Hysterectomy for PFD
Surgery is the primary treatment approach for pelvic floor prolapse. Although a wide range of surgical methods for uterine prolapse is available, there are no uniform standards and guidelines[15]. Currently, the main surgical method is apical vaginal suspension, during which, the uterus can be removed or preserved. However, hysterectomy is often performed to decrease the recurrence of PFD. In fact, the rate of recurrence of pelvic floor prolapse is lower after concomitant intraoperative removal of the uterus[16]. Furthermore, because the incidence of pelvic floor prolapse increases with decreasing estrogen[17],many patients who opt for surgery are menopausal, have no fertility requirements, and occasionally require concomitant hysterectomy due to combined uterine fibroids. In our selected patients, hysterectomy was performed prior to suspension of the vaginal stump.
Safety, advantages, and drawbacks of SSLF
Currently, SSLF, uterosacral ligament suspension, and minimally invasive sacrocolpopex fixation are the usual surgical approachesfor apical vaginal suspension. The overall perioperative safety of the three procedures is comparable, andpostoperative readmissions and reoperations remain rare. In fact, the rates of readmission (2%–3%) and reoperation (1%–2%) are similar for all the three procedures[18]. Several studies have suggested that SSLF grants a low postoperative recurrence rate[19][18], faster postoperative recovery[20], lower costs, and lower rates of difficult and painful intercourse than several other surgical procedures[21].Furthermore, SSLF is less invasive because it is a transvaginal operation and allows for removal of the uterine appendages, repair of the anterior and posterior vaginal segments, and suspension of the stump. It also corrects urinary incontinence and enterocele, thus making it thepreferred surgical route, especially for elderly and frail patients. In our analysis, we found that patients inGroup 1 predominantly had severe prolapse, whereasthose in Group 2 predominantly mild prolapse. Moreover, the long duration of menopause in patients in Group1 indicates that SSLF is preferred for patients with severe prolapse and a long postmenopausal duration.
However, SSLF involves the sacrospinous ligament, which is located relatively deep in the posterior peritoneumand is surrounded by important neurovascular organs, thus making thisoperation difficult. Improper surgical procedures may cause complications such as intestinal perforation as well as injuries to the internal pudendal arteries, sacral plexus vessels, sciatic nerve, and pudendal nerves. Bleeding is often caused by the presence of vascular variations, improper punctures, or incorrect hemostatic techniques. Because the gaps between the pelvic floor tissues is deep and hidden, bleeding cannot be detected in time at the intraoperative or postoperative stages. Even if bleeding is detected, it is difficult to stop bleeding even with complete exposure under direct vision or local compression. Therefore, there is a possibility of the requirement for reoperation.The incidence of life-threatening bleeding has been reported to be approximately 2.5%[22]. As a consequence, many physicians are concerned about complications,and thus,SSLF is notwidely performed. In addition, an improved insight into the causes and extent of bleeding during SSLFis still needed.
Occurrence of HBL: surgical complications and clinical outcomes
HBL was first proposed by Sehat et al. in 2000[23]and has gained increasing attention in recent years. For example, one study of patients undergoing anterior, lumbar, and intervertebral fusion surgery found that HBL accounted for 39% of the TBL[24], whereasanother study reported that HBL was as high as 67% [25, 26]. Further, it appears thatapproximately 40% of HBL is caused by hemolysis and approximately 60% is caused by tissue extravasation[25, 26]..Some studies have also reported that HBL in the perioperative period of artificial knee replacement accounts for approximately 50% of TBL and that it can reach 547–1,473mL; however, the mechanism of its occurrence is unclear[27]. Our data also indicated that HBL is a non-negligible risk.In this study, while EBL, preoperative hemoglobin,and VBL did not significantly differ between the two groups, TBL was significantly higher in patients who had received SSLF, probably due to the higher HBL levels observed in these patients.
The volume of HBL is usuallygreater than what would be expected, consequently causinghemodynamic instability throughout the procedure and increasing the incidence of surgical complications. Furthermore, HBL adversely affects the postoperative recovery and clinical outcomes of patients[28]and even prolongs the duration of hospitalization. Some patients may even require reoperation. Tian et al.[3]reported that HBL increases the incidence of postoperative anemia and the need for transfusion, during which, complications such as hemolytic or non-hemolytic febrile reactions and allergic reactions may arise. Anemia decreases the recovery and tissue repair capacity of the operated patient, affects the blood supply to the surgical wound, and delaysits healing. Further, persistent HBL redistributes blood perfusion to the body organs, which may induce or aggravate preexisting cardiovascular and cerebrovascular diseases, increase the burden on the kidneys, and even endanger life[29]. As shown in our data, there were no significant differences in serious complications and recurrence rate between patients who underwent SSLF or LHUS. Furthermore, patients with feveror incisional infections could not be discharged; therefore, no significant difference could be detected in the number of hospitalization days.
HBL-associated risk factors
A growing number of articles in recent years have explored the factors associated with hidden bleeding. Zhao et al.[30]conducted a study on 111 patients with stage IA-IIA cervical cancer who underwent extensive total vaginal hysterectomy combined with pelvic lymph node dissection. Multiple linear regression analysis revealed that age and longer duration of open radical surgery were independent risk factors for perioperativeHBL and that patients with squamous cervical cancer had higher perioperative HBL than patients with any other cervical cancer. On the other hand, BMI, the International Federation of Gynecology and Obstetrics (FIGO) stage, hypertensive status, and diabetic status were not risk factors. For patients undergoing laparoscopic radical cervical cancer surgery, longer operative time, diabetic status, and squamous cervical cancer were risk factors for perioperative HBL, whereas FIGO stage and hypertensive status were not.
Our group[31]has previously studied perioperative HBL in 209 patients with uterine fibroids who underwent myomectomy. Of these, 105 patients underwent open myomectomy and 104 underwent laparoscopic myomectomy. In the present study, multiple linear stepwise regression analysis revealed that longer operative duration, number of removed fibroids, and removal of interstitial fibroids were risk factors for increased perioperative HBL during myomectomy.
Another study[32] calculated the volume of HBL and assessed the risk factors in patients after posterior lumbar interbody fusion (PLIF). Multiple linear regression analysis showed that BMI of >24 kg/m2, PLIF, and prolonged operative time were risk factors for HBL, whereas age, sex, type of surgery, symptom duration,disease type, urine-specific gravity unit (SGU), plasma albumin (ALB) level, glomerular filtration rate, glucose level, and hypertension were not.
It has also been found[33] that intraoperative blood transfusion can be used as an early warning indicator of perioperative HBL.
Sacrospinous ligament-associated hidden bleeding
Currently, only few articles in the literature have described hidden bleeding during SSLF. Our study found that HBL is associated with the mode of surgical choice, age at menopause, and degree of uterine prolapse. Furthermore, more hidden bleeding was observed from the sacrospinous ligament than from the sacral ligament inmild prolapse cases. However, in severe prolapse patients, there was no significant difference between the two. This may be related to the fact that in mild prolapse patients, the anterior-posterior vaginal segments of the sacrospinous ligament, which are repaired relatively infrequently, can be repaired without being stripped,whereasthe anterior-posterior vaginal wall needs to be stripped in sacrospinous ligament suspension.
Age at menopause is a closely related indicator of HBL. This could be explained by the fact that after menopause, uterine artery resistance increases and blood flow decreases. The pulsatility and resistance indexes of the arcuate arteries were significantly reducedin postmenopausal women beyond 3 and 6months after commencing continuous combined estrogen replacement therapy compared with synthetic estrogen replacement[34, 35][26, 27]. However, neither regimen had an effect on the internal iliac artery. Therefore, increased blood flow resistance in the uterine artery increases bleeding during hysterectomy. In addition, many collateral vessels are present in the uterine artery; therefore, bleeding is more likely both at the intraoperative and postoperative stages. Therefore, TBL and HBL could be reduced if hysterectomy is not performed concomitantly to PFD-correcting surgeries. More data are needed to demonstrate this.
Reducing HBL
The ways to reduce hidden bleeding has been a consistent question within the related literature. Previous research has suggested[3] that the prophylactic use of low-molecular-weight heparin calciumincreases both perioperative blood loss and the risk of intraspinal hemorrhage during intraspinal anesthesia. However, another study has shown[36] that the perioperative use of low-molecular-weight heparin calcium is effective in preventing postoperative deep vein thrombosis in the lower extremities, as well as perioperative total, hidden, or overt blood loss. However, because no case of venous thrombosis was present in this trial, more research is needed to demonstrate the pros and cons of heparin use. Another randomized clinical trial found that topical tranexamic acid administration can effectively reduce postoperative blood loss in pelvic hemiarthroplasty surgeries[37] . Howerve, we did not use it in this study to consider the problem of thrombosis. While itis generally believed that subcutaneous injection of norepinephrine may reduce intraoperative bleeding, in our study, subcutaneous injection of norepinephrine did not affect intraoperative bleeding. This was similar to the results in the study by Cohen etal. A randomized study was conducted by Cohen[38]during endoscopic sinus surgery under general anesthesia, 10 and 12patients were randomizedto the epinephrine and saline group, respectively. Theepinephrine and norepinephrine levels were measured following injection in all patients. The epinephrine levels were similar in both groups immediately after injection; however, 15 minutes after injection, the epinephrine level was significantly higher in saline-injected patients. Thus, the authors concluded that injection of an epinephrine/lidocaine mixture does not produce higher blood levels of epinephrine when compared to saline injection and did not induce harmful side effects. The surgical field was bloodier in saline-injected patients (P <0.05) however objective estimation of blood loss was not different between the two groups.
Limitations of this study
This study has its limitations. Here in, we performed a regression analysis. Further, the drainage fluid have contained some exudate, which increases the amount of dominant bleeding,butdoes not affect the total amount of bleeding. Thus exudates may have effect the amount of HBL.