelvic Fractures: A Prospective Study

Severe pelvic fractures continue to be a major problem for trauma surgeons. Early identification of patients who would benefit from therapeutic angiographic embolization (AE) of pelvic bleeding would be beneficial. We hope to identify simple risk factors that would pinpoint patients who would benefit from therapeutic AE. This is a prospective observational study at an academic Level I trauma center. All blunt trauma patients with a pelvic fracture admitted from December 2003 to February 2007 were included. AE was performed for hemodynamic instability (systolic blood pressure < 100 mmHg), fracture pattern (sacroiliac joint [SIJ] disruption, butterfly, open book), or CT demonstrating a large pelvic hematoma. AE was considered therapeutic if contrast extravasation was noted and addressed with embolization. Main outcomes measures were positive angiography and mortality. Stepwise logistic regression was performed to identify predictors of therapeutic AE. A predictive model was built based on these independent risk factors to estimate the probability of a therapeutic AE. One hundred thirty-seven (23%) of 603 patients with pelvic fractures had angiography. Therapeutic AE was performed in 85 patients (62%). Indications for angiography included hemodynamic instability (58%), fracture pattern (26%), and CT findings (9%). Nineteen patients (22%) with therapeutic AE had no hypotension or tachycardia. Independent predictors for therapeutic AE were SIJ disruption (odds ratio [OR]: 4.5; 95% CI, 1.6 to 12.6; p = 0.005), female gender (OR: 3.9; 95% CI, 1.5 to 10.0; p = 0.005), and duration (in minutes) of systolic blood pressure < 100 mmHg (OR: 1.4; 95% CI, 1.1 to 1.9; p = 0.007). Presence of SIJ disruption, female gender, and duration of hypotension can reliably predict patients who would benefit from AE. This predictive model can help early identification of patients who would benefit from pelvic angiography.

Cross-sectional imaging of the pelvic tumors and tumor-like lesions in gynecologic patients—misinterpretation points and differential diagnosis

Computed tomography and/or magnetic resonance imaging were performed in 42 female patients with suspected pelvic mass. Surgical and histopathological reports were compared to the imaging findings, yielding mismatch in five (17.8%) patients. One benign cyst and one case of postirradiation fibrosis were characterized as recurrent tumors, one surgically transposed ovary as metastasis, and an ovarian torsion as ovarian tumor, and a pelvic hematoma was mistaken for abscess. The most common false-positive finding on a per-lesion basis was that of enlarged lymph nodes.

Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization

Extraperitoneal bleeding from the inferior epigastric artery (IEA) and its branches is a rare complication of blunt pelvic trauma; however, it can result in life-threatening hemorrhage, even in cases of minimally displaced fractures of the pelvic ring. We report the case of a patient who had posttraumatic pelvic hematoma and cardiovascular collapse caused by avulsion of the right pubic branch of the IEA related to undisplaced fractures of the pubic rami. CT scanning followed by angiography showed leakage of contrast from the IEA. Transcatheter arterial embolization was performed to successfully control the hemorrhage. There have been very few previous reports of IEA injury related to stable fractures of the pubic rami successfully treated by transcatheter arterial embolization.

Embolization as first‐line treatment in the management of puerperal hematoma in a case of congenital urogenital anomaly

This case report highlights the need for detailed consideration of a patient's entire medical history before complex surgical management. This is a complex case of congenital urogenital anomaly that had obstetric complications. Our patient had a pelvic hematoma following a home birth, which was treated with pelvic artery embolization. We are fortunate to have local expertise in pelvic artery embolization and demonstrate excellent multidisciplinary management of a complex case.

Laparoscopic robotic-assisted gastrointestinal surgery: the Geneva experience.

