Multidisciplinary Management of Cutaneous Gluteus Vaginal Fistula After Sacrospinous Ligament Fixation

Abstract

Introduction:

Cutaneous gluteal vaginal fistula is a rare but significant postoperative complication which may present years after sacrospinous ligament fixation (SSLF) surgery There is limited data on the management of cutaneous vaginal fistula following SSLF.

Case description:

This case report describes a 77-year-old who presents twenty years after SSLF with cutaneous gluteal vaginal abscess and fistula. She underwent successful management with CT-guided percutaneous drainage of gluteal abscess and placement of guiding cutaneous vaginal catheter, laparoscopic pelvic wall dissection and evaluation, and transvaginal localization and removal of the infected permanent suture.

Discussion:

Multi-disciplinary approach should be considered in the treatment of chronic fistula status post SSLF, including interventional radiology, urogynecology, and minimally invasive gynecologic surgery.

INTRODUCTION

Cutaneous gluteal vaginal fistula is a rare complication after sacrospinous ligament fixation (SSLF). Despite its low prevalence, it represents a serious consideration due to risks for infection and decreased quality of life. Most reported cases of postoperative gluteal vaginal fistula are associated with mesh placement, slings, or tape.^1–5 This case report describes the surgical management of a patient who is 20 years post-SSLF presenting with persistent vaginal bleeding and cutaneous discharge due to gluteal abscess and cutaneous fistula, and provides a review of the existing literature on the subject.

CASE REPORT

This is a 77-year-old female, who initially underwent vaginal hysterectomy, bilateral salpingo-oophorectomy, anterior and posterior colporrhaphy, and SSLF at age 55 in 2001. For apical vaginal suspension, two nonabsorbable sutures were placed in the right sacrospinous ligament. There were no initial reported complications.

Subsequent follow-up visits from an outside hospital documented patient complaints of irregular vaginal spotting and discharge for several years. She presented with purulent discharge from her right buttock in late 2020. After initial failure of a course of oral antibiotic therapy, pelvic magnetic resonance imaging showed a complex abscess and sinus tract extending from the skin into the deep pelvis and surrounding the right gluteus maximus muscle. The patient was treated with oral and intravenous antibiotics, wide incision and drainage, and excisional debridement of the right gluteal area at an outside hospital; however, she remained symptomatic. Patient was referred to colorectal surgery for evaluation for a possible rectovaginal cause of her symptoms; however, the patient's prior colonoscopy was negative for colorectal fistula. The patient was then referred to our service for evaluation.

On initial evaluation, the patient complained of continuous right lower buttock discharge and intermittent vaginal serosanguinous spotting. Physical examination revealed yellow drainage from a < 00.5 cm opening above the right buttock. Vaginal examination revealed atrophic vaginal mucosa with evidence of small granulomatous lesions at the right upper vaginal apex in the area of the sacrospinous ligament. Given the history of SSLF and deep chronic abscess and fistula, the source was thought to be the nonabsorbable suture material used for SSLF. The specific suture material was not included in the initial operative report. Removal of the sutures and deep drainage of the abscess using a multidisciplinary approach, including interventional radiology (IR), urogynecology, and minimally invasive gynecologic surgery (MIGS), was planned.

Five days before surgery, IR performed computed tomography and fluoroscopic-guided percutaneous abscess drainage and fistulogram. A 10-degree locking loop drain was placed into the gluteal abscess for drainage. One day before surgery, a 6-degree locking loop drain was crossed percutaneously into the fistula and into the vagina for localization of vaginal end of the fistula (Figure 1, 2).

Figure 1.

Panel of computed tomography with contrast images showing percutaneous fistula with leakage to labial folds on last image.

Figure 2.

Computed tomography and fluoroscopic fistulogram with contrast dye (left) and drains (right) passed percutaneously from gluteal abscess (white arrow) to vagina (yellow arrow).

The patient was then brought to the operating room for a combined vaginal and laparoscopic exploratory surgery and removal of nonabsorbable suture. The patient was placed under general anesthesia and positioned in dorsal lithotomy position. Cystoscopy was performed and the bladder was observed to be intact with normal functioning ureters. Bilateral ureteral catheters were placed. Laparoscopic surgery for evaluation of the right deep pelvis was then performed. Right pelvic wall dissection was performed to the level of the levator ani muscle. The obturator nerve, ureter, and blood vessels in the area of the right lateral pelvic wall were identified and protected. No intrapelvic abscess was noted.

Subsequently, a vaginal incision was created around the vaginal tract of the fistula guided by the percutaneous vaginal catheter (Figure 3). Sharp dissection was carried to the level of the right sacrospinous ligament. Two sutures covered in purulent discharge became evident at the vaginal apex, and these sutures were completely and sharply excised from the right sacrospinous ligament and vaginal apical area. The sutures were white in color and appeared similar to Mersilene material (Figure 4). The site was copiously irrigated. Laparoscopic evaluation was performed concomitantly to ensure that there were no injuries to the right pelvic wall structures, the bladder, the right ureter, or the bowel. The guiding cutaneous vaginal catheter was removed while the cutaneous gluteal abscess drain was kept in place. The vagina was repaired with 2-0 delayed absorbable sutures, and adequate support of the vaginal apex and no pelvic organ prolapse was noted.

