Lumbosacral spondylodiscitis due to rectal fistula following mesh penetration 7 years after colpopexy

Spondylodiscitis After Surgery for Pelvic Organ Prolapse: Description of a Rare Complication and Systematic Review of the Literature

Background: Spondylodiscitis can be a rare complication of gynecological surgery, typically of procedures involving the sacrum and the sacrospinous ligament. This report presents a case of spondylodiscitis arising after a laparoscopic sacrocolpopexy with a mesh. We also review the literature finding 52 cases of spondylodiscitis following sacrocolpopexy and (or) rectopexy with or without a mesh.

Methods: We performed a comprehensive search from the electronic databases MEDLINE (Pubmed), Scopus, Web of Science, Embase, CINAHL, and Google Scholar from 1990 to February 2021 in order to identify case reports or case series reporting on spondylodiscitis after rectopexy or sacrocolpopexy.

Results: We identified 52 total postoperative spondylodiscitis. We examined the mean age of patients, the surgical history, the time from initial surgery to spondylodiscitis, the presenting symptoms, the diagnostic tools, the medical and surgical treatment, the type of mesh used, the surgical access, and the possible causes of spondylodiscitis.

Conclusions: Diagnosis of spondylodiscitis may be challenging. From our review emerges that recurrent pelvic pain and lumbosciatalgia may be signals of lumbar spondylodiscitis. Magnetic resonance is the gold standard examination for spondylodiscitis. Surgical practice needs to be improved further in order to establish the best procedure to minimize the incidence of this complication. Awareness of symptoms, timely diagnosis, and treatment are fundamental to prevent irreversible complications.

Conservative Management of Spondylodiscitis after Laparoscopic Sacral Colpopexy: A Case Report and Review of Literature

Sacral colpopexy is one of the standard procedures to treat apical pelvic organ prolapse. In most cases, a synthetic mesh is used to facilitate the colposuspension. Spondylodiscitis is a rare but potentially serious complication that must be promptly diagnosed and treated, despite the lack of consensus in the management of this complication. We report one case of spondylodiscitis after a laparoscopic supracervical hysterectomy and sacral colpopexy treated conservatively. We also present a literature review regarding this rare complication. A conservative approach without mesh removal may be possible in selected patients (stable, with no vaginal lesions, mesh exposure or severe neurologic compromise). Hemocultures and culture of image-guided biopsies should be performed to direct antibiotic therapy. Conservative versus surgical treatment should be regularly weighted depending on clinical and analytical progression. A multidisciplinary team is of paramount importance in the follow-up of these patients.

Radiation proctitis-related lumbar spondylodiscitis due to Actinomyces odontolyticus: a rare finding

Lumbar spondylodiscitis due to radiation proctitis-related fistula is a rare finding in the literature. After having isolated Actinomyces odontolyticus, a rare finding in the osteomuscular system, we present one of such cases.A 75-year-old patient with a history of rectum adenocarcinoma, submitted to surgery and radiotherapy, presented himself in our emergency department with a 3-month history of lumbar pain radiating to both legs. Physical examination was compatible with cauda equina syndrome and subsequent investigation revealed L4-L5 spondylodiscitis. Despite a 6-month antibiotic therapy regimen, the symptoms recurred. Intravertebral disc biopsy revealed A. odontolyticus and directed antibiotic therapy was started. However, the symptoms recurred after a new 6-month antibiotic therapy regimen, this time with rectal purulent drainage. Additional study revealed two rectal fistulae. It was assumed those were caused by radiation proctitis and constituted the primary cause of spondylodiscitis. Laminectomy was performed with a satisfactory clinical response.

Lumbosacral discitis as a rare complication of laparoscopic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Sacrocolpopexy is considered to be the gold-standard procedure for apical compartment prolapse. However, complications such as sacral hemorrhage, small bowel obstruction, port site herniation, mesh erosion, mesh exposure, and occasionally discitis may occur. The aim of this study is to show laparoscopic treatment of L5-S1 discitis 3 months following laparoscopic sacrocolpopexy.

METHODS

Two surgical interventions of a case with narrated video footage is presented.

RESULTS

Laparoscopic sacrocolpopexy following hysterectomy in the first part and re-laparoscopy because of a diagnosis of discitis refractory to medical treatment, and removal of mesh along with anterior L5-S1 discectomy for curative debridement in the second part is demonstrated.

CONCLUSION

Frequency of postoperative discitis has been increased by the widespread use of a laparoscopic approach. In order to reduce the complication rate, surgical technique allowing the needle to penetrate only the depth of the anterior longitudinal ligament and usage of monofilament suture for mesh attachment is recommended. In treatment, removal of the sacral mesh, and even extensive tissue debridement, may be necessary.

A systematic review of the management of synthetic mesh erosion of the rectum following urogynaecological surgery

AIM

Synthetic rectal mesh erosion is a challenging complication following urogynaecological surgery. The aim of this study was to determine the optimal management of rectal mesh erosion following urogynaecological surgery.