The continuing development of robotic surgery supports its use in laparoscopic gastrointestinal surgery. Our study retrospectively reviewed the surgical outcome and patient’s satisfaction of gastrointestinal laparoscopic robotic procedures. From January 2003 to September 2007, 94 patients (27 women, 67 men) with a mean age of 53 years (range 19–84 years) underwent laparoscopic surgery with a da Vinci robotic system. There were 40 colorectal cases (43%), 31 anti-reflux surgery cases (33%) and 14 obesity surgery cases (15%); the remaining cases consisted of gastric and gallbladder surgery, intra-abdominal tumour excisions, and hepatic cyst resections. The majority of the cases (88, 94%) were performed for benign disease. The mean operative time was 153 min (range 60–330 min). One patient needed a blood transfusion. The mean body mass index was 25 (range 16–47). No death occurred. Five cases (5.3%) were converted to conventional laparoscopic surgery (n = 3) or to laparotomy (n = 2). Morbidity consisted of one Nissen redo surgery to loosen a tight anti-reflux valve 6 days after robotic surgery, a robotic left ureter repair and pelvic haemorrhage following proctectomy requiring re-operation to control haemostasis and to remove pelvic haematoma. Mean follow-up time was 11 months (range 15 days to 34 months). One case of incisional trocar hernia needed re-operation. Overall patient’s satisfaction was high: few scars were cheloïd, while functional surgical outcome was rated high by most of the patients. Our preliminary experience was encouraging, with minimal morbidity and very high acceptance by patients.

Tratamiento de complicaciones post-cirugías antiincontinencia con “sling”

Reports on postoperative complications of anti-incontinence surgery followed the widespread use of synthetic slings. In this paper we describe the more frequent complications, such as obstruction, pelvic hematoma, bladder and urethral injuries, to facilitate the management of these complications

Editorial Comment on: Complication Rates of Tension-Free Midurethral Slings in the Treatment of Female Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Comparing Tension-Free Midurethral Tapes to Other Surgical Procedures and Different Devices

Objectives: To evaluate the complication rates of tension-free midurethral slings compared with other surgical treatments for stress urinary incontinence, including other tension-free midurethral slings. Methods: A systematic review of the literature using MEDLINE, EMBASE, and Web of Science was performed in January 2007. Meta-analysis was conducted by using the Review Manager software 4.2. Results: Our search identified 33 randomized controlled trials reporting data on complication rates. Our meta-analysis showed that complication rates were similar after tension-free vaginal tape (TVT) and Burch colposuspension, with the exclusion of bladder perforation, which was more common after TVT (p = 0.0001), and reoperation rate, which was significantly higher after Burch colposuspension (p = 0.02). TVT and pubovaginal sling were followed by similar complication rates. With regards to the comparisons among retropubic tapes, TVT and intravaginal slingplasty had similar complication rates, whereas suprapubic arc sling (SPARC) was complicated by higher rates of voiding lower urinary tract symptoms (LUTS) (p = 0.02) and reoperations (p = 0.04). Comparing retropubic and transobturator tapes, the occurrence of bladder perforations (p = 0.007), pelvic haematoma (p = 0.03), and storage LUTS (p = 0.01) was significantly less common in patients treated by transobturator tapes. Conclusions: Tension-free slings were followed by lower risk of reoperation compared with Burch colposuspension, whereas pubovaginal sling and tension-free midurethral slings had similar complication rates. With regards to different tension-free tapes, voiding LUTS and reoperations were more common after SPARC, whereas bladder perforations, pelvic haematoma, and storage LUTS were less common after transobturator tapes. The quality of many evaluated studies was limited.

Correction prothétique des prolapsus génito-urinaires selon la technique du hamac transobturateur infracoccygien: résultats à moyen terme

The aim of this study was to evaluate the anatomical and functional medium-term efficacy and possible complications of vaginal prosthetic surgery with transobturator and infracoccygeal support to treat genital urinary prolapse. A prospective and monocentre study was conducted, from February 2002 till February 2005. All the patients with or without stress urinary incontinence (SUI), who presented either a recurrent prolapse, either a voluminous genital prolapse of stage 3 or 4 notably a dominant cystocele, either a post-hysterectomy vaginal vault prolapse or even a prolapse of lesser importance but in a context of obesity, were operated according to the transobturator infracoccygeal sling technique. One hundred and three patients with a mean age of 65+/-11 years (41-84) were enrolled, with once on two SUI. Thirty percent of the patients had recurrent prolapse and 44% post-hysterectomy vaginal vault prolapse. With a mean follow-up of 32+/-13 months (12-53), the success rate of the technique was estimated to be 97% anatomically (three failures) and 89% in terms of urinary symptoms (69% of patients were cured, 20% were improved and 11% failed). Quality of life of the patients was sharply improved and their degree of satisfaction was high. Sexuality of the population which was limited here (44% of active patients) did not seem very modified by surgery. Complications were represented by a case of urinary retention observed with a secondarily pelvic haematoma, a low rectal injury without consequence, three blood transfusions. Three patients developed de novo overactive bladder. The prostheses exposure rate was 16%, once requiring on two one re-intervention. Prostheses were perceived during the postoperative evaluation by the examiner for 43% of the patients. But examination was painful only in 9,7% of the cases. Combined treatment of vaginal prolapse and associated urinary incontinence is possible by the use of a single transvaginal prosthesis. The medium-term anatomical and functional results are very good. The results on continence are good and a subsequent specific procedure is always possible in the case of failure or insufficient improvement. The prostheses exposure rate is similar to that observed with synthetic transvaginal prostheses. The exact tolerance of vaginal prosthetic repair of the prolapse of young women being this day an unknown, we remain careful on the extension of the indications of this technique in this category of population.

