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Spondylodiscitis after sacrocolpopexy
European Journal of Obstetrics & Gynecology and Reproductive Biology 187 (2015) 72–77
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTERS TO THE EDITOR—BRIEF COMMUNICATIONS Spondylodiscitis after sacrocolpopexy Dear Editors, A 61-year-old patient (gravida 3, para 3) of postmenopausal status presented at our outpatient urogynecology clinic with bulging and dysuria. She did not have stress urinary incontinence, urgency, urge incontinence or nocturia. Comorbidities included breast cancer that had been treated with tumorectomy, radiotherapy, chemotherapy and tamoxifen 16 years earlier. Gynaecological examination showed a cystocele (Pelvic Organ Prolapse Quantification System Stage IV), uterine prolapse (Stage III), rectocele (Stage II) and occult urinary incontinence. The patient was scheduled for sacrocolpopexy with polypropylene mesh, and subtotal laparoscopic hysterectomy with salpingoophorectomy and a transobturator sling. The postoperative period was unremarkable. However, 12 days after surgery, the patient presented to the emergency department with lumbar pain [visual analogue scale (VAS) score 8–10/10), fever and dyspnoea. Laboratory examinations showed C-reactive protein (CRP) of 163 mg/l and a white blood cell count of 16.57 109/l. Computed tomography (CT) showed signs of pyelonephritis and no signs of abdominal collection or ureteral/renal dilation. A CT angiogram of the chest showed no pulmonary embolism. The patient commenced antibiotic therapy (ceftriaxone and amikacin) and oxygen therapy. After treatment, the patient continued to have fever and low back pain. A lumbar magnetic resonance imaging (MRI) scan, new abdominal CT scan and vaginal examination showed no abnormalities. Urine culture was negative; however, blood culture was positive for group B streptococcus. Endocarditis was ruled out by echocardiography. Radioleucoscintigraphy showed no sign of infection of the lumbar disc or the mesh; however, infection was noted in the lungs. The group-B-streptococcus infection was treated with amoxicillin and gentamycine. Gentamycine was stopped after 3 days as the patient was afebrile, and CRP decreased from 200 to 80 mg/l. Despite this improvement, lumbar pain persisted and a second MRI scan was performed 1 month later in an effort to diagnose the cause of the chronic pain. This examination was the first to find signs of spondylodiscitis. Antibiotics were changed to levofloxacin and amoxicillin. One day later, the patient underwent re-operation; a section of the promontory knot was removed, and the stitch and 2 cm of mesh next to the promontory underwent ablation. The patient experienced an immediate improvement in pain (VAS score 2–3/10). Mesh culture found a small colony of Staphylococcus aureus with rare leukocytes. The patient underwent antibiotic treatment and rehabilitation for 6 and 10 weeks, respectively. At an outpatient follow-up visit, the patient reported improvement in pain and a complete return to daily activities. A control MRI showed some lasting signs of spondylodiscitis. This case report highlights the fact that spondylodiscitis, despite being a rare cause of mesh complications after sacrocolpopexy, 0301-2115/ß 2015 Elsevier Ireland Ltd. All rights reserved.
usually presents with clear clinical signs including fever, lumbar back pain and (sometimes) vaginal discharge. The timeframe for symptomatic disease varies widely, and symptoms can present days to years after surgery. Factors associated with this timeframe are still unknown [1]. This patient presented with fever and lumbar back pain, as well as abnormal laboratory results. Despite an inconclusive MRI for spondylodiscitis, antibiotic treatment was commenced. To our knowledge, there have been 29 cases describing this complication [2,3], with a greater number of cases in recent years due to the popularization of prolapse mesh surgery. Propst et al. [2] recently published a literature review calling for a high index of suspicion of spondylodiscitis in patients who present with back pain after sacralcolpopexy. Surgeons do not need to wait for complementary diagnosis before starting treatment, as delayed treatment can worsen a patient’s prognosis. Treatment for spondylodiscitis should commence when a patient presents with clinical symptoms, such as malaise and low back pain after sacrocolpopexy. During surgical removal of the mesh, surgeons should begin by approaching areas that do not present adhesions in order to enter the fibrotic space; this will increase exposure when dissecting the mesh. Additionally, probes can be used to delineate the vesicovaginal and rectovaginal spaces in order to prevent bladder and bowel injury [4]. References [1] Nygaard IE, McCreery R, Brubaker L, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol 2004;104:805–23. [2] Propst K, Tunitsky-Bitton E, Schimpf MO, Ridgeway B. Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature. Int Urogynecol J 2014;25:21–31. [3] Anand M, Tanouye SL, Gebhart JB. Vesicosacrofistulization after robotically assisted laparoscopic sacrocolpopexy. Female Pelvic Med Reconstr Surg 2014;20:180–3. [4] Chamsy D, Lee T. Laparoscopic excision of sacrocolpopexy mesh. J Minim Invasive Gynecol 2014;21:986.
