Symptomatic pelvic hematoma following hysterectomy: risk factors, bacterial pathogens and clinical outcome.

BACKGROUND: Pelvic hematoma is a common finding following hysterectomy which at times may become infected causing substantial morbidity. The aim of this study was to describe the incidence, clinical manifestation and identify risk factors for infected pelvic hematoma. We also attempted to identify specific bacterial pathogens which may cause this phenomenon. METHODS: We conducted a retrospective cohort study at a tertiary university teaching hospital. Included were all women who underwent hysterectomy and were diagnosed with a pelvic hematoma following surgery from 2013 to 2018. In an attempt to assess possible risk factors for infected pelvic hematoma women with asymptomatic pelvic hematoma were compared to women with an infected pelvic hematoma. RESULTS: During the study period 648 women underwent hysterectomy at our medical center. Pelvic hematoma was diagnosed by imaging in 50 women (7.7%) including 41 women who underwent vaginal hysterectomy and 9 women who underwent abdominal hysterectomy. In 14 (2.2%) cases the hematoma became infected resulting in need for readmission and further treatment. Women who underwent vaginal surgery were more likely to return with infected pelvic hematoma compared to women who underwent open abdominal or laparoscopic surgery (4.5% vs. 1.1%, p < 0.05). In 8 women bacterial growth from hematoma culture was noted. Enterococcus faecalis, was the most abundant pathogen to be isolated in this sub-group. CONCLUSION: Vaginal route of hysterectomy is a risk factor for infected pelvic hematoma following hysterectomy. Most of these infections were caused by anaerobic bacteria which may not be sufficiently covered by current antibiotic prophylactic regimens.

Vascular complication after sacrospinous ligament fixation with uterine preservation.

AIM OF THE VIDEO: Sacrospinous ligament fixation (SSLF) is a minimally invasive transvaginal procedure for correcting apical prolapse. Amongst perioperative complications, life-threatening hemorrhage has a reported occurrence rate ranging from 0.2 % to 2 %. We present a case of arterial hemorrhage following SSLF and a multispecialty approach to its successful management. METHODS: The video demonstrates the development of an unexpected progressive postoperative hematoma following left-side sacrospinous hysterocolpopexy via the anterior approach, despite minimal intraoperative bleeding. The mechanism of formation of the hematoma could have been laceration of an aberrant vaginal branch of the inferior vesical artery secondary to pulling the anchor which is tied off at the cervix after closure. To treat these patients effectively, it is essential for the surgeon to make a timely diagnosis, and in our patient, embolization of the inferior vesical artery provided a safe and effective treatment for the pelvic hemorrhage that eliminated the need for an invasive surgical intervention. CONCLUSION: Life-threatening bleeding is a rare complication of transvaginal SSLF. Pelvic vessel embolization can provide an effective, minimally invasive alternative to surgical re-exploration.

Management of arterial and venous hemorrhage during sacrospinous ligament fixation: cases and review of the literature.

INTRODUCTION AND HYPOTHESIS: Sacrospinous ligament fixation (SSLF) for pelvic organ prolapse repair can incur significant intraoperative hemorrhage. Management of vascular injury is challenging because of limited visualization of the surrounding pararectal space and is not well described in the literature. METHODS: We evaluate cases of intraoperative venous and arterial hemorrhage during SSLF. Based on a review of the literature, we present a systematic approach to the treatment of venous and arterial hemorrhage associated with SSLF. RESULTS: Vascular injury to the hypogastric and pudendal venous plexi may be controlled using directed compression and topical hemostatic agents. Vascular injury to the inferior gluteal artery, its coccygeal branch, or other arteries, may require embolization. CONCLUSION: Life-threatening bleeding is a rare complication of transvaginal SSLF. Knowledge of surrounding pelvic vascular anatomy, treatment options, and communication with ancillary staff is essential for the treatment of sacrospinous ligament hemorrhage.

Two cases of pelvic hematoma after prostatic urethral lift surgery.