Rokitansky Syndrome: Clinical Experience and Results of Sigmoid Vaginoplasty in 23 Young Girls

The Mayer-Rokitansky-Kuster-Hauser syndrome (Rokitansky syndrome) is a frequently misdiagnosed congenital anomaly of the female genital tract. Of several surgical treatments sigmoid vaginoplasty is among the few that provide a functional self-lubricating neovagina. We evaluated the results of sigmoid neovagina in girls affected by the Rokitansky syndrome. We followed 26 patients with the Rokitansky syndrome between 1990 and 2005. Diagnosis was based on clinical examination, normal ovarian hormones and pelvic ultrasound or magnetic resonance imaging. Associated anomalies were detailed. Vaginoplasty was performed in 23 patients. Functional results and complications were assessed. Renal anomalies were found in 11 patients (42%) and skeletal anomalies in 6 (23%). Six girls (23%) had a family history of the Rokitansky syndrome and/or renal agenesis. Vaginoplasty was performed at a mean age of 16 years (range 10.3 to 18.8). Median postoperative followup was 3.4 years. Postoperative complications included lower extremity compartment syndrome (1 patient), pelvic hematoma (1), mucosal prolapse (2), cystitis (2) and introital stenosis (1). Of the 23 patients undergoing surgery 9 (39%) had an active sex life postoperatively. Sigmoid vaginoplasty is a valuable procedure in girls with the Rokitansky syndrome. We recommend reconstruction during adolescence because the local conditions are excellent and it allows adaptation of the anatomy to physical development.

FAST Is Less Accurate in the Presence of Major Pelvic Fracture

Anatomic distortion caused by pelvic fracture displacement and hematoma formation may lessen the accuracy of hemoperitoneum detection by four-quadrant

Occurrence of Postoperative Hematomas After Prolapse Repair Using a Mesh Augmentation System

Mesh-augmented repair kits are increasingly being used for anterior compartment defect repair and can be associated with complications. Two cases are presented of postoperative pelvic hematomas confirmed on computerized tomography scan after anterior repair with a mesh-augmented anterior vaginal prolapse repair system. Both resolved without requiring drainage, although one patient did require a blood transfusion, and the other required intravenous antibiotics to treat an infected hematoma. Significant complications may arise from this new technology. Further studies are needed to determine whether the benefits of this technology outweigh its risk of use.

Efficacy Analysis of Trans-obturator Tension-free Vaginal Tape (TVT-O) Plus Modified Ingelman-Sundberg Procedure versus TVT-O Alone in the Treatment of Mixed Urinary Incontinence: A Randomized Study