L.G. Brito* G. Giraudet J.-P. Lucot M. Cosson Service de Chirurgie Gyne´cologique, Hopital Jeanne de Flandre, Centre hospitalier Re´gional Universitaire de Lille, Lille, France *Corresponding author at: Service de Chirurgie Gyne´cologique, Hopital Jeanne de Flandre, Centre hospitalier Re´gional Universitaire de Lille, Lille 59000, France. Tel.: +33 652602709 E-mail address: [email protected] (L.G. Brito). 25 June 2014 http://dx.doi.org/10.1016/j.ejogrb.2015.02.024
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTERS TO THE EDITOR—BRIEF COMMUNICATIONS Spondylodiscitis after sacrocolpopexy Dear Editors, A 61-year-old patient (gravida 3, para 3) of postmenopausal status presented at our outpatient urogynecology clinic with bulging and dysuria. She did not have stress urinary incontinence, urgency, urge incontinence or nocturia. Comorbidities included breast cancer that had been treated with tumorectomy, radiotherapy, chemotherapy and tamoxifen 16 years earlier. Gynaecological examination showed a cystocele (Pelvic Organ Prolapse Quantification System Stage IV), uterine prolapse (Stage III), rectocele (Stage II) and occult urinary incontinence. The patient was scheduled for sacrocolpopexy with polypropylene mesh, and subtotal laparoscopic hysterectomy with salpingoophorectomy and a transobturator sling. The postoperative period was unremarkable. However, 12 days after surgery, the patient presented to the emergency department with lumbar pain [visual analogue scale (VAS) score 8–10/10), fever and dyspnoea. Laboratory examinations showed C-reactive protein (CRP) of 163 mg/l and a white blood cell count of 16.57 109/l. Computed tomography (CT) showed signs of pyelonephritis and no signs of abdominal collection or ureteral/renal dilation. A CT angiogram of the chest showed no pulmonary embolism. The patient commenced antibiotic therapy (ceftriaxone and amikacin) and oxygen therapy. After treatment, the patient continued to have fever and low back pain. A lumbar magnetic resonance imaging (MRI) scan, new abdominal CT scan and vaginal examination showed no abnormalities. Urine culture was negative; however, blood culture was positive for group B streptococcus. Endocarditis was ruled out by echocardiography. Radioleucoscintigraphy showed no sign of infection of the lumbar disc or the mesh; however, infection was noted in the lungs. The group-B-streptococcus infection was treated with amoxicillin and gentamycine. Gentamycine was stopped after 3 days as the patient was afebrile, and CRP decreased from 200 to 80 mg/l. Despite this improvement, lumbar pain persisted and a second MRI scan was performed 1 month later in an effort to diagnose the cause of the chronic pain. This examination was the first to find signs of spondylodiscitis. Antibiotics were changed to levofloxacin and amoxicillin. One day later, the patient underwent re-operation; a section of the promontory knot was removed, and the stitch and 2 cm of mesh next to the promontory underwent ablation. The patient experienced an immediate improvement in pain (VAS score 2–3/10). Mesh culture found a small colony of Staphylococcus aureus with rare leukocytes. The patient underwent antibiotic treatment and rehabilitation for 6 and 10 weeks, respectively. At an outpatient follow-up visit, the patient reported improvement in pain and a complete return to daily activities. A control MRI showed some lasting signs of spondylodiscitis. This case report highlights the fact that spondylodiscitis, despite being a rare cause of mesh complications after sacrocolpopexy, 0301-2115/ß 2015 Elsevier Ireland Ltd. All rights reserved.
usually presents with clear clinical signs including fever, lumbar back pain and (sometimes) vaginal discharge. The timeframe for symptomatic disease varies widely, and symptoms can present days to years after surgery. Factors associated with this timeframe are still unknown [1]. This patient presented with fever and lumbar back pain, as well as abnormal laboratory results. Despite an inconclusive MRI for spondylodiscitis, antibiotic treatment was commenced. To our knowledge, there have been 29 cases describing this complication [2,3], with a greater number of cases in recent years due to the popularization of prolapse mesh surgery. Propst et al. [2] recently published a literature review calling for a high index of suspicion of spondylodiscitis in patients who present with back pain after sacralcolpopexy. Surgeons do not need to wait for complementary diagnosis before starting treatment, as delayed treatment can worsen a patient’s prognosis. Treatment for spondylodiscitis should commence when a patient presents with clinical symptoms, such as malaise and low back pain after sacrocolpopexy. During surgical removal of the mesh, surgeons should begin by approaching areas that do not present adhesions in order to enter the fibrotic space; this will increase exposure when dissecting the mesh. Additionally, probes can be used to delineate the vesicovaginal and rectovaginal spaces in order to prevent bladder and bowel injury [4]. References [1] Nygaard IE, McCreery R, Brubaker L, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol 2004;104:805–23. [2] Propst K, Tunitsky-Bitton E, Schimpf MO, Ridgeway B. Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature. Int Urogynecol J 2014;25:21–31. [3] Anand M, Tanouye SL, Gebhart JB. Vesicosacrofistulization after robotically assisted laparoscopic sacrocolpopexy. Female Pelvic Med Reconstr Surg 2014;20:180–3. [4] Chamsy D, Lee T. Laparoscopic excision of sacrocolpopexy mesh. J Minim Invasive Gynecol 2014;21:986.
L.G. Brito* G. Giraudet J.-P. Lucot M. Cosson Service de Chirurgie Gyne´cologique, Hopital Jeanne de Flandre, Centre hospitalier Re´gional Universitaire de Lille, Lille, France *Corresponding author at: Service de Chirurgie Gyne´cologique, Hopital Jeanne de Flandre, Centre hospitalier Re´gional Universitaire de Lille, Lille 59000, France. Tel.: +33 652602709 E-mail address: [email protected] (L.G. Brito). 25 June 2014 http://dx.doi.org/10.1016/j.ejogrb.2015.02.024