Complications from TVT Surgery

[DC1056]

I had TOT surgery for stress incontinence May 2007.  I experienced no stress incontinence for about a year.  At that point, I went back to the urogyn office and was told that the mesh had eroded into my vagina.  They did another surgery to remove the mesh.  Last week, I had TVT surgery to address the stress incontinence once again.  I woke up in the recovery room feeling HORRIBLE.  The doc didn't come by post-op; I was sent home with a substantial amount of vaginal packing and a catheter with a urine bag strapped to my leg.  I was in an enormous amount of pain that night and kept having "hot flash" like sensations.  The next morning I went back into the doc's office and she ordered an abdominal CT scan.  That showed a 8 inch wide x 3 inch high "blood clot" in my lower abdomen.  She also ordered a CBC and my hemoglobin was 10.  She said that the hematoma would resolve on it's own and that I should not take aspirin - only Tylenol.  I had another CBC 2 days later and my hemoglobin was 9.5.  She told me to take iron supplements.  My abdomen is extremely distended, there is slight cramping, and I am uncomfortable.  I am also VERY tired and need to nap alot and feel lightheaded.  Today when I sneezed, I noticed that urine did come out (this did not happen post-op when I had my first TOT surgery in 2007).   I have several questions:  Was this hematoma caused by cutting of a vein or artery during surgery?  Will it just "resolve" on it's own?  If so, how long would it normally take to resolve?  If my hemoglobin count keeps going down, at what point would I need a blood transfusion?  Can they drain the hematoma?  Could the mesh sling still be in place and be effective after the swelling/hematoma goes away?  Should I just tell her to remove the sling and deal with the stress incontinence as before?  Any other suggestions that you can give regarding treatment, recovery, and signs of problems to watch out for would be greatly appreciated.  Thanks VERY much.  DC

[David A Burks, MD]

Hi,  Unfortunately you have had several common complications of sling surgery.  One of the possible complications of the TOT is erosion of the synthetic mesh into the vagina.  Your doctor did the appropriate thing and removed the eroded mesh. Sometines the patient stays dry, other times the stress incontinence recurs and the patient needs another sling.  A possible complication of the TVT approach is injury to blood vessels in the pelvis around the bladder and pelvic floor muscles and tissues. The risk occurs when passing needles to place the sling and can happen to any patient. Bleeding can also occur during the dissection to put the sling around the urethra. A hematoma is a blood collection in the space around the bladder/urethra and is usually self limited and will stop spontaneously.   Rarely is another operation required.  Unfortunately you may have pelvic discomfort for a few weeks until the hematoma gets reabsorbed. If the pelvic pain is untolerable a CAT scan guided drain can be placed into the collection for drainage and relief of the pressure, but this has potential complications as well.  If you are symptomatic from the blood loss including dizziness and lightheadedness, and/or your blood count continues to drop, you may need a blood transfusion. Going back to the OR  now could be dangerous and cause more bleeding.  Unfortunately I agree that the best thing is to wait it out, assuming  the bleeding as stopped, and the hemoglobin is stable. Let the hematoma resolve and see what happens to the incontinence problem three months post op.  If your doctor is experienced doing slings then he/she knows how to handle this complication.    It's almost always best to avoid more surgery at this point. Report any fever, chills or worsening pain to your doctor immediately. Good Luck