ObjectiveThe treatment of women with mixed urinary incontinence still poses a great challenge. This study evaluated surgical outcomes of combined trans-obturator tension-free vaginal tape (TVT-O) and modified Ingelman-Sundberg (IS) procedure for the treatment of mixed urinary incontinence. MethodsA randomized controlled trial was conducted. Ninety-six women diagnosed with mixed incontinence were randomized, with 49 allocated to TVT-O plus IS and 47 to TVT-O alone. A baseline urodynamic study and evaluation of quality of life (QOL) was conducted. The primary outcome measure was objective assessment of surgical outcomes, and the secondary outcome measure was warning time. ResultsObjective surgical response rate was significantly higher in the TVT-O plus IS group than in the TVT-O alone group (84.8% vs. 62.8%; p=0.019). Furthermore, a significant increase in warning time was observed in the TVT-O plus IS group (from 3.9 to 9.4min; p=0.006), but the increase in warning time within the TVT-O alone group was not statistically significant (from 4.3 to 4.5min; p=0.695). Postoperative complications were similar in the two study groups with respect to pelvic hematoma, nerve injury, sepsis, mesh erosion, and fistula formation. However, fever occurred more frequently in the TVT-O plus IS group (30.4% vs. 20.9%; p=0.026). ConclusionsMixed urinary incontinence can potentially be treated with a one-step combined surgery using trans-obturator sling plus modified IS procedure. Although surgical time and blood loss were significantly increased in the TVT-O plus IS group, overall morbidity was not significantly increased.

Sonographically Diagnosed Vault Hematomas Following Vaginal Hysterectomy and Its Correlation with Postoperative Morbidity

Objective. Our aim is to investigate sonographically detectable vault hematomas after vaginal hysterectomy and its relation to postoperative morbidity. Methods. We studied a group of 103 women who had undergone vaginal hysterectomy for benign causes apart from uterovaginal prolapse. Transabdominal ultrasound examinations were carried out 24 to 72 hours after surgery to assess the presence of vault hematomas. Ultrasound findings were correlated with clinical data and postoperative morbidity. Results. The incidence of vault hematoma was found 19.4% in present study. In these patients, 40% (8/20) had fever while only 2.4% (2/83) of cases without vault hematoma suffered from fever. Out of all women having vault hematoma, 70% (14/20) had small-sized hematoma and 30% (6/20) had large-sized hematoma. Fifty percent of patients (3/6) with large-sized hematoma, as compared to only 35% (5/14) with small-sized hematoma, suffered from febrile morbidity. Large-sized hematomas drained by vaginally, while all small-sized pelvic hematomas managed by watchful expectancy successfully. The significant difference was found mean hemoglobin drop and postoperative stay in the hematoma group or without hematoma group. Conclusion. Sonographic detection of vaginal vault fluid collection is common after hysterectomy, but such a finding rarely indicates additional treatment. Though febrile morbidity was more in cases with vault hematoma, the number of such patients was too small to be significant. Vaginal ultrasound examination should not be performed routinely after hysterectomy.

Vaginal birth after cesarean delivery in twin gestations: A large, nationwide sample of deliveries

The purpose of this study was to assess the maternal morbidity associated with attempted vaginal birth after cesarean (VBAC) in twin gestations using a large, nationwide sample of deliveries. Data for this study were obtained from an administrative dataset, the Nationwide Inpatient Sample, a representative sample of discharges from non-Federal hospitals, for the years 1993 to 2002. Patients admitted nonemergently for the delivery of twin gestations who had a history of previous cesarean delivery were selected. Patients that either delivered vaginally or who had discharge codes that indicated labor before cesarean delivery were defined as the trial of labor group, while patients who had a cesarean delivery without discharge codes that indicated labor were defined as the elective cesarean group. Various complications of delivery were analyzed for each group. We identified 4705 women who underwent an elective cesarean delivery and 1850 women who underwent a trial of labor. For women who had a trial of labor, 836 (45.2%) delivered vaginally. The rate of uterine rupture was higher in the trial of labor group than in the elective cesarean group (0.9% vs 0.1%, P < .001), and the rate of wound complications was lower (0.6% vs 1.3%, P < .02). The rates of other complications including hysterectomy, transfusion, major postpartum infection, thromboembolism, uterine dehiscence, and pelvic hematoma were not significantly different between the 2 groups. Our study showed a significantly higher rate of uterine rupture in the trial of labor group that is similar to the rates reported for trial of labor after cesarean in singleton pregnancies.