Introduction: There are few reports of pelvic hematoma after prostatic urethral lift. Here, we report two cases of pelvic hematoma in Japan. Case presentation: The first case was a 71-year-old man with benign prostatic hyperplasia who underwent prostatic urethral lift. Although the procedure was uneventful, he experienced lower abdominal pain the day after the operation. CT revealed a hematoma in the right pelvis; however, it was manageable with conservative treatment. The second case was a 68-year-old man. The procedure was uneventful; however, 6 days after the operation, a subcutaneous hematoma appeared in the lower abdomen. CT revealed a hematoma in the left pelvis. We then performed pelvic hematoma removal surgery. Conclusions: Pelvic hematomas after PUL may requires attention, particularly in men with the narrow pelvises. Appropriate compression of the prostate and a high lithotomy position procedure could effectively avoid the occurrence of pelvic hematomas.

Pelvic hematoma: The same complication with different etiology after patent foramen ovale closure.

Well-known complication associated with patent foramen ovale (PFO) closure include infection, acute cardiac tamponade, and local complications such as adjacent arterial or nerve damage, hemorrhage, and thrombophlebitis. Pelvic hematoma is rare and potentially fatal complication. This paper reports two cases of severe hemorrhagic shock within1 day after PFO closure. Both female patients presented to our department with history of headaches and were diagnosed with PFO. Both patients underwent percutaneous PFO closure from the right femoral vein. One day after the procedure, both patients experienced pelvic hematoma and were successfully rescued by compression hemostasis and uterine artery embolization. Both patients recovered well during follow-up. Life-threatening pelvic hematoma associated with PFO closure has a certain incidence and should be considered. Peripheral vascular complications after PFO closure can be safely treated but should not be ignored. We believe that the prevention of vascular mechanical damage during surgery is important. The possibility of spontaneous uterine artery rupture should be considered for unexplained pelvic hematoma. Although it is a rare complication, severe bleeding after PFO closure remains unpredictable. Timely and correct diagnosis and appropriate treatment are required. If the timing is delayed, there could be serious consequences.

Angioembolization for massive pelvic hematoma after prostatic urethral lift.

Introduction: Pelvic hematomas are a rare complication of prostatic urethral lift. We would like to report the first case of massive pelvic hematoma after prostatic urethral lift that was successfully managed by selective angioembolization. Case presentation: An 83-year-old gentleman with benign prostatic hyperplasia underwent prostatic urethral lift. Although the procedure was uneventful, he developed shock while in the recovery room. Urgent contrast computed tomography scan showed a large heterogenous hematoma at the right pelvis extending to the right retroperitoneum with contrast extravasation noted. Urgent angiogram confirmed extravasation from the right prostatic artery. Angioembolization with coils and 33% N-butyl cyanoacrylate glue was successfully performed. Conclusion: Prostatic urethral lift can be complicated by the rare massive pelvic hematoma, possibly more common in small prostates. With a prompt contrast computed tomography scan, pelvic hematomas can be managed with angioembolization first and hopefully prevent open exploratory surgery.

Pelvic Hematoma After UroLift: A Case Report and Literature Review.

UroLift is a novel, minimally invasive surgical technique used to treat bladder outlet obstruction due to benign prostatic hyperplasia (BPH). UroLift was granted US FDA approval in 2013, and so far, it has gained acceptance and popularity worldwide. In this case report, we present a 69-year-old male patient that developed a pelvic hematoma with subacute clinical manifestations two months following UroLift. The patient was managed conservatively, resulting in the complete resolution of the hematoma. As more surgeons are trained, and the caseload increases, we expect to see more complications related to this novel technique. Surgeons should be aware of this procedure's potential short- and long-term complications.

Large Vaginal Hematoma in a Puerperium Patient: Treating a Delayed Diagnosis & Management Caused by an Incomplete Clinical Examination.