Figure 3.

Intraoperative transvaginal view of bilateral ureteral stents and computed tomography-guided percutaneous vaginal catheter.

Figure 4.

Two sutures removed with ruler for size comparison.

Final laparoscopic evaluation was performed. Complete hemostasis with no damage to surrounding structures was visualized. Cystoscopy was performed to confirm the lower urinary tract, bladder, and ureters were intact. The total procedure time was 4.5 hours, with an estimated blood loss of 50 mL.

The patient tolerated the procedure well and was discharged home on the same day with oral antibiotics. The postoperative course was uneventful. The cutaneous gluteal abscess drain was removed outpatient on postoperative day 12 when there was no more drainage. At six-week follow-up, the cutaneous fistula was well-healed with no drainage noted (Figure 5). The vaginal apex was well supported. At six-month follow-up, the patient reported no recurrence of vaginal or cutaneous discharge.

Figure 5.

Gluteal cutaneous vaginal fistula at postoperative visit.

DISCUSSION

Up to 50% of women in the United States are found to have pelvic organ prolapse (POP) on physical examination, with 3% to 6% of women presenting with symptoms of vaginal bulge or protrusion. Moreover, up to 18% of women undergo surgical correction for POP, resulting in more than 300,000 procedures in the United States each year alone.¹⁰ Vaginal hysterectomy and vaginal apex suspension with repair of vaginal wall prolapse are effective treatments for most women with uterovaginal and anterior and posterior vaginal wall prolapse. Vaginal repairs, such as SSLF, are relatively low-risk surgeries with high success rates of up to 97%.¹¹ The most common complication after SSLF is temporary right buttock pain that is self-resolving and may be treated with conservative methods, such as nonsteroidal anti-inflammatory drugs. Other potential complications include bleeding and hematoma at the site of SSLF from the gluteal vessels, sciatic nerve damage resulting in pain radiating to the leg, and neurologic impairment requiring exploration and immediate removal of SSLF sutures.¹¹

Cutaneous gluteal vaginal fistula is a rare complication of SSLF that can go untreated or unresolved for years. The resulting delayed presentation of chronic fistula with possible abscess may present a challenge to manage. The few reported cases of delayed presentation of postoperative gluteal vaginal fistula are associated with mesh placement for POP surgery and are secondary to extruded, infected, and eroded mesh occurring as long as 13 years after initial surgery.^1–5 Moreover, in the few reported cases on gluteal vaginal fistula associated with suture placement, the fistulas are secondary to migrated and exposed suture with vaginal exposure or tissue erosion, which may be more easily identified.^6–7 Sutures and mesh associated with Mersilene material, in particular, have been reported to be associated with complications in vaginal prolapse surgery, including vaginal exposure and tissue erosions.⁸

In our case, upon referral, we were presented with the conundrum of the cause and origin of the cutaneous gluteal fistula, and why the patient had not responded to previous drainage and antibiotic therapy. Upon review of the patient's gynecologic and surgical history, we identified as a likely cause the remote history of total vaginal hysterectomy, bilateral salpingo-oophorectomy, and SSLF procedure for vaginal prolapse. This raised suspicion for possible infection of nonabsorbable suture placed at the time of SSLF causing an abscess in the deep pelvis and surrounding the right gluteus maximus muscle. To cure the abscess and the fistula, the infected sutures had to be removed. We planned to drain the abscess initially with the assistance of the IR service, which also helped to identify the fistula tract by placing a drain percutaneously into the fistula tract, and to find and remove the sutures under direct vaginal approach with a concomitant laparoscopic evaluation.

CONCLUSION

There are currently no reported cases on such delayed presentation of cutaneous gluteal vaginal fistula 20 years following SSLF, and specifically related to Mersilene sutures. However, there are well documented reports of tissue infection, granuloma, and fistula formation associated with these permanent sutures.⁹ Thus, the use of Mersilene material in the form of suture or mesh for pelvic surgery is not recommended.

We present a case with successful recognition and management of delayed presentation of cutaneous vaginal fistula with a multidisciplinary approach, including IR imaging and drainage placement, laparoscopic survey of the pelvis to rule out pelvic abscesses in the pelvic side wall, and percutaneous catheter guided vaginal dissection and identification of the infected and eroded sutures under direct laparoscopic observation to minimize possible risk of rectal, bladder, and ureter injuries.

Clinical suspicion of rare complications, such as cutaneous fistula, even from remote pelvic surgeries, should be considered in the differential diagnosis in patients with prior SSLF surgery.