Diagnostic peritoneal aspiration — the foster child of DPL: A prospective observational study

Background The abdomen is routinely considered as a possible source of bleeding in hypotensive and unevaluable blunt multitrauma patients. These patients are often unstable to be transported for abdominal computed tomography (CT). Emerging data on Focused Assessment with Sonography for Trauma (FAST) exam questions its initially reported high accuracy. We hypothesized that Diagnostic Peritoneal Aspiration (DPA), without a full lavage, accurately detects intraperitoneal blood if present in sufficient volume to cause hypotension and warrant emergent operation. Methods Over 24 months (July 2002–June 2004), 62 severe blunt trauma patients (Injury Severity Score: 32 ± 17) with admission systolic blood pressure equal to or less than 90 mmHg were enrolled prospectively. Percutaneous DPA was performed after FAST. Aspiration of any quantity of blood was considered a positive test. Sensitivity and specificity of DPA and FAST were calculated against findings from abdominal CT, laparotomy, or autopsy. Results Twenty-two patients (35%) required emergent laparotomy and 39 (63%) died. DPA was performed in less than 1 min with no complications. Sensitivity and specificity of DPA was 89% and 100%, respectively, whereas for FAST it was 50% and 95%. Two (3%) false negative DPA were recorded; one patient had a minor liver laceration with 250 ml of free blood and the other a leaking retroperitoneal pelvic hematoma in the presence of cirrhosis with 600 ml of bloody ascitic fluid. There were no false positive DPA. Nine (14.5%) false negative and two (3%) false positive FAST were recorded in patients who were found to have at laparotomy 1575 ± 1070 ml of hemoperitoneum on average. Conclusions Percutaneous DPA is accurate, rapid, safe, and superior to FAST for the diagnosis of abdominal blood as the source of hemodynamic instability, requiring emergent surgery, in blunt multitrauma patients.

Diagnostic et traitement des ruptures de l'urètre postérieur

Rupture of posterior urethra is usually seen in major traumas with associated pelvic fractures. Clinical presentation classically associates blood at the uretral meatus and urinary retention. Urinary diversion should be achieved by suprapubic puncture and major associated traumatic injuries (abdominal, orthopaedic, and neurological lesions) must be treated prior to urological management. Retrograde uretrocystography is performed a few days later in order to localize and classify the urethral lesion. Treatment of posterior urethral ruptures has evolved over the years. Immediate open repair is no longer recommended. The supra-pubic catheter can be left in place until Resorption of the pelvic hematoma. Obliteration occurs in 100% of the cases and is treated by open surgery at 3 months. More and more patients are treated by early endoscopic realignment which has diminished by half the incidence of urethral strictures. Impotence and incontinence secondary to trauma or surgery occur in 20% and 10% of the patients respectively. Long term follow-up should be achieved in every patient.

Perioperative Complications of Radical Cystectomy in a Contemporary Series

ObjectivesRadical cystectomy is the preferred standard treatment for patients with muscle-invasive bladder cancer. With improvements in intra- and perioperative care lower complication rates have been reported. We retrospectively evaluated our series of patients who underwent radical cystectomy for advanced bladder cancer for perioperative complications as well as operative time, postoperative hospital stay and transfusion rates. Patients and methodsBetween April 1993 and August 2005, 516 radical cystectomies were performed for muscle infiltrating transitional cell carcinoma and other types of neoplastic diseases of the bladder at our institution. The average age was 66.3 yr (31–89). ResultsThe perioperative mortality rate was 0.8%. A total of 141 patients (27.3%) developed at least one perioperative complication. The most frequent medical complications were subileus in 20 (3.9%) patients, deep venous thrombosis in 24 (4.7%), and enterocolitis in 10 (1.9%). Surgical complications included pelvic lymphoceles in 42 (8.1%) patients, wound dehiscence in 46 (8.9%), pelvic hematoma in 4 (0.8%), peritonitis in 4 (0.8%) and small bowel obstruction in 4 (0.8%). The total early reoperation rate was 6.2%. Operative time, postoperative hospital stay and average number of blood units transfused decreased over the period 1993–2005. ConclusionsRadical cystectomy today is a procedure with an acceptable rate of perioperative morbidity and mortality. Improvements in surgical technique and anaesthesia as well as increased quality of perioperative care in recent years have resulted in reduced morbidity and shorter hospital stay.