Here, we report a case where the lack of pelvic examination in a puerperium patient led to a delay in diagnosis and appropriate management of a large posterior vaginal wall hematoma for about a month. The patient had a history of difficult vaginal breech delivery of a macrosomic asphyxiated baby 28 days prior, following which, she started having gradually increasing distension of the abdomen, inability to void urine and pass stools by herself, and a history of fever on and off. Her family members took her to a private hospital for a consultation, where she was examined and assessed. However, a pelvic examination was not done. A CT scan of the abdomen and pelvis showed a large organized hematoma of size 13.6cm×11.1cm×10.5cm with a volume of 802 ml in the pouch of Douglas. Following this report, diagnostic laparoscopy was done on day 10 of puerperium where a large hematoma was seen beneath the peritoneum in the pouch of Douglas without any intraperitoneal collection. As the hematoma was not seen to be expanding, conservative management was done with 5 units of blood transfusion and antibiotic coverage, and the patient was discharged. However, the patient's symptoms were not relieved due to which she presented to us on day 28 of puerperium with the same symptoms. On pelvic examination, purulent, foul-smelling discharge was present in the vagina, and a huge tense bluish bulge was seen in the posterior vaginal wall more towards the right side obliterating the whole vagina. After taking informed consent and with proper pre-operative preparations of laparotomy, the hematoma was drained vaginally, and approximately 1300 ml of blood and clots were removed, following which, the patient had a speedy recovery and relief of her symptoms.

Catamenial Pneumothorax in a Patient with Endometriosis: A Case Report.

Pelvic pain is a common presentation to the emergency department (ED). For female patients, endometriosis can be difficult to diagnose and can have life-threatening complications if missed. In this case report, we present a case of a patient initially presenting to the ED with a few days of crampy lower abdominal pain. After initial imaging, she was found to have a large pelvic hematoma with concern for active extravasation and a large hemothorax. After further evaluation, she was suspected of having endometriosis leading to thoracic endometriosis and a catamenial pneumothorax. Although endometriosis is not typically an emergent diagnosis, the complications of significant endometrial tissue spread can cause life-threatening impacts. Clinicians should consider complications of endometriosis in females of menstruating age.

Pelvic Hematoma With Acute Hemorrhage Secondary to Inferior Vena Cava Filters.

Recurrent deep vein thrombosis (DVT) and inferior vena cava (IVC) thrombosis are well-known complications of inferior vena cava filters (IVCFs); however, pelvic hematoma is a rare finding. In this study, we present a case of a 41-year-old female who presented with severe abdominal pain. Extensive bilateral lower extremity DVT, thrombosis extending up to the level of IVCF, and a pelvic hematoma with acute hemorrhage were diagnosed. Mechanical thrombectomy of the IVC, bilateral iliac, and femoral veins with stent placement in the external iliac veins was performed under general anesthesia. This rarely reported case remains a challenge to diagnose and treat because of its complex mechanisms and multiple risk factors. Our case highlights the importance of the surgical strategy adopted and the need for a good initial assessment.

Endoscopic management of a spontaneous rectus sheath hematoma causing bladder perforation.

Rarely pelvic hemorrhage events can lead to bladder perforation. We present a 48-year-old female who developed a spontaneous rectal sheath hematoma which perforated her bladder. Her case was monitored with serial MRI imaging and managed with two endoscopic clot resections which demonstrated new epithelialization of the bladder wall across the hematoma point of entry. We conclude that the bladder has an impressive potential to heal and select cases of symptomatic invasive bladder hematomas may be monitored with serial imaging and managed endoscopically.

Infected pelvic hematoma following vaginal hysterectomy with uterosacral ligament suspension for treatment of apical prolapse.

