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Necrotizing fasciitis complicating transobturator tape operation
IUGA Academy. Yasa C. Jun 30, 2018; 212933; 472 Topic: Stress Incontinence
Cenk Yasa
Cenk Yasa

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472

Necrotizing fasciitis complicating transobturator tape operation

Yasa, C1; Dural, O1; Usta,1; Celik, E1; Salduz, A1; Gungor Ugurlucan, F1

1: ?stanbul University School of Medicine

Introduction: Necrotizing fasciitis characterized by widespread necrosis of the subcutaneous adipose tissue, fascia or muscle. The disease is difficult to diagnose in its early stages and progresses quickly with high mortality and morbidity. Early cutaneous signs (erythema, edema, and occasionally crepitus) are nonspecific, but because the infection spreads so rapidly, prompt diagnosis and early treatment are of paramount importance. In transobturator tape (TOT) operation, sling placement may be associated with infectious complications.

Objective: Evaluation and management of necrotizing fasciitis that developed after TOT operation.

Methods: We present a case of TOT procedure complicated by necrotizing fasciitis that was resolved with extensive surgical drainage, vacuum-assisted dressing, hyperbaric oxygen therapy and antibiotic treatment.

Results: A 34-year-old female presented to our emergency department with vaginal discharge and increasing pain in her thighs after TOT operation. Her bilateral thigh was tender and swollen, inspection of vagina showed dehisced of periurethral incision, purulent discharge and exposed mesh material that had been inserted 5 days before for stress urinary incontinence in another clinic (Figure 1). On examination, patient was febrile to 38.4°C, had a pulse 110 beats per minute and with a blood pressure of 110/70 mmHg. Laboratory studies included a white blood cell count of 21.500/ml with 78% neutrophils, a hemoglobin of 11.5 gr/dl and platelet count of 292.000/ml. A CRP also obtained and it was 371 mg/dl. A magnetic resonance imaging study of pelvis and thigh showed bilateral fasciitis originating from obturator fossa and extending to popliteal area (Figure 2). Intravenous vancomycin and meropenem was started with diagnosis of sepsis. The mesh of TOT was removed under anesthesia and the obturator and thigh abscesses were incised and drained (Figure 3). Following radical a vacuum-assisted dressing and hyperbaric oxygen therapy was applied for ten days. Microbiologic culture ultimately grew B-hemolytic streptococcus sensitive to meropenem. The wound healing was good, which made further surgery unnecessary. The process of wound repair was completed in about 55 days (Figure 4).

Conclusion: Surgical procedures as TOT operation are popularly adopted in the surgical management of stress urinary incontinence because of their minimal invasiveness, high success rate and long lasting effects. Necrotizing fasciitis is difficult to diagnose early; it is a rapidly progressive infection with high mortality and disability rate. Surgical debridement, antibiotic coverage and supportive care are vital to quality care. Knowledge of this unusual complication after this surgery could direct surgeons to early diagnosis and prompt treatment.

References

  1. Delorme E: Transobturator urethral suspen- sion: mini-invasive procedure in the treat- ment of stress urinary incontinence in women (in French). Prog Urol 2001;11:1306– 1313.
  2. Deval B, Haab F: Management of the compli- cations of the synthetic slings. Curr Opin Urol 2006;16:240–243
  3. Rafii A, Jacob D, Deval B: Obturator abscess after transobturator tape for stress urinary incontinence. 720–723.

Figure 1. Inspection of vagina showed dehisced of periurethral incision and exposed mesh material

Figure 2. Bilateral fasciitis originating from obturator fossa and extending to popliteal area

Figure 3. Mesh was removed and obturator and thigh abcesses were incised and drained.

Figure 4. The process of wound repair was completed in about 55 days

Disclosure:

Work supported by industry: no.

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