FEMALE UROLOGY

A Magnetic Resonance Imaging-Based Study of Retropubic Haematoma after Sling Procedures: Preliminary Findings
Giri SK, Wallis F, Drumm J, Saunders JA, Flood HD
Department of Urology, University Hospital, Limerick, Ireland
BJU Int. 2005; 96: 1067-71

• Objective: To determine, using magnetic resonance imaging (MRI), the incidence of retropubic haematoma and any associated clinically significant effects after a xenograft (porcine dermis) sling (XS) or the tension-free vaginal tape (TVT) procedure.
• Patients and Methods: Between October 2003 and March 2004, 24 consecutive patients presenting with stress urinary incontinence (SUI) were enrolled in this prospective study; 12 each underwent an XS or TVT procedure. A vaginal balloon pack was used for only 3 h after XS and not after TVT. All patients had pelvic MRI 6-8 h after surgery. The primary outcome measure was the incidence and distribution of retropubic haematoma after each sling technique. Secondary outcome measures included the interval to the first three spontaneous voids, the bladder emptying efficiency of the first three voids, a visual analogue scale pain score at 24 h after surgery, and the short-term (6-month) cure rate for SUI.
• Results: Overall, six (25%) patients (four XS and two TVT) developed a retropubic haematoma. Most commonly, they spread along the right paravesico-urethral space between the right half of the levator ani and the bladder neck. Patients with large haematomas took significantly longer to void (median 14.5 vs 6.0 h, P = 0.048). There was no difference in pain score in patients with or with no haematoma. None of the patients had clinically detectable haematomas in the suprapubic wound. All six patients with haematomas were cured or improved at the 6-month follow-up.
• Conclusions: MRI is a useful noninvasive method for detecting retropubic haematomas soon after surgery. There was a surprisingly high incidence of retropubic haematomas, especially after the XS procedure. Retropubic haematomas may influence postoperative voiding efficiency.
  
  
• Editorial Comment
  The authors review 24 patients who underwent a suburethral sling using either xenograft or tension free vaginal tape. All patients had a pelvic MRI approximately 6-8 hours after surgery. The MRI was utilized to evaluate for the development of a retropubic hematoma. The radiographic findings were then correlated to the presence of voiding or voiding dysfunction and pain postoperatively. The authors found that 25% of the patients developed a retropubic hematoma with a degree of lateralization to the right. There was no difference in the pain perceived by patients with or without hematoma and those with large hematomas took a greater time to normal voiding. All patients with hematomas were either cured or improved at their last follow-up.
  This is an interesting report and raises many clinical questions. That only 25% of patients had a hematoma detected at 4-6 hours postoperatively may strike many patients as surprising. In addition, that there was some lateralization to the patient’s right does indicate that there may be the potentiality that hematomas are somewhat technically based more on the surgeon’s dominant hand than on the patient’s anatomy. Many surgeons historically have found that hematoma formation may not be such a bad thing with regards to operative success. Classically, the success of an MMK was based on the formation of a retropubic scarification fixing the bladder neck and proximal urethra in a retropubic procedure. In fact, Lee et al in a publication in 1979, upon performing a secondary repair found that those patients that were redo’s had inadequate scarification and the authors subsequently coined the “alleged MMK” (1). Of note is that both techniques had hematomas though the xenograft had four hematomas while the TVT had two. Thus indicating a potential technique related incidence of hematoma generation as opposed to patient’s anatomy. The patient’s had a vaginal pack for just 3 hours after surgery and none of the patients had a clinically detectable hematoma in the suprapubic wound. It will be of great interest to see in the future if the authors would consider repeating this study but having one group being operated upon by a right surgeon while the other having a left handed dominant surgeon perform the surgery to see if there is a lateralization of hematoma formation. In addition, repeating the study while having the vaginal pack placed overnight would also be of great interest. The continence rates at 2-3 years postoperatively may shed further light on earlier surgeon’s notations on the need for retropubic fibrosis for long-term success; will those patients with a large hematoma and potentially greater scarification retropubically be drier than those which did not.

Reference
1. Lee RA, Symmonds RE, Goldstein RA: Surgical complication and results of modified Marshall-Marchetti-Krantz procedure for urinary incontinence. Obstet & Gynecol. 1979; 53:447-450.

Dr. Steven P. Petrou
Associate Professor
Mayo Clinic College of Medicine
Jacksonville, Florida, USA