A Pelvic Drain Can Often Be Avoided After Radical Retropubic Prostatectomy—An Update in 552 Cases

ObjectivesThe routine placement of a pelvic drain following radical retropubic prostatectomy (RRP) may not be required. We describe our experience in 552 consecutive RRPs to emphasise the safety of this approach and explain our rationale for avoiding a drain when possible. MethodsRRP was performed in 552 consecutive patients with clinically localised adenocarcinoma of the prostate between January 2002 and June 2005. Clinical and pathologic information was documented for each patient. After the prostate was removed and the anastomotic sutures tied, the bladder was gently filled with approximately 50 ml of saline through the urethral catheter. If there was no leak, a drain was not placed. ResultsA drain was not placed in 419 (76%) of the 552 patients. We compared the postoperative complication rates in those with (D+) and without (D−) a drain. There were 27 (5%) immediate postoperative complications and no significant difference between the two groups (D+, 6%; D−, 5%; p=0.629): three (1%) patients who did not have a drain had a urinoma, one (1%) who had a drain had a lymphocele, and two (2%) who had a drain had a small pelvic haematoma. ConclusionsIf the bladder neck is preserved or meticulously reconstructed, there may be little extravasation and, thus, routine drainage is unnecessary. Our 4-year experience indicates that morbidity is not increased by omitting a drain from the pelvic cavity after RRP in properly selected cases.

Prostatectomía radical en pacientes con antecedentes de RTU próstata

To perform a retrospective evaluation of surgical complications and morbidity in patients undergoing radical retropubic prostatectomy (RRP) as elective treatment for organ-confined prostate cancer in our center with previous transurethral resection of the prostate (TURP). Between 1980-2004 we performed 59 radical prostatectomies in patients with previous TURP. We analyze the morbidity and mortality of the RRP, its functional outcomes, and the accordance between clinical and pathological stage. Mean time between TURP and RRP was 16 months. Mean patient age at the time of diagnosis was 63 years. Clinical stage: 16 T1a, 18T1b, 20T1c, 3T2a, 2T2b. Average surgical time was 180 minutes. Intraoperative events: technical difficulties in the dissection of the gland 57%, bladder neck preservation 27%, neuro vascular bundles preservation 3.39%, ureter ligation 1.69%, rectal laceration 1.69, urethrorrhagia 1.69%, urinary leak 5%, and blood transfusions 11.8%. Postoperative complications: urinary tract infection 10.17%, wound infection 10.17%, pelvic hematoma 5.08%, deep vein thrombosis 1.69%, and one sudden death of unknown cause one month after surgery. Pathologic report: 49pT2b, 8 pT3 and 2pT4. Late complications: erectile dysfunction 85.7%, vesicourethral anastomosis stenosis 10.3%, and complete urinary incontinence 3%. Radical retropubic prostatectomy in patients with previous TURP is technically more difficult and has comparable outcomes to RRP patients without previous TURP.

Cystocèle et incontinence urinaire d'effort : évaluation d'un traitement global par monoprothèse

The aim of this study is to evaluate the effectiveness and the potential complications in the short and medium terms of the transobturator and infracoccygeal hammock, a surgical technique suggested to treat in one sole operating time, by vaginal way, cystocele and stress urinary incontinence. From February 2002 till August 2004, 45 patients aged 66+/-11 years on average, presenting a stage 3 or stage 4 cystocele associated with stress urinary incontinence (proven for 40 of them and masked by the prolapse itself for the other five) benefited from this new surgical procedure. With a mean follow-up of 31+/-9 months, the success rate of the technique is estimated at 98% on the anatomical aspect (one single failure) and at 91% on the urinary aspect (73% of the patients were cured, 18% improved and 9% in failure). No patient presented urinary retention except one with an infected pelvic hematoma requiring its evacuation and the partial ablation of the prosthesis. Postvoid residual volume at discharge was 83 ml. Two patients developed de novo bladder overactivity. Unfortunately we had to regret nearly 18% of exposed prosthesis. This result should be improved by the exclusive use of polypropylene monofilament prosthesis with broad meshes, weak weights and by reduced vaginal scars. Total treatment by monoprosthesis of cystoceles with associated stress urinary incontinence constitutes an interesting prospect for some high-risk genital urinary prolapses for anatomical repetition or post-operative dysvoiding. Patients with recurrent failures of prolapse surgical cure, those with a large cystocele or by extension with a complete prolapse of the three floors, and even those with a post-hysterectomy prolapse have perhaps found a durable solution with their problem.