METHOD

A systematic review was undertaken following a pre-defined protocol registered with PROSPERO (CRD42018112425) in accordance with PRISMA guidelines. Searches of MEDLINE online database, Cochrane Library and clinical trial registries (ClinicalTrials.gov, EU Clinical Trials, ISRCTN registry) were performed. The included articles were heterogeneous - therefore a narrative synthesis was performed.

RESULTS

Fourteen studies were included in the review: 11 case reports, one case series, one retrospective cohort and one prospective multicentre trial. Fourteen rectal mesh erosions were identified. Eight (57%) of the rectal erosions underwent major abdominal surgery. In two of these cases, the abdominal approach was used only after failure of the transanal route. Five (36%) of the mesh erosions were managed using a transanal approach. In one case, the mesh passed without intervention.

CONCLUSION

Synthetic rectal mesh erosion can be managed successfully via either a transanal or a transabdominal approach with a partial or complete excision of the mesh. An examination under anaesthetic with an attempted transanal removal of mesh should be considered the first step in the management of this condition before consideration of more invasive surgery.

Management of lumbar spondylodiscitis developing after laparoscopic sacrohysteropexy with a mesh: A case report and review of the literature

INTRODUCTION

Lumbar spondylodiscitis is a rare and severe complication of laparoscopic sacrohysteropexy with a polypropylene mesh. However, a case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy has not been reported so far. We present a case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy with a mesh. We also discuss 33 cases of lumbar spondylodiscitis following sacral colpopexy and (or) rectopexy with a mesh.

PATIENT CONCERNS

A 46-year-old woman with 3 previous vaginal deliveries underwent laparoscopic mesh sacrohysteropexy for stage III uterine prolapse. One month after surgery, the patient developed persistent symptoms, such as stiffness of the lumbosacral portion, low back pain (LBP), persistent swelling, pain between the right iliac crest and the buttock, inability to bend down, and pain in the right lower limb. Symptoms were alleviated by a nonsteroidal anti-inflammatory drug. However, in the last 7 days, symptoms worsened and she was unable to stand or walk. The patient had very limited leg mobility.

DIAGNOSIS

Blood routine examination, erythrocyte sedimentation rate, C-reactive protein, and magnetic resonance imaging (MRI) of the lumbar spine indicated lumbar pyogenic spondylodiscitis.

INTERVENTIONS

Removal of mesh and hysterectomy via laparoscopy were performed immediately, and antibiotics were given simultaneously. However, on the basis of MRI findings and persistent symptoms, debridement, laminectomy, spinal canal decompression, bone grafting, and internal fixation via pedicle screw placement were performed 5 months after laparoscopic sacrohysteropexy.

OUTCOMES

All symptoms were alleviated 5 days after the operation. The patient could stand in the erect position and raise her lower limbs within 2 weeks. She could resume her normal activities within 2 months after the operation, and her X-ray appeared normal.

CONCLUSION

Persistent LBP and radiating pain may be the signals of lumbar spondylodiscitis. MRI is the gold standard diagnostic examination for lumbar spondylodiscitis. Awareness of symptoms, such as LBP and radiating pain symptoms, timely diagnosis, mesh removal, and referral to orthopedists are important to prevent more severe complications. Surgical practice needs to be improved further and any other infections should be treated immediately as the most likely causes of lumbar spondylodiscitis are related to the mesh and other infections.

Spondylodiscitis after minimally invasive recto- and colpo-sacropexy: Report of a case and systematic review of the literature

Background:

Rectopexy and colpopexy are established surgical techniques to treat pelvic organ prolapse. Spondylodiscitis (SD) after rectopexy and colpopexy represents a rare infectious complication with severe consequences. We presented a case of SD after rectopexy and performed a systematic review.

Methods:

A systematic literature search was performed to identify case reports or case series reporting on SD after rectopexy or colpopexy. The main outcomes measures were time from initial surgery to SD, presenting symptoms, occurrence of mesh erosion or fistula formation and type of treatment.

Results:

Forty-one females with a median age of 59 (54–66) years were diagnosed with SD after a median of 76 (30–165) days after initial surgery. Most common presenting symptoms were back pain (n = 35), fever (n = 20), pain radiation in the legs (n = 9) and vaginal discharge (n = 6). A mesh erosion (n = 8) or fistula formation (n = 7) was detected in a minority of cases. The treatment of SD consisted of conservative treatment with antibiotics alone in 29%, whereas 66% of the patients had to undergo additional surgical treatment. If a revision surgery was necessary, more than one intervention was performed in 40%. Mesh and tack excision was performed in most cases (n = 21), whereas a neurosurgical intervention was necessary in 10 patients.

Conclusion:

Although a rare complication, surgeons performing rectopexy and colpopexy must be aware of the potential risk of SD Careful suture or tack placement into the anterior longitudinal ligament at the level of the promontory while avoiding the disc space is of paramount importance. Prompt diagnosis and multidisciplinary management are the cornerstones of a successful treatment.