OBJECTIVE: Vaginal hysterectomy with uterosacral ligament suspension (VUSLS) is a common procedure for apical prolapse repair. Data regarding pelvic hematoma following this procedure is scarce. The aim of this study was to describe the occurrence of infected and non-infected pelvic hematoma in women following VUSLS and to assess for specific risk factors for infection. METHODS: We performed a retrospective cohort study, including all women who underwent VUSLS for treatment of apical prolapse between 2010 and 2020. Patients with and without pelvic hematoma by ultrasound were compared. A subgroup analysis compared patients with infected vs non infected hematomas. RESULTS: During the study period, 316 women underwent VUSLS for treatment of apical prolapse. Sixty-six (20.9%) were diagnosed with a pelvic hematoma, and in seventeen (5.4%) women the hematoma became infected. The majority (76%) of pelvic hematomas were located above the vaginal cuff. Women in the hematoma group had increased rates of hypothyroidism and concomitant anterior colporrhaphy. However, following multivariate analysis, these differences were no longer significant. Subgroup analysis comparing women with infected versus non-infected pelvic hematoma was performed. No differences were noted with respect to surgical outcomes (clinical, anatomical, or composite). Women with infected hematoma had higher rates of posterior colporrhaphy during surgery (33.3% vs 9.5%, p = 0.039). This difference remained significant following multivariate analysis (aOR = 8.87, CI 1.1-73.0). CONCLUSION: Pelvic hematoma following VUSLS is common as opposed to infected pelvic hematoma which seldom occurs. Concomitant posterior colporrhaphy was associated with infection.

Rectus Sheath Hematoma Causing Bladder Outlet Obstruction.

A 93-year-old woman on Coumadin with history of atrial fibrillation and chronic obstructive pulmonary disease (COPD) presented with urinary retention for one day. Computed tomography (CT) of abdomen and pelvis demonstrated grade 3 rectus sheath hematoma (RSH), with the hematoma dissecting between the transversalis fascia and muscle into the prevesical space. The large-sized hematoma caused compression at the bladder outflow tract causing urinary retention. In view of age and the patient being a poor surgical candidate, the patient was managed by percutaneous drain of the hematoma to reduce size to relieve urinary symptoms. The hematoma shrunk in size over the period of next few weeks and thereby avoided surgical intervention.

Vaginal cuff closure technique and the risk for infected pelvic hematoma after vaginal hysterectomy.

OBJECTIVES: Infected pelvic hematoma is a relatively common complication of vaginal hysterectomy, manifesting with postoperative pain and fever which often necessitate surgical drainage. We aimed to assess the effect of the surgical technique for vaginal cuff closure on the incidence of this complication. STUDY DESIGN: Until March 31, 2010, our surgical protocol for vaginal hysterectomy included complete vaginal cuff closure. After this date, all surgeries were performed using another technique, by which a patent tract was left at the vaginal cuff for drainage of blood, secretions and debris. We reviewed medical records of all women who underwent vaginal hysterectomy for pelvic organ prolapse in our institution between January 2006 and November 2015, including demographic, clinical and surgical data. We compared the incidence of postoperative infected pelvic hematomas before and after March 31, 2010. RESULTS: We identified 325 women who underwent vaginal hysterectomy during the first time period (group I) and 243 women who underwent this procedure during the second time period (group II). While demographic and clinical data were not significantly different between the two groups, the incidence of infected pelvic hematomas necessitating hospitalization was significantly lower in group II (3.8% vs. 13.5%, p<0.0001). CONCLUSIONS: A significant reduction in the incidence of infected pelvic hematoma following vaginal hysterectomy was noted using a surgical technique that allows for drainage of blood and debris through the vaginal cuff.

Subepithelial pelvic hematoma of the kidney (Antopol-Goldman Lesion).

Renal pelvic hematoma (Antopol Goldman lesion) is a rare but significant condition that may clinically mimick a renal or a pelvic neoplasm. Differential diagnosis and optimal treatment are still not known certainly. A 80-year-old male patient admitted to the emergency department with gross hematuria/clot retention and right flank pain. Magnetic resonance imaging (MRI) imaging revealed a filling defect in the right renal pelvis. Diagnostic flexible uretrorenoscopy was performed and a renal pelvic tumor was excluded. A 6 Fr double J (DJ) ureteral catheter was placed for 4 weeks while the patient was under an antifibrinolytic therapy. Filling defect was not detected at 3(rd) month control MRI. During 6 months of the follow-up period, gross hematuria or any abnormal radiological finding was not encountered.