Spondylodiscitis as a complication after sacrocolpopexy

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Abstract

Background: Sacrocolpopexy using a synthetic mesh implant is a highly effective method for the surgical correction of apical pelvic organ prolapse. Despite good long-term outcomes, the procedure is associated with the risk of developing mesh-associated complications, with purulent spondylodiscitis being the most severe. This complication has not been previously described in the Russian literature.

Objective: To highlight the issue of diagnosis and treatment of spondylodiscitis as a complication of sacrocolpopexy based on the analysis of a clinical case and data from modern literature.

Materials and methods: A clinical case of a 66-year-old female patient who developed spondylodiscitis at L5–S1, osteomyelitis, and a paraspinal abscess after laparoscopic sacrocolpopexy with total hysterectomy was analyzed. A review of modern approaches to the diagnosis and treatment of this complication was conducted. MRI and CT were used for verification of the diagnosis. After conservative antibiotic therapy proved ineffective, laparoscopic excision of the infected mesh implant was performed.

Results: Conservative antibiotic therapy failed to relieve the symptoms of spondylodiscitis. Laparoscopic removal of the infected polypropylene implant resulted in rapid regression of clinical symptoms: complete pain relief was noted on the 2nd postoperative day and the patient was discharged for outpatient treatment on the 4th day. Full rehabilitation was achieved within 20 days.

Conclusion: The presented case confirms that surgical excision of the infected mesh implant is the most effective treatment method, while antibiotic therapy is often ineffective. To minimize the risk of complications, it is important to strictly follow to the rules of asepsis and to avoid performing hysterectomy and placing a synthetic prosthesis simultaneously. Surgeons should maintain a high index of suspicion for this complication in patients presenting with low back pain postoperatively.

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About the authors

Vitaly F. Bezhenar

Pavlov First St. Petersburg State Medical University, Ministry of Health of Russia

Email: ivanoffmd@gmail.com
ORCID iD: 0000-0002-7807-4929
SPIN-code: 8626-7555

Dr. Med. Sci., Professor, Head of the Departments of Obstetrics, Gynecology and Neonatology/Reproductology, Head of the Clinic of Obstetrics and Gynecology, Main Supernumerary Specialist Obstetrician-Gynecologist of the Health Committee of St. Petersburg

Russian Federation, 197022, St. Petersburg, Leo Tolstoy str., 6-8

Peter M. Palastin

Pavlov First St. Petersburg State Medical University, Ministry of Health of Russia

Email: ivanoffmd@gmail.com
ORCID iD: 0000-0003-3502-2499
SPIN-code: 8008-8723

PhD, Teaching Assistant at the Department of Obstetrics, Gynecology and Neonatology

Russian Federation, 197022, St. Petersburg, Leo Tolstoy str., 6-8

Oleg A. Ivanov

Pavlov First St. Petersburg State Medical University, Ministry of Health of Russia

Author for correspondence.
Email: ivanoffmd@gmail.com
ORCID iD: 0000-0002-6596-4105
SPIN-code: 8620-9749

PhD Student, Department of Obstetrics, Gynecology and Neonatology, Senior Laboratory Assistant, Department of Obstetrics, Gynecology and Neonatology

Russian Federation, 197022, St. Petersburg, Leo Tolstoy str., 6-8

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2. Fig. 1. Dorsal view of the female pelvis. Anchorage points for apical suspension: black dots on the sacrospinous ligament are the most commonly used fixation points for unilateral fixation, transparent dots for bilateral fixation of the sacrospinous ligament. Three bilateral dots on the uterosacral ligament are used for suspension of the uterosacral ligament. Dots on the promontory are used for sacrocolpopexy. The uterus and tubes are shown as dotted lines; the vagina is shown as a solid line [1]

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3. Fig. 2: a) Post-contrast T1-weighted image showing normal vertebral height with marked bone marrow edema in the L5-S1 disc consistent with osteomyelitis (arrow); b) MRI 1 month later: post-contrast T1-weighted image showing loss of normal lumbar lordosis, endplate compression with marked irregularity around the fluid-filled disc space with extensive cellulitis formation that significantly reduces the diameter of the central canal and compresses the dural sac (arrow) [17]

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4. Fig. 3. Presacral abscess (long arrow) extending from the L5 vertebral body downwards towards the pelvis and laterally, involving the left iliopsoas muscle. From the main presacral fluid collection, tubular structures (short arrow) containing gas extend downwards towards the distal pelvis (CT scan) [17]

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5. Fig. 4. Removed mesh for sacrocolpopexy: A — anterior fixation with a removed portion of the bladder; P — posterior vaginal fixation; S — sacral fixation [29]

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6. Fig. 5, 6. MRI results showing clear signs of osteomyelitis at the L5–S1 level

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7. Fig. 7, 8. CT images showing clear signs of osteomyelitis at the L5–S1 level

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8. Fig. 9, 10, 11, 12. Stages of excision of an infected polypropylene mesh